Nurose Karim, MD
International Stroke Conference 2021
March 17–19, 2021
Session: Stroke in Pregnancy: What To Expect When They’re Expecting (150, On Demand)
Eliza C. Miller, MD, MS: In this session, Dr. Miller pointed out three important topics: epidemiology, mechanism and prevention. The trend in maternal mortality in pregnancy in the United States increased from 1987 until 2016. And so is the rate of maternal stroke. The incidence is 30/100,00 deliveries. Half are hemorrhagic with a mortality of 10-16%, which is different than stroke in the general population, where 85% of strokes are ischemic. Hypertension is the leading cause, and there is some racial disparity among the prevalence. The risk is higher in the non-White population (African American, Asian and Hispanic). Migraine is another stroke risk factor, which increases the risk of hypertension and preeclampsia, which ultimately are risk factors for stroke.
The diagnostic criteria for Pre-eclampsia per ACOG and ISSHP is new onset hypertension at the gestational age greater than 20 with proteinuria or without proteinuria with a new onset headache unresponsive to the treatment or new onset focal neurological deficit.
The take-home message from this talk was, headache and hypertension in pregnancy are red flags and should be taken seriously.
Cheryl Bushnell, MD: In this session, Dr. Bushnell talked about reperfusion therapy in pregnant stroke patients. Most of our data on reperfusion in pregnancy comes from the Canadian best practice consensus statement. Regarding IV alteplase, the guideline says: “it is reasonable to give IV Alteplase to a pregnant patient with disabling ischemic stroke who meets existing criteria for thrombolysis. The risk-benefit consideration can be complex in the setting of pregnancy; thus, the decision should be undertaken with consultation with a physician with experience in acute stroke treatment either in-person or through tele stoke modalities.”
Peri-partum cardiomyopathy and PFO are the two cardiac sources that should be evaluated in women who developed stroke with a large vessel occlusion (LVO) during pregnancy or post-partum. Thrombolysis and endovascular thrombectomy likely do not cause excessive harm in pregnancy-related strokes.
Eric Smith, MD, MPH: In this session, Dr. Smith talked about expected stroke outcome in pregnant patients. In general, in pregnancy, mortality is higher with ICH than ischemic stroke and SAH. There are three areas of outcome: direct effect to the mother that can lead to maternal death, indirect effects that include risk of ionizing radiation exposure and treatments like IV thrombolysis and thrombectomy and the post stroke outcomes leading to residual effects and how it affects the newborn care and self-care.
Regarding imaging and the risk of radiation exposure, typical head CT has an exposure of ~0.001 mGy. CTA+Endovascular thrombectomy is ~0.0024 mGy. The occupational limit for pregnant women is 5 mGy, so these images are still less than the limit. Theoretically, the carcinogenic risk is negligible: 1:200,000-1:1000,000.
Neha Dangayach, MD: This session was based on the talk about hemorrhagic stroke, cerebral venous sinus thrombosis (CVST) and other cerebrovascular risk factors in pregnancy. The care of pregnant stroke patients, like any other stroke patient, is multidisciplinary. It involves a lot of teams from ER to stroke team, neurocritical care, maternofetal, OBGYN, neurosurgery, social worker and therapies.
CVST has the highest risk from the third trimester until 6 weeks postpartum. Images of choice could be CTH/CTV or MRI/MRV. Treatment is low molecular weight heparin throughout the pregnancy and up to 6 weeks postpartum and then switch to vitamin K antagonist for a total of 6 months. The recurrence of CVST is usually low, but it is recommended to use LMWH prophylactically in the subsequent pregnancies.
Subarachnoid hemorrhage (SAH): 5.4% of SAH in women are in pregnant women. 8% of patients are African American, 7% Hispanic, and 4% White. Before 26 weeks, maternal health takes the priority. Between 26 and 34 weeks, it is individualized case by case, and after 34 weeks, it is maternal fetal dyad.