Stroke In Pregnancy Research Articles

Migraine and its Association with Stroke in Pregnancy: A National Examination.

Background: Migraine prevalence has been estimated to be as high as 25% during reproductive years. Despite this, and the known significantly lower odds of acute stroke being correctly diagnosed among women versus men, little is known about the migraine-stroke connection in this vulnerable population. Our study seeks to provide a consolidated examination of cerebrovascular and obstetric complications of migraines in pregnant women and to evaluate the role of concurrent comorbidities. Methods: We utilized the 2016-2020 Healthcare Cost and Utilization Project's National Inpatient Sample with the International Classification of Diseases, 10th Revision diagnostic codes to compare pregnant patients with migraines with those without migraines. Multivariable logistic regression was used to examine the incidence of subtypes of stroke while controlling for confounding variables. Results: Overall, 19,825,525 pregnant patients were evaluated; 219,175 (1.1%) had a concomitant diagnosis of migraine. Pregnant patients with migraines were more likely to suffer ischemic (0.1% versus 0.0%) or hemorrhagic stroke (0.3% versus 0.1%). On multivariate analysis, acute ischemic stroke was most strongly associated with migraine with aura (odds ratio [OR], 23.26; 95% confidence interval [CI], 18.46-29.31), followed by migraine without aura (OR, 8.15; 95% CI, 4.79-13.88). Conclusions: Pregnant women with migraine are at a significantly increased risk for both ischemic and hemorrhagic stroke. Pregnant women with migraines should be cautioned that they may be at an increased risk of stroke, particularly if they are experiencing an aura, and encouraged to contact their medical providers to rule out neurological complications.

First Reported Case of Tenecteplase for Treatment of Acute Ischemic Stroke in Pregnancy (P1-5.011)

First Reported Case of Tenecteplase for Treatment of Acute Ischemic Stroke in Pregnancy (P1-5.011)

Acute Cerebrovascular Accident in Pregnancy Due to Hyperhomocysteinaemia Secondary to Vitamin B12 Deficiency: A Case Report

Stroke in pregnancy is rare but is one of the leading causes of morbidity and mortality in developed countries. Pregnancy, as a prothrombotic state, acts as a precursor for stroke. Preeclampsia, eclampsia, amniotic fluid embolism, hypertension, diabetes, and many other factors predispose to the development of stroke. Endothelial cell injury leading to arteriosclerosis, causing a stroke, has been associated with raised homocysteine levels. Hereby, the authors present a case of a 26-year-old Gravida 3 Pregnancy 1 Live 1 Abortion 1 (G3P1L1A1) at 35 weeks gestation with a cephalic presentation who complained of a headache for two days, sudden onset of weakness in the right upper limb and lower limb with an inability to walk without support and inability to speak since 12 hours, associated with one episode of vomiting. Magnetic Resonance Imaging (MRI) brain showed acute infarcts in the left fronto-parietal lobes and capsule region with haemorrhagic transformation in the left frontal lobe. Serum vitamin B12 measured by Electroluminescence Assay (ECLA) was found to be low at 113pg/mL (normal range -191-771pg/mL). Serum homocysteine levels measured by enzymatic method were elevated at 46 umol/L (normal range 3-18 umol/L). A diagnosis at 34 weeks of pregnancy with acute cerebrovascular accident with right hemiparesis with Broca’s aphasia due to hyperhomocysteinaemia secondary to vitamin B12 deficiency was made. Prompt diagnosis and treatment are known to decrease morbidity in women with cerebrovascular accidents. MRI brain with venogram is known to be the gold standard procedure in diagnosing stroke. Thrombolytic therapy has proven beneficial in the treatment of the disease and in preventing its progression. Prenatal and natal supplementation with folic acid/vitamin B12 in the first trimester of pregnancy prevents Vitamin B12 deficiency and raised homocysteine levels in the maternal serum, thereby decreasing the incidence of stroke.

Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy.

Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.

Ischaemic Stroke in Pregnancy: Case Report and Review of Literature

ABSTRACT Stroke continues to be one of the main causes of death in developed countries and the incidence in pregnancy appears to be increasing. Our case describes a 34-year-old woman presenting in her third trimester with a sudden onset of slurred speech, right hemiparesis, facial nerve central palsy, psychomotor agitation and pain in the right lower limb related to ischaemic stroke in the left middle cerebral artery. The aim of our case report is to know the current recommendations for the investigation and management of acute stroke and how they apply to pregnancy, to understand the secondary prevention of stroke and the safety of these strategies in pregnancy and to recognise the importance of multidisciplinary input in the management of pregnancy and delivery in women with stroke.

