Stroke in Pregnancy

1. See Also
   1. Cerebrovascular Accident Risk in Women
   2. Cerebrovascular Accident
   3. CVA Management
   4. Transient Ischemic Attack
   5. CVA Thrombolysis
   6. CVA Blood Pressure Control
   7. Prevention of Ischemic Stroke
   8. Anticoagulation in Ischemic Stroke
2. Epidemiology
   1. Incidence: 10-30 per 100,000 pregnancies in U.S.
3. Risk Factors
   1. See Cerebrovascular Accident Risk in Women
   2. Preeclampsia or Eclampsia
   3. Pregnancy hematologic disorders (e.g. HELPP Syndrome)
   4. Cesarean Pregnancy
   5. Congenital Heart Defects
   6. Gestational Diabetes
   7. Migraine Headaches especially with aura (see above)
      1. Migraine Headache may cause stroke or stroke mimic
4. Differential Diagnosis
   1. See Cerebrovascular Accident (includes stroke mimics)
   2. Reversible Cerebral Vasoconstriction Syndrome
5. Imaging
   1. CT Head and CT Angiogram Head and Neck (standard CVA Evaluation)
      1. Radiation exposure to fetus is low (0.01 rads)
      2. Iodinated contrast appears safe (with low risk of transient Thyroid dysfunction)
         1. Bourjelly (2010) Radiology 256(3): 744-50 [PubMed]
   2. MRI Brain
      1. Evaluate for CVA not identified on CT (or perform MRI instead of CT if delayed presentation >12-24 hours)
      2. Do not use gadolinium contrast in pregnancy
      3. MRA Brain may be performed instead of CTA if no delays
6. Management
   1. CVA Thrombolysis (tPA)
      1. Similar indications and Consultation with Stroke Neurology for presentations <3 to 4.5 hours and significant deficit
      2. tPA is a large molecule that does not cross placenta
      3. Thrombolytics risk signficant uterine bleeding
   2. Intervention Radiology and Neurology
      1. Similar indications for large vessel Occlusion (esp. <12 hours)
      2. Risk of bleeding with Glycoprotein IIB/IIIA Inhibitor often used in perioperative period and for vessel perforation
      3. Stent placement typically requires longer term use of Platelet ADP Receptor Antagonist (e.g. Plavix)
         1. Risk of Postpartum Hemorrhage
   3. Antiplatelet Therapy in CVA and TIA
      1. Aspirin 81 mg orally daily may be used (avoid full dose Aspirin in pregnancy)
7. References
   1. Pensa and Roth in Herbert (2020) EM:Rap 20(10): 6-7
   2. Grear (2013) Clin Obstet Gynecol 56(2): 350-9 +PMID:23632643 [PubMed]