predictors of stroke and stroke mimics during pregnancy · past medical history post partum...
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Predictors of Stroke and
Stroke Mimics During
PregnancyChelsea Meyer, DO MA
Jennifer Majersik, MD
Jennifer Murrilo
Adam De Havenon, MD
University of Utah
International Stroke Conference 2018
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No Disclosures
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Stroke in Pregnancy• Ischemic and hemorrhagic strokes are more common in the
peripartum period
• According to a study in 2011 by Kuklina EV, Tong X, al. • 71 per 100,000 pregnancy-related stroke hospitalizations in US per year
• 3 times the prevalence of non-pregnant women
• Increased by 43% when comparing 1994-95 to 2006-07
• Includes cerebral venous sinus thrombosis, PRES, RCVS
• Eclampsia is a clear risk factor
• Increased prevalence of hypertension and heart disease
1. Kuklina EV, Tong X, et al. “Trends in pregnancy hospitalizations that included a stroke in the United States from 1994 to 2007: Reasons for concern?” Stroke 2011;42(9):2564-2570
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Complications of Treating Acute Strokes in
Pregnancy
– Radiation
• Head/neck radiation has less risk than thoracic
and abdominal
– Risk of systemic thrombolysis in pregnancy
• 8% hemorrhagic complications in pregnant
patients (2)
• Not a contraindication
• Does not cross placenta
2. Demchuk Adam. “Yes, Intravenous Thrombolysis Should be Administered in Pregnancy When other Clinical and Imaging Favorable.” Stroke. 2013;44:864-865
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HYPOTHESIS
Using readily available clinical data, we could accurately
predict vascular versus non-vascular causes of
neurologic symptoms in pregnancy
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Methods• ICD-9 codes for pregnancy and stroke within the same
year
– 30,000 patients identified as pregnant in 2009-2014 at the
University of Utah
– 112 of those had ICD-9 code for stroke or other cerebrovascular
disorders
• Excluded if:
– Stroke or stroke mimic occurred postpartum
– Stroke prior to pregnancy but established care for pregnancy
– Not seen by a neurologist or neurosurgeon
• 39 total patients meeting criteria
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Comprehensive Review of Risk Factors
Demographics Obstetrics History
Social History Antepartum Labs
Family History Delivery Information
Past Medical History Post partum Complications
Medications Stroke Evaluation
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Methods
• Logistic regression models to compare
predictive ability of different covariates
– Evaluated area under the curve to establish
most predictive model
• Two outcomes in regression models
– Ischemic strokes compared to mimics
– Mimics compared to all vascular disease
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Results - Etiology
Etiology # of Patients % of Patients
Ischemic Stroke 12 30.8%
Venous Sinus Thrombosis 8 20.5%
Intracerebral Hemorrhage 3 7.6%
Transient Ischemic Attack 2 5.1%
Complicated Migraine 7 17.9%
Non-Epileptic Convulsion 3 7.6%
Seizure 2 5.1%
Conversion Disorder 2 5.1%
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Predicting Mimics Compared to
Vascular Causes
• Model 4 • History of miscarriage
• Age<30
• Migraines
• AUC of 0.85
• Positive Predictive Value
75%
• Negative Predictive Value
69%
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Predicting Ischemic Strokes
Compared to Other Etiologies
• Model 3 • Age > 30
• Family history of 1st degree
relative with stroke
• AUC of 0.76
• Positive Predictive Value
100%
• Negative Predictive Value
74%
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Conclusions
• Promising models using clinical risk
factors to predict:
– Ischemic strokes from other causes of
acute focal neurologic symptoms in pregnant
patients
– Non-vascular disease (eg. migraine) from
vascular causes of acute neurologic
symptoms in pregnant patients
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Discussion
• Strengths
– Highly specific models
– Risk factors can be obtained quickly without
additional testing
• Limitations
– Small, single-center retrospective review
– Sensitivity could be improved
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Future Directions
• Could a scoring system be created to
accurately predict vascular versus non-
vascular causes of neurologic changes in
pregnant patients?
– Helpful in rapid decision making
– Reduce risk of potentially harmful testing and
treatments
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Acknowledgements• Adam De Havenon, MD
• Jennifer Majersik MD
• Jennifer Murrilo
• Stroke Division at University of Utah
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QUESTIONS?
Thank you!