Postpartum vasculopathy as a rare cause of stroke – what every neurologist should remember

Stroke in pregnancy and the puerperium is a rare condition. The treatment of ischaemic stroke (IS) in pregnancy and the puerperium is difficult and requires the attending physicians to take quick decisions. Postpartum vasculopathy (PV) may be one of the causes of postpartum stroke. The aetiology of PV is not fully understood. It most often occurs in the first week after delivery. The trigger factors include vasoconstrictive substances that are present in the blood of women in the postpartum period. Most frequently, this condition occurs in a subsequent pregnancy, and the primary symptom is a very severe headache. The characteristic feature of PV is the angiographic image of the cerebral vessels, where segmental vasoconstriction and tortuous course of the vessels are visible, which resembles beads impaled on a string. This disease is a monophasic condition and, once the disease has progressed, there are no contraindications for a subsequent pregnancy. No standard management has been established, but most authors agree that acute phase treatment includes cessation of vasoconstrictors using calcium channel antagonists, magnesium intravenously, corticosteroids, and treatment of associated conditions like headache, high blood pressure, cerebral oedema, seizure. It also applies ASA, heparin when it’s needed, we present a women with an IS in the course of PV treated successfully.

Stroke in Pregnancy: A Case Report.

case reports; hypertension; intracerebral haemorrhage; pregnancy; stroke.

Stroke in Pregnancy

Stroke in Pregnancy

Stroke in Pregnancy and Puerperium - Current Knowledge, Questions and Controversies

Stroke associated with pregnancy and the postpartum period (SiPP) is not common but its consequences can be devastating both for the mother and the child. Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. SiPP is heterogeneous both in aetiology and presentation as it includes both ischemic and haemorrhagic events as well as cerebral venous thrombosis. Specific risk factors for SiPP have been identified and well described, such as hypertensive disorders of pregnancy and a prothrombotic state. However, it is still a controversial issue if pregnancy should be considered a risk factor for stroke, although pregnancy and postpartum period clearly increase the stroke risk compared to non-pregnant time. Recent European Stroke Organization [ESO] guidelines addressed the management of acute SiPP while other issues, particularly primary and secondary prevention are still under investigated. There is also a lack of research and knowledge regarding long-term mother and foetus/child outcomes post-SiPP. This paper addresses current knowledge on SiPP management and prognosis and discusses new challenging clinical scenarios including the relationship between COVID-19 infection and SiPP.

Stroke Around Pregnancy; Protection and Prevention!

As per recent studies, incidence of stroke is increasing in pregnant women. It is essential to be vigilant and well-versed in managing stroke in pregnancy, as both the mother and the baby are prone to stroke-related injury. In this viewpoint article, we have reviewed the current data from research publications on the incidence, prevalence, risk factors, and clinical presentation of stroke in pregnancy. Finally, we have discussed the plan of investigations and the current treatment guidelines for stroke in pregnancy.

Stroke in Pregnancy and Post-partum – Latest Developments in Conduct and Management

Stroke in pregnancy and post-partum is a rare occurrence, yet with increasing incidence in the last decades. With a crude incidence rate of up to 30 per 100,000 pregnancies, high morbidity and mortality, research is needed to standardize prevention, diagnosis, treatment, and management of these cases. We present stroke particularities during pregnancy and puerperium and the current information from published articles regarding the latest developments in medical conduct. The mechanisms of stroke in pregnancy differ from those in the general population and are mostly in relation to the physiological changes during pregnancy. Stroke during pregnancy and post-partum is a rare but debilitating occurrence; with limited evidence and no clear guidelines, the treatment should be always individualized, and the risk-benefit ratio should always be considered.

Subarachnoid Hemorrhage During Pregnancy and Puerperium: A Population-Based Study.

