TOG Flashcards
What is the incidence of stroke in pregnancy?
📌30 / 100,000
(3 times more at the same age )
📌 90 % occur peripartum or in 6 weeks after delivery
What is the greatest cause of maternal death from stroke?
What is the mortality rate?
📌Mortality rate : 8- 20 %
📌Greatest cause of death from stroke Is ICH
What is the aetiology of stroke in pregnancy?
Ischemic / haemorrhage / venous thrombosis: have a similar contribution
( general population ischemic is the major cause)
🔴 fatality rate & disability are higher with hemorrhagic stroke
What is the recurrence rate of stroke in subsequent pregnancies?
0 - 1.8 %
🚩 with concurrent thrombophilia 👉 20%
What are the independent risk factors for stroke in pregnancy?
1- age > 35 y
2- migraine
3- gestational diabetes ( MAXIMUM RISK)
4- preeclampsia / eclampsia
5- pre existing hypertension
What are pregnancy specific conditions that contribute to stroke ?
🚩Hypercoagulability :
1- OHSS
2- hyperemesis gravidarum
3- preeclampsia ( ischemic/ hemorrhagic)
🚩Prothrombin conditions: ( ischemic)
1- APL 2- SSD
3- thrombocytopenia purpura
4- mechanical heart valve
5- hemolytic uremic syn
6- cardiomyopathy
🚩 amniotic fluid embolism ( rare)
What are the symptoms of the stroke that the patient may presented with?
ONLY 40 % presenting with TYPICAL symptoms:
1- unilateral numbness
2- weakness of face led arm
3- dysphasia
4- hemianopia
5- ataxia / dysarthria
How to recognize symptoms of stroke based on FAST campaign?
1- face dropping
2- arm weakness
3- speech difficulties
4- time to call
Any seizure after 20 w of pregnancy & up to 2 w postnatally is caused by….
Eclampsia
What are the features suggestive of ICH ( sub arachnoid hemorrhage)?
Hypertension + bradycardia 👉 suggest ICH rather than a stroke
🚩[ Hypertension is a consequence rather than a causative factor]
What are the scales used in assessing a patient with a stroke ?
1- NIHSS
2- MODIFIED RANKIN 0-6 ( based on disability)
What is the most accurate imaging assessment in a patient with suspected stroke?
Combination of CT perfusion + CT angiogram
🚩Ct perfusion⬆️specificity ischemia
🚩Ct angiogram:⬆️specificity arterial stenosis
What is safer imaging method in a pregnant woman suspected of stroke Ct angiogram or Ct perfusion
Ct angiogram
Cause less radiation than Ct perfusion
What is the first investigation that should be done on arrival to hospital in a pregnant woman with stroke?
Non contrast CT
Radiation exposure 0,5 - 1 mGy
❤ fetal radiation dose of less than 100 mGy is not associated with adverse effects on human being
What is the preferred first line imaging modality in pregnancy with stroke?
MRI
no exposure to radiation
No harmful effects shown at 1,5 T or less
* theoretical fetal ear damage due to acoustic noise level
After imaging the brain what further investigations should be done in a pregnant woman with stroke?
What is the first line?
1- 12 h ECG
2- 24 h cardiac holter
*FIRST LINE: TRANSTHORACIC ECHO
4- blood glucose:( exclude hypoglycemia)
5- CBC - troponin - coagulation profile- LFTs - urea - electrolytes- lipid profile
6- carotid & lower limb Doppler
🚩 thrombophilia screening Not recommended in pregnancy
What is the management of the stroke in pregnancy?
IV thrombolysis in stroke care unit
🚩rt-PA ( recombinant tissue plasminogen activator) WITHIN 4,5h
Of stroke onset
🚩risk of hemorrhage: 2-6 %
🚩does not cross the placenta
🚩pregnancy is a relative contraindication : ICH / systemic bleeding/ anaphylaxis
🚩no studies : on its safety in breastfeeding
What is the absolute contraindication of rt-PA ?
ICH
What is post stroke thrombolysis care?
- bedrest 24 h
- no arterial or central line or nasogastric tube 24h
- NO ASPIRIN/ CLOPIDOGREL / ANTICOAGULANTS 24h
🚩 repeat Ct 24-36h
What is the management of intracerebral hemorrhage?
1- hemostasis
2- correlation of coagulopathy & thrombocytopenia
3- aggressive BP control < 140
4- SHOULD have intermittent pneumatic compression from the day of admission
What is the main cause of posterior reversible encephalopathy syndrome ( PRES)?
PRES: mainly associated with Preeclampsia & eclampsia
Coexistence with renal disease
How are patients with PRES presented?
Rapid onset of: headache + seizures + altered consciousness + visual disturbance ( acute hypertension)
On MRI : what is the commonest areas in involved in patient with PRES?
Parieto - occipital
What is the management for secondary prevention of the stroke?
🚩recurrent strokes account for 25- 30 of all strokes
1- control BP
2- ASPIRIN: within 24-48h ( for patients receiving thrombolysis aspirin should be delayed 24 h)
3- CLOPIDOGREL + ASPIRIN: within 24h continued 21 days (in ischemic stroke )
4- atrial fibrillation: anticoagulant within 4-14 days of the onset of neurological symptoms (LMWH)
