Stroke : Highlights of Selected Articles
Section Editor: José Rafael Romero, MD
Volume 50 ◼ Number 1 ◼ January 2019
Stroke and Cerebrovascular Disease in Pregnancy: Incidence,
Temporal Trends, and Risk Factors
Stroke in pregnancy is uncommon but carries significant mortality
and morbidity. Liu et al, report current data in a developed country
pertaining the incidence, temporal trends, risk factors, and case fa-
tality associated with cerebrovascular disease and stroke in preg-
nancy. Information extracted demonstrated to be complete and
accurate, using various sources. The overall incidence of stroke was
13.4 cases per 100.000 deliveries over 14 years (2003–2016). A total
of 51.7% of cases occurred in the puerperium, and case fatality rate
was 7.4%. Approximately 60% of stroke cases were intracerebral
hemorrhage and nearly 30% were ischemic strokes. There was a
significant increase in incidence rates from 10.8 cases per 100.000
deliveries in 2003 to 2004 to 16.6 cases per 100.000 deliveries in
2015 to 16. Stroke during pregnancy resulted in significantly longer
hospital stay. In multivariable-adjusted analyses significant risk fac-
tors for stroke included maternal age older than 35years, gestational
hypertension, chronic hypertension, preeclampsia, eclampsia, con-
nective tissue disorders, sepsis, postpartum hemorrhage with blood
transfusion, and congenital heart disease. Additional predictors for
ischemic stroke included human immunodeficiency virus infection
and migraine. The authors estimated that ≈20.3% of stroke cases
could be prevented if hypertensive disorders were eliminated from
the pregnant women. This study reported lower incidence rates com-
pared with those observed in the United States. The results highlight
the morbidity and mortality carried by a stroke during pregnancy, and
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the potential for prevention of a large proportion of strokes. See p 13.
Outcomes After Use of Standard- and Low-Dose Non–
Vitamin K Oral Anticoagulants in Asian Patients With Atrial
Fibrillation
In this study, Cho et al compared the relative effectiveness and safety
of standard- and low-dose nonvitamin K oral anticoagulants (NOACs)
versus warfarin in a nationwide, population-based cohort of antico-
agulant-naïve Korean patients with nonvalvular atrial fibrillation.
The study included 56 504 patients, 18.4% receiving warfarin, 22.3%
dabigatran, 37.2% rivaroxaban, and 22.1% apixaban. Compared with
standard dose, low-dose NOACs use was associated with older age,
higher risk profiles for baseline comorbidities, and higher CHA2DS2-
VASc scores. Compared with warfarin, NOACs use was associated
with older age and lower proportion of chronic kidney disease. For
adjusted analyses, groups were balanced for confounders using pro-
pensity score weighting methods. Adjusted hazard ratios of ischemic
stroke, systemic embolism, or mortality were significantly lower for
all NOACs compared with warfarin. Dabigatran and apixaban use
was associated with a lower risk of major or any bleeding than war-
farin; rivaroxaban showed a similar bleeding risk to warfarin. There
was a trend towards reduced effectiveness with lower NOAC doses.
In the subgroup of patients younger than 75 years without chronic
kidney disease, lower NOAC dosing was associated with lower clin-
ical benefit, particularly for apixaban. This study suggests greater ef-
ficacy and safety for NOACs than warfarin and calls for caution on
the use of lower-dose NOACs in subgroups of patients were it may
not be justified. See p 110.
Impact of Microbleeds on Outcome Following Recana­
lization in Patients With Acute Ischemic Stroke
Choi et al studied the clinical effect of presence, burden, and location
of cerebral microbleeds (CMBs) on clinical outcomes in patients with
acute ischemic stroke treated with intravenous thrombolysis and me-
chanical thrombectomy. They performed focused analyses on the sub-
group with successful recanalization. The outcomes studied included
modified Rankin Scale score at 3 months, early neurological deteri-
oration, hemorrhagic transformation, symptomatic intracranial hem-
orrhage, presence of new CMBs, and mortality at 3 months. A total
of 1532 patients treated with intravenous thrombolysis or mechanical
thrombectomy were included. The prevalence of CMBs was 10.8%,
with 62.4% located in strictly lobar regions. Functional independence
(modified Rankin Scale score of 0–2) was seen in 43.5% patients.
Complete recanalization was seen in 55.9% of patients with large
vessel occlusions. In multivariate analyses, there was no significant
association between CMB presence and 3-month favorable outcomes
across all patients. However, only in patient with recanalization, CMB
presence was associated with lower odds of favorable outcomes (odds
ratio [OR]=0.57; 95% CI, [0.33−0.97]), particularly lobar CMB. In a
sensitivity analysis, high CMB burden of 5 or more was negatively
associated with functional outcome 3 months. Although recanaliza-
tion was associated with 3-month favorable outcomes in all patients
(OR=3.32; 95% CI, [2.53−4.36]), in patients with CMBs, the benefit
of recanalization was not observed (OR=1.27; 95% CI, [0.60−2.65]).
In multivariate analysis, CMBs presence was significantly associated
with symptomatic intracerebral hemorrhage in all patients (OR=2.55;
95% CI, [1.39−4.67]) and in patients with recanalization (OR=3.21;
95% CI, [1.37−7.49]). In subgroup analysis, CMBs were associ-
ated with a higher risk of symptomatic intracerebral hemorrhage
in patients with baseline National Institutes of Health Stroke Scale
score >12 (P=0.011). The results suggest that CMB affect negatively
clinical outcomes in patients with acute ischemic stroke treated with
revascularization therapies and that high CMB burden (≥5) is more
relevant than only presence of CMBs. See p 127.