Pregnancy-related subarachnoid hemorrhage (pSAH) is rare, but it causes high mortality and morbidity. Nevertheless, data on pSAH are limited. The objectives here were to examine the incidence trends, causes, risk factors, and outcomes of pSAH in a nationwide population-based cohort study in Finland covering 30 years. We performed a retrospective population-based cohort study and nested case-control study in Finland for the period 1987-2016 (Stroke in Pregnancy and Puerperium in Finland). The Medical Birth Register was linked to the Hospital Discharge Register to identify women with incident stroke during pregnancy or puerperium. A subcohort of women with SAH is included in this analysis. The temporal connection of SAH to pregnancy and clinical details were verified from patient records. The unadjusted incidence of pSAH was 3.21 (95% CI, 2.46-4.13) per 100 000 deliveries. No significant increase occurred in the incidence throughout the study period. However, the age of the mother had a significant increasing effect on the incidence. In total, 77% of patients suffered an aneurysmal pSAH, resulting in death in 16.3% of women and with only 68.2% achieving good recovery (modified Rankin Scale score 0-2) at 3 months. Patients with nonaneurysmal pSAH recovered well. The significant risk factors for pSAH were smoking (odds ratio, 3.27 [1.56-6.86]), prepregnancy hypertension (odds ratio, 12.72 [1.39-116.46]), and pre-eclampsia/eclampsia (odds ratio, 3.88 [1.00-15.05]). The incidence of pSAH has not changed substantially over time in Finland. The majority of pSAH cases were aneurysmal and women with aneurysm had considerable mortality and morbidity. Counseling of pregnant women about smoking cessation and monitoring of blood pressure and symptoms of pre-eclampsia are important interventions to prevent pSAH.

Role of MicroRNAs in Cardiac Disease with Stroke in Pregnancy.

Pregnancy-related cardiovascular disease with stroke remains a considerable source of higher maternal morbidity and mortality occurs in periods of pregnancy, delivery, and postpartum. It is essential to counsel the mother before pregnancy by an expert cardiologist and obstetric team to discuss any event related to preexistent cardiac or past preeclampsia for estimation of maternal and fetal risks. In pregnancy, the cardiac state includes hypertensive disorders, ischemic heart disease, valvular disease, and postpartum stroke. The incidence of stroke is increasing in pregnancy, particularly in postpartum, and its strong relationship with hypertensive disorders of pregnancy (preeclampsia). The combined cardiologist and obstetrics team requires during pregnancy mainly due to the approach to the management of a cardiac disease that subsequently prevents stroke postpartum. Therefore, a general perception of cardiac disease during pregnancy, delivery, and postpartum should be a core knowledge extent for all cardiovascular and clinicians. Many studies provided linked that deregulation of microRNAs (miRNAs) in maternal circulation and placenta tissue may development of pregnancy complications including preeclampsia considered a diagnostic marker. The desire of this review provides a detailed outline of current knowledge and dealing in this field with strength on the physiological changes during pregnancy.

Hemorrhagic Stroke in Pregnancy.

Hemorrhagic stroke carries a high risk of disability and mortality. The obstetrical population is at increased risk. Prompt diagnosis and maternal stabilization with a multidisciplinary approach are the mainstays in management. Computed tomography head is the diagnostic imaging of choice and is considered safe in pregnancy. Fetal status optimization before neurosurgery and delivery should be considered if the fetus is viable or if worsening maternal condition. Obstetric indications guide the mode of delivery. Cesarean delivery may be indicated to reduce increasing intracranial pressure. Neuraxial anesthesia should be considered to minimize catecholamine surges, reduce sedation, and control blood pressures.

Pregnancy-Related Stroke: A Review.

The maternal risk of strokes in the United States is approximately 30/100,000 pregnancies, and strokes are the eighth leading cause of maternal death. Because of the relationship between stroke and significant neurological disability/maternal death, obstetrical health care providers must be able to identify, evaluate, diagnosis, and treat these women. PubMed was searched using the search terms "stroke" OR "cerebrovascular accident" OR "intracranial hemorrhage" AND "pregnancy complications" OR "risk factors" OR "management" OR "outcome." The search was limited to the English language and was restricted to articles from 2000 to 2020. There were 319 abstracts identified, and 90 of the articles were ultimately used as the basis of this review. Presenting stroke signs and symptoms include headache, composite neurologic defects, seizures, and/or visual changes. Diagnosis is typically made with computed tomography scan using abdominal shielding or magnetic resonance imaging without contrast. Management options for an ischemic stroke include reperfusion therapy with intravenous recombinant tissue plasminogen activator catheter-based thrombolysis and/or mechanical thrombectomy. Hemorrhagic strokes are treated similarly to strokes outside of pregnancy, and that treatment is based on the severity and location of the hemorrhage. Early recognition and management are integral in decreasing the morbidity and mortality associated with a stroke in pregnancy. This study was an evidence-based review of stroke in pregnancy and how to diagnose and mange a pregnancy complicated by a stroke.

Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke.

