title: Strokes Associated With Pregnancy and Puerperium: A Nationwide Study by the Japan Stroke Society.
abstract: The incidence and cause of strokes associated with pregnancy and the puerperium are still not fully understood. The aim of this study was to characterize pregnancy-related strokes in Japan using a large-scale survey with current imaging techniques.
  
  
  
  A retrospective analysis was conducted based on clinical chart reviews in 736 stroke teaching hospitals certified by the Japan Stroke Society between 2012 and 2013, using a web-based questionnaire requesting the detailed clinical course without any personally identifying information. The collection rate of this questionnaire was 70.5%, with 151 pregnancy-associated strokes extracted.
  
  
  
  Hemorrhagic strokes were observed in 111 cases (73.5%), ischemic strokes in 37 (24.5%), and mixed type in 3 cases (2.0%). The estimated incidence of pregnancy-associated stroke was 10.2 per 100 000 deliveries. Major causes of hemorrhage were aneurysm (19.8%), arteriovenous malformation (17.1%), pregnancy-induced hypertension (11.7%), and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) (8.1%). Preexisting cerebrovascular diseases responsible for hemorrhage were detected in 59 cases (53.1%). Among the ischemic strokes, 28 (75.7%) were arterial and 9 (24.3%) were venous infarctions. The most frequent cause of arterial infarctions was reversible cerebral vasoconstriction syndrome. Hemorrhagic stroke showed much poorer prognosis than ischemic stroke.
  
  
  
  The incidence of pregnancy-associated stroke in Japan did not seem higher than that in other Asian and Western countries. The proportion of hemorrhagic stroke among Japanese women was much higher than that in white women. Preexisting cerebrovascular diseases and reversible cerebral vasoconstriction syndrome play a key role in hemorrhagic and ischemic stroke, respectively.
authors.affiliation: From the Stroke and Pregnancy Survey Committee of the Japan Stroke Society, Tokyo, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (K.Y., Y.T., S.M.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan (J.C.T.); Department of Neurology, Keio University School of Medicine, Tokyo, Japan (N.S.); and Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan (A.O.). kazuy@kuhp.kyoto-u.ac.jp.
authors.forename: Kazumichi
authors.initials: K
authors.lastname: Yoshida
authors.affiliation: From the Stroke and Pregnancy Survey Committee of the Japan Stroke Society, Tokyo, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (K.Y., Y.T., S.M.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan (J.C.T.); Department of Neurology, Keio University School of Medicine, Tokyo, Japan (N.S.); and Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan (A.O.).
authors.forename: Jun C
authors.initials: JC
authors.lastname: Takahashi
authors.affiliation: From the Stroke and Pregnancy Survey Committee of the Japan Stroke Society, Tokyo, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (K.Y., Y.T., S.M.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan (J.C.T.); Department of Neurology, Keio University School of Medicine, Tokyo, Japan (N.S.); and Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan (A.O.).
authors.forename: Yohei
authors.initials: Y
authors.lastname: Takenobu
authors.affiliation: From the Stroke and Pregnancy Survey Committee of the Japan Stroke Society, Tokyo, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (K.Y., Y.T., S.M.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan (J.C.T.); Department of Neurology, Keio University School of Medicine, Tokyo, Japan (N.S.); and Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan (A.O.).
authors.forename: Norihiro
authors.initials: N
authors.lastname: Suzuki
authors.affiliation: From the Stroke and Pregnancy Survey Committee of the Japan Stroke Society, Tokyo, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (K.Y., Y.T., S.M.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan (J.C.T.); Department of Neurology, Keio University School of Medicine, Tokyo, Japan (N.S.); and Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan (A.O.).
authors.forename: Akira
authors.initials: A
authors.lastname: Ogawa
authors.affiliation: From the Stroke and Pregnancy Survey Committee of the Japan Stroke Society, Tokyo, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (K.Y., Y.T., S.M.); Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan (J.C.T.); Department of Neurology, Keio University School of Medicine, Tokyo, Japan (N.S.); and Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan (A.O.).
authors.forename: Susumu
authors.initials: S
authors.lastname: Miyamoto
mesh_terms: D000328:Adult; D005260:Female; D006306:Health Surveys / Q000379:methods; D006801:Humans; D007564:Japan / Q000453:epidemiology; D049590:Postpartum Period; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000175:diagnosis / Q000453:epidemiology*; D011644:Puerperal Disorders / Q000175:diagnosis / Q000453:epidemiology*; D012189:Retrospective Studies; D012955:Societies, Medical; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology*; D055815:Young Adult
keywords: cerebrovascular diseases; gestational age; morbidity; pregnancy; prognosis