A review of stroke in pregnancy TOG 2019

Question 1

What is the incidence of pregnancy-related stroke?

Answer 1

30/100,000

Question 2

How much more common is stroke in pregnant vs non pregnancy 15-44yrs?

Answer 2

5 x times

Question 3

What are 4 main type of stroke

Answer 3

Cerebral infarction
Cerebral vein thrombosis
Intracranial haemorrhage
Subarachnoid haemorrhage

Question 4

When is stroke most likely to occur during pregnancy?

Answer 4

90% permpartum
AN strokes very rare

Question 5

Fatalist of haemorrohagic and ischiaemic stroke in pregnancy

Answer 5

Haemorrhage 50%
Ischaemic 33%

ICH greatest cause of death

Question 6

Most common cause of stroke in non-pregnant and pregnant population

Answer 6

Non-pregnant 80-85 ischaemic
Preg equal haemorrhage, CVT, ischaemic

Question 7

Independent RF for stroke

Answer 7

Mat Age >35
Migrane
GDM - highest RF
PET/Eclampsia

Question 8

Bradcardia is a symptom of which type of stroke

Answer 8

Significant ICH, raised ICP

Question 9

What scores should be calculated from the history?

Answer 9

National institutes of Health Stroke Scale (NIHSS) scores
or
Rankin score

Question 10

What imaging to Ix stroke

Answer 10

Same as not pregnant
1st Non-contract CT
MRI head
Can performed CT angiogram,

Question 11

If CT angiogram performed, what needs to be monitored in foetus?

Answer 11

TFTs fir 1st 2 weeks of life

Question 12

Additional investigations to consider for causes of stroke in young woman?

Answer 12

12 lead ECG
24 hours ECH
Prolonged cardiac monitor
TOE ?PFO
ECHO + bubble test ?PFO
PET bloods
Lipid profil
Thombophilia screen
Carotid and lower limb doppler

Question 13

1st line investigation after ischaemic stroke?

Answer 13

Transthoracic ECHO + ‘bubble test’

Question 14

1st line treatment for acute ischaemic stroke in pregnancy

Answer 14

Thrombolysis (IV alteplase) within 4.5 hrs, ig intracranial haemorrhage has been excluded

Avoid aspirin for 1st 24 hrs after thrombolysis, increases risk of subsequent ICH

Question 15

When should thombectomy with IV thombolysis within 6 hours be offered?

Answer 15

Confirmed occlusion of proximal antioer circulation on CTA or MRA

Question 16

Contraindications to thrombolysis

Answer 16

Intracerebral haemorrhage
Suspected subarachnoid haemorrhage, even if normal computed tomography (CT)
Neurosurgery, head trauma within the last 3 months
Systolic blood pressure >185 mmHg, diastolic blood pressure >105 mmHg
History of intracerebral haemorrhage
Known intracerebral arteriovenous malformation, neoplasm or aneurysm
Active internal bleeding
Suspected/confirmed endocarditis
Known bleeding diathesis
○ Platelets <100 000
○ Heparin within 48 hours
○ Current use of warfarin with international normalised ratio (INR) >1.7
○ Direct thrombin inhibitors or factor Xa inhibitors
Blood glucose <2.8 or >22.2 mmol/L, with resolution of symptoms when corrected

Question 17

Medical treatment ICH

Answer 17

Corrrect coagulopathy/thrombocyopenia
Correct high low BM
BP control
VTE prophylaxis
Withhold anti platelets and anticoagulation

Can consider surgical decompression

Question 18

Management cereal venous thrombosis

Answer 18

LMWH/unfractionated heparin
Can consider thrombolysis/thromboectomy
If raised ICP IV mannitol

Question 19

Management posterior reversible encephalopathy syndrome

Answer 19

BP control
MgSu

Question 20

Risk of stroke in future pregnancy if no thrombophilia

Answer 20

0-1.8%
0.5% outside pregnancy

Question 21

If previous stroke + thrombophilia, risk of stroke?

Answer 21

20%