Pregnancy is a female-specific risk factor for stroke. Although pregnancy-associated stroke (PAS) is a rare event, PAS leads to considerable maternal mortality and morbidity. It is estimated that 7.7–15% of all maternal deaths worldwide are caused by stroke and 30–50% of surviving women are left with persistent neurological deficits. During last decade, several studies have reported an increasing incidence of PAS. The objective of this review is to summarize studies on time trends of PAS in relation to trends in the prevalence of stroke risk factors in pregnant women. Seven retrospective national healthcare register-based cohort studies from the US, Canada, UK, Sweden, and Finland were identified. Five studies from the US, Canada, and Finland reported an increasing trend of PAS. Potential biases include more sensitive diagnostics and improved stroke awareness among pregnant women and professionals toward the end of the study period. However, the concurrent increase in the prevalence of several stroke risk factors among pregnant women, particularly advanced age, hypertensive disorders of pregnancy, diabetes, and obesity, indicate that the findings are likely robust and should be considered seriously. To reduce stroke in pregnancy, increased awareness among all medical specialties and pregnant women on the importance of risk-factor management during pregnancy and stroke symptoms is necessary. Important preventive measures include counseling for smoking cessation and substance abuse, treatment of hypertensive disorders of pregnancy, use of aspirin in women at high risk for developing preeclampsia, and antithrombotic medication and pregnancy surveillance for women with high-risk conditions. Epidemiological data from countries with a high risk-factor burden are largely missing. National and international registries and prospective studies are needed to increase knowledge on the mechanisms, risk factors, management, and future implications for the health of women who experience this rare but devastating complication of pregnancy.

European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum.

Pregnancy, postpartum and menopause are regarded as periods women are more vulnerable to ischaemic events. There are conflicting results regarding stroke risk and hormone replacement therapy (HRT) during menopause. Stroke in pregnancy is generally increasing with serious consequences for mother and child; therefore, recommendations for acute treatment with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) are needed. The aim of this guideline is to support and guide clinicians in treatment decisions in stroke in women. Following the “Grading of Recommendations and Assessment, Development and Evaluation (GRADE)” approach, the guidelines were developed according to the European Stroke Organisation (ESO) Standard Operating Procedure. Systematic reviews and metanalyses were performed. Based on available evidence, recommendations were provided. Where there was a lack of evidence, an expert consensus statement was given. Low quality of evidence was found to suggest against the use of HRT to reduce the risk of stroke (ischaemic and haemorrhagic) in postmenopausal women. No data was available on the outcome of women with stroke when treated with HRT. No sufficient evidence was found to provide recommendations for treatment with IVT or MT during pregnancy, postpartum and menstruation. The majority of members suggested that pregnant women can be treated with IVT after assessing the benefit/risk profile on an individual basis, all members suggested treatment with IVT during postpartum and menstruation. All members suggested treatment with MT during pregnancy. The guidelines highlight the need to identify evidence for stroke prevention and acute treatment in women in more vulnerable periods of their lifetime to generate reliable data for future guidelines.

Spotlight on the May 25 Issue

#### Notable in Neurology This Week This issue features an article that investigates the influence of cognitive demands on motor performance during acute stroke recovery; another examines the associations between neighborhood socioeconomic status and 90-day poststroke outcomes. A featured article determines the prevalence and natural history of sporadic inclusion body myositis in a 40-year population-based study. ### Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987–2016 Pregnancy-associated stroke is associated with considerable maternal morbidity and mortality. In this Finnish population-based, chart-validated cohort study, the incidence of pregnancy-associated stroke doubled from 1987 …

Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987-2016.

To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS. We performed a retrospective population-based cohort study and nested case-control study in Finland from 1987 to 2016. The Medical Birth Register (MBR) was linked to the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period in 5-year age groups and pregnancy/postpartum period was calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors. After chart review, 29.6% (257 of 868) of cases were PAS. The incidence of PAS was 14.5 (95% confidence interval [CI] 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987 to 1991 to 2012 to 2016 (p < 0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from 20 to 24 years to >40 years of age (p < 0.0001). During the early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable-adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95% CI 1.2-2.7), migraine (OR 16.3, 95% CI 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95% CI 2.5-6.3) were the most important risk factors for PAS. PAS incidence is increasing, stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium. This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine, and hypertensive disorders of pregnancy are associated with an increased risk of PAS.

Stroke in Pregnancy and Perinatal Period

Stroke in Pregnancy and Perinatal Period