ESOC 2019 Session: WOMEN AND STROKE The session started with Anita Arsovska from Macedonia who talked about specific risk factor for women.

Key take away points from her presentation are listed below.

Conventional risk factors in women

1) Atrial fibrillation is higher in women, women less likely to be prescribed anticoagulants, receive lower dosage of NOACs

2) Migraine is higher in women

3) Cognitive impairment is higher in women, women less likely to be treated with anti-dementia drugs

Specific risk factors

1) Premenopausal women have increased (twice) risk of ischemic stroke (but based on small numbers)

2) Age at menarche (less than 10 and higher than 17) increases the risk of ischemic stroke

3) Age less than 45 of natural menopause increases the risk of total CVD mortality

4) Surgical menopause, bilateral oophorectomy with or without hysterectomy increase CVD risk

5) Combined oral contraceptives (COC) are thrombogenic, associated with increased CVD risk

6) 9x higher risk in the peripartum period (Increased risk of ischemic stroke and intracerebral hemorrhage)

• Eclampsia and preeclampsia are the strongest risk factors for ischemic stroke and intracerebral hemorrhage (24% – 48%). The risk is potentiated by preexisting genitourinary tract infection, chronic hypertension, prothrombotic states, and coagulopathies

Ana Catarina Fonseca talked about primary prevention of stroke in women. She reminded the audience that – Reducing the burden of stroke in women through primary prevention should be a goal of public health – When considering primary prevention in women we should not only take into account the traditional vascular risk factors but also women specific risk factors – Women representation in primary prevention clinical trials for stroke should be fostered.

Zuzana Govinova shared with the attendees the final version of ESO guidelines about stroke prevention in women. Aspirin is recommended for primary prevention for women ≥65 years of age after consideration of the 10-year risk of CVD and whether this and age outweigh the risk of haemorrhage.

Giving to account consequences of severe stroke, IVT should be considered in pregnant women with disabling ischemic stroke who otherwise meet eligibility criteria for IVT and in stroke due to large vessel occlusion ET is recommended (comparison IVT and ET is difficult due to small numbers, there is trend to lower risk of maternal hemorrhage with ET alone). In the absence of specific data from RCTs showing sex differences in the response to treatment with IV thrombolysis and as the efficacy and safety of IV thrombolysis have been showed overall in RCTs and its effectiveness and safety confirmed from real-world data, we recommend that IV thrombolysis is given to eligible women, also aged >80 years old. We recommend endovascular treatment with (when indicated) or without IV thrombolysis to eligible women including women >80 years because the application of an upper age limit is not currently justified. Women may have lower mortality but higher rates of stroke and systemic embolism and GI bleeding. However, women should still be treated with NOACs where indicated based on current guidelines. Seana Gall talked about preeclampsia and stroke. Preeclampsia not only increases the risk of stroke during pregnancy but also into the longer term. Maternal and paternal factors increase the risk of preeclampsia. There is a need to develop and test effective interventions to reduce stroke risk in the longer term in women with preeclampsia.

Finally Kaustubh Limaye exposed the key concepts of the relation between SAH and pregnancy. •The incidence of sSAH in pregnancy has increased from 5.4 (2002) to 8.5 (2014) per 100,000 deliveries (P-trend < 0.001) in US from 2002 to 2014. •Etiologies of sSAH in pregnancy are diverse but are likely different than the causes of the illness in non-pregnant women of the same age •Outcomes were better for pregnant women as compared to non-pregnant women even in cases of presumed aSAH. •We did not find any correlations with median household income or insurance status and allotment of treatment resources.