sSAH Rates Up in Pregnant Women, Stroke Rehabilitation Services Floundering

JANUARY 26, 2018
Matt Hoffman
Kaustubh Limaye, MDKaustubh Limaye, MD
Credit: American Heart Association
Two new studies have revealed new insight into the consequences of stroke, showing that not only have rates of spontaneous subarachnoid hemorrhage (sSAH)—a rare kind of stroke—increased among pregnant women but also that many patients who have had a stroke are not recipients of proper rehabilitation care.

The study, presented at the American Stroke Association’s International Stroke Conference 2018 in Los Angeles, California, was led by Kaustubh Limaye, MD, a clinical assistant professor in the Division of Cerebrovascular Diseases at the University of Iowa, in Iowa City.

Information on sSAH in pregnant is found sporadically, making data collection difficult, even with a dataset including 73,691 admissions for the condition.

However, a review of those records included information for 3989 pregnant women with sSAH, aged 15–49 years, spanning from 2002 to 2014. The data detailed that in that 12-year timeframe, admittance to the hospital for sSAH increased 2% (4.16% to 6.33%; P <.001), with 20-19-year olds emerging as the population accounting for the highest percentage of sSAH—20%.

“We need to increase awareness in the medical community about the increasing trend of spontaneous subarachnoid hemorrhage in pregnancy because management of these patients continues to be a clinical conundrum,” Limaye said in a statement.

Despite the alarming increase in sSAH among pregnant women, those with sSAH who were pregnant fared better than those who weren’t pregnant. The mortality rate was 8% among pregnant women compared to 17% for non-pregnant women (P <.001).

While mortality may be lower for pregnant women, those surviving stroke are not managing well post-discharge, mainly due to lack of rehabilitation.

The COMPASS study, also presented at the conference, found that regardless of where patients are referred to—home-based or outpatient—for rehabilitation, those who have had a stroke often do not receive the proper recovery services.

“We don’t know the exact reasons why these patients did not receive rehabilitation, but we assume it has to do with the co-pay that is associated with outpatient therapy services, even for those who have insurance.  Home health, on the other hand, does not include co-pays, but there were still over half of those referred who did not receive it,” Cheryl Bushnell, MD, MHS, a study author, professor of neurology, and director of the Wake Forest Baptist Stroke Center at Wake Forest Baptist Health in Winston Salem, North Carolina, said in a statement. “Clearly we need more research to understand these factors.”

COMPASS explored the results of 369 patients that had a stroke and their experiences 30 days post-hospital discharge, including only patients who had been referred to rehabilitation at either