Panel: George Bovis, MD Philip Gorelick, MD, MPH Thomas Grobelny, MD Barbara Parilla, MD Susan Rubin, MD

Moderator: Wayne Rubinstein, MD

Case Discussion Stroke Risk in Women: Hot Topics

Objectives • Discuss the clinical practice of stroke in women

– evaluation of acute neurologic presentations

– consideration of atypical stroke mechanisms

– immediate and ongoing management

– assessment of recurrence risk

– recommendations for secondary stroke prevention

Case #1 • 35 y/o RH woman, 1 week after NSVD and PPTL,

presenting with three days of severe headache

• Transiently responsive to sumatriptan

• Distinct from prior migraine: bilateral, throbbing, neck pain,

photophobia, no focal neurological symptoms

• Time course of onset not specified

• 140/90, 72, 37o, normal neurologic exam

• Non contrast head CT unremarkable

Case #1 • No positional component apparent

• CBC, CMP, INR, normal

• CSF: no cells, protein 7.4, glucose 46

– ? ̶

• Tentative diagnosis of status migranosis

• DHE protocol initiated

• Methylprednisolone IV

• HD-2: unresponsive appearing post ictal, 180/90

Case #1 • EEG unremarkable

• Phenytoin

• Labetalol for BP control

• Clindamycin for tongue swelling

• Heparin drip

• Gradual neurological improvement

• Transient visual symptoms

• TCD negative for vasospasm

• MRI and MRA improved

• Warfarin

• Levetiracetam

• No subsequent events

• Complete neurological

recovery

Case #1

Case #2 • 22 RH woman presents with

– Novocain-like numbness spreading from left hand to shoulder

– followed by inability to lift her left arm for 10-15 minutes

– associated with loss of vision in the left periphery

– resolved within 30 minutes after initial symptoms

– followed by a mild nondescript headache

• Prior history of headache, never diagnosed with migraine

• The patient’s mother had a stroke due to PFO while young

Case #2 • 100/55, 80, 36o, subjective left sensory,

otherwise normal neurologic examination

• Urine HCG positive (serum 408)

– G4 P1021, LMP 5 weeks ago

– G1 spontaneous abortion

– G2 term NSVD

– G3 ectopic s/p LSC R salpingectomy

• CT head normal

• Transthoracic echocardiogram normal

Case #2

Case #2 • Transesophageal echocardiogram:

– small patent foramen ovale

– left-to-right shunt with coughing

– no atrial septal aneurysm

• Venous duplex and V/Q normal

• Hematology recommended enoxaparin anticoagulation

• ANA17, LA, AT-III, Pro S, Cardio Ab, Phos-ser Ab, V genotype

• Pro C 77, MTHFR heterozygote C677T

• Spontaneous abortion at 8 weeks gestation

Case #3 • 20 y/o RH woman with acute onset aphasia and right

hemiplegia

• Came home from grocery shopping, had intercourse with

boyfriend, got dressed, walked out of bathroom holding

Aleve bottle at 14:10

• Suddenly looked dazed, not talking, sat down on floor,

slumped over to the right

• ED arrival at 14:54

Case #3 • Flight from France 2 days prior to presentation

• Had 4 wisdom teeth extracted in France 12 days prior

• PMH: infrequent migraines; no history of VTE

• Meds: OCP (Loestrin)

• SH: non-smoker, no drug use, rare EtOH

• FH: no history of VTE, stroke, MI, rheum disorder

• ROS: +headache; otherwise negative

Case #3 • VS: T 97.7, HR 101, BP 123/79

• general exam normal, no carotid bruits, no murmur

• expressive aphasia providing best 1 word answers with

dysarthria; follows commands throughout L side

• L gaze preference, R field cut and R UMN facial droop

• dense R hemiparesis – arm 0/5, leg weak w/d to noxious

• NIHSS = 15

Case #3 • Head CT normal

• TPA initiated at 15:35 (85 min from LKN, 41 min DTN)

cerebral blood flow

cerebral blood volume

mean transit time

Case #3 • Aphasia improved

• Hemiparesis improved

• L mandible abscess

Stroke mechanism?

• Routine labs normal

• TTE and TEE normal

• Pro-coagulants normal

• Rheum panel negative

Case #3 • Warfarin x 3 months

• Language normal

• Right facial weakness

• 4+/5 spastic R-1/2paresis

Case #4 • 27 y/o RH woman presenting with persistent headache and

multiple daily episodes of:

– R arm and leg heaviness

– R hand numbness and paresthesia

– Bilateral tunnel vision R>L

– symptoms are independent, last 3-5 minutes, sudden onset/offset

• 5 months ago intermittent L arm and leg numbness

• 2 months ago, 3-5 minutes of expressive aphasia

Case #4 • No medications or PMH

• FH stroke in the elderly, no coagulopathy or pregnancy losses

• ½ PPD x8 years, quit 2 months ago

• Normal vitals, body habitus, and general examination

• MS and HIF intact

• L>R papilledema with L retinal hemorrhages

• Normal motor, sensory and cerebellar exams

• Normal tendon reflexes, flexor plantars, normal gait

FLAIR 10/8/2013

FLAIR 8/21/2013

Case #4 • Factor V heterozygous, MTHFR heterozygous

• Pro S, Pro C, AT III, prothrombin genotype, b2, ACL, LA

• Heparin --> enoxaparin --> warfarin x 6-12 months

• 2 months later:

– Daily headache, intermittent visual loss, leg weakness, ataxia

– R>L florid disc edema and right temporal field loss

• INR 2.5 warfarin --> enoxaparin

Case #4 • 4 months later:

– R face, arm, leg numbness and L arm weakness

– Anti-Xa assay for enoxaparin therapeutic at 1.02

Case #4 • 2 months later:

– recurrent R numbness and L hemiparesis

– headache, papilledema, CSF OP = 270 mm

arterial capillary venous

Case #4 • Transitioned to apixaban for long term

• LMWH if pregnancy desired

• Headache resolved

• Papiledema improved

• Transient episode of RUE numbness

Closing Remarks • Maximum 3.75 hours AMA PRA Category 1 Credits

– Participation in the entire activity

– Evaluation form: advocatehealth.com/cme

– Print or download CME certificate

• Maximum 3.75 ANCCA Contact Hours

– Attendance of the entire event

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Thank you to our organizers, speakers and participants!