Cerebrovascular accidents (CVAs) during pregnancy are uncommon but can have devastating consequences. The causes of CVA in both the pregnant and the non-pregnant state are diverse and require thorough investigation. Recent studies have indicated that embolic stroke in young adults may be caused by paradoxical emboli through a patent foramen ovale (PFO), suggesting that the presence of a PFO should be specifically sought in pregnant or postpartum women presenting with CVA. This review will outline the causes of CVAs in pregnancy and the role of paradoxical emboli, with a focus on PFO.
JamesAH, BushnellCD, JamisonMG, MyersER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol2005;106:509–16
2.
JaigobinC, SilverFL. Stroke and pregnancy. Stroke2000;31:2948–51
3.
LanskaDJ, KryscioRJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke2000;31:1274–82
4.
LanskaDJ, KryscioRJ. Stroke and intracranial venous thrombosis during pregnancy and puerperium. Neurology1998;51:1622–8
5.
SharsharT, LamyC, MasJL. Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Ile de France. Stroke in Pregnancy Study Group. Stroke1995;26:930–6
6.
KittnerSJ, SternBJ, FeeserBR, Pregnancy and the risk of stroke. N Engl J Med1996;335:768–74
7.
JengJS, TangSC, YipPK. Incidence and etiologies of stroke during pregnancy and puerperium as evidenced in Taiwanese women. Cerebrovasc Dis2004;18:290–5
8.
LiangCC, ChangSD, LaiSL, HsiehCC, ChuehHY, LeeTH. Stroke complicating pregnancy and the puerperium. Eur J Neurol2006;13:1256–60
9.
CarlinA, AlfirevicZ. Physiological changes of pregnancy and monitoring. Best Pract Res Clin Obstet Gynaecol2008;22:801–23
10.
LangenfeldMR, SimmonsLA, McCrohonJA, Nitric oxide does not mediate the vasodilation of early human pregnancy. Heart Lung Circ2003;12:142–8
11.
HellgrenM. Hemostasis during pregnancy and puerperium. Haemostasis1996;26(Suppl. 4)244–7
12.
DavisGL. Hemostatic changes associated with normal and abnormal pregnancies. Clin Lab Sci2000;13:223–8
13.
ChantH, McCollumC. Stroke in young adults: the role of paradoxical embolism. Thromb Haemost2001;85:22–9
14.
WieseKM, TalkadA, MathewsM, WangD. Intravenous recombinant tissue plasminogen activator in a pregnant woman with cardioembolic stroke. Stroke2006;37:2168–9
15.
HagenPT, ScholzDG, EdwardsWD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc1984;59:17–20
16.
LamyC, GiannesiniC, ZuberM, Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial septal aneurysm. Stroke2002;33:706–11
17.
CujecB, MainraR, JohnsonDH. Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks. Can J Cardiol1999;15:57–64
18.
HommaS, SaccoRL. Patent foramen ovale and stroke. Circulation2005;112:1063–72
19.
MorandiE, AnzolaGP, AngeliS, MelziG, OnoratoE. Transcatheter closure of patent foramen ovale: a new migraine treatment?J Interv Cardiol2003;16:39–42
20.
DowsonA, MullenMJ, PeatfieldR, Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation2008;117:1397–404
21.
GargP, ServossSJ, WuJC, Lack of association between migraine headache and patent foramen ovale: results of a case-control study. Circulation2010;121:1406–12
22.
ThanopoulosBV, DardasPD, KaranasiosE, MezilisN. Transcatheter closure versus medical therapy of patent foramen ovale and cryptogenic stroke. Catheter Cardiovasc Interv2006;68:741–6
23.
RomeroJR, FreyJL, SchwammLH, Cerebral ischemic events associated with ‘bubble study’ for identification of right to left shunts. Stroke2009;40:2343–8
24.
ChimowitzMI, NemecJJ, MarwickTH, LorigRJ, FurlanAJ, SalcedoEE. Transcranial Doppler ultrasound identifies patients with right-to-left cardiac or pulmonary shunts. Neurology1991;41:1902–4
25.
JamesAH, BrancazioLR, PriceT. Aspirin and reproductive outcomes. Obstet Gynecol Surv2008;63:49–57
26.
WilsonAM, BoyleAJ, FoxP. Management of ischaemic heart disease in women of child-bearing age. Intern Med J2004;34:694–7
27.
HommaS, SaccoRL, Di TullioMR, SciaccaRR, MohrJP. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation2002;105:2625–31
28.
MasJL, ArquizanC, LamyC, Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med2001;345:1740–6
29.
WindeckerS, WahlA, NedeltchevK, Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol2004;44:750–8
30.
MohrJP, ThompsonJL, LazarRM. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med2001;345:1444–51
31.
BridgesND, HellenbrandW, LatsonL, FilianoJ, NewburgerJW, LockeJE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation1992;86:1902–8
32.
TaaffeM, FischerE, BaranouskiA, Comparison of three patent foramen ovale closure devices in a randomized trial (Amplatzer versus CardioSEAL-STARflex versus Helex occluder). Am J Cardiol2008;101:1353–8
33.
SchraleRG, OrmerodJ, OrmerodOJ. Percutaneous device closure of the patent foramen ovale during pregnancy. Catheter Cardiovasc Interv2007;69:579–83
34.
VijM, MowbrayD. Pregnancy outcome in patients with patent foramen ovale and cerebral embolism. Eur J Obstet Gynecol Reprod Biol2008;140:147–8
35.
LamyC, HamonJB, CosteJ, MasJL. Ischemic stroke in young women: risk of recurrence during subsequent pregnancies. French Study Group on Stroke in Pregnancy. Neurology2000;55:269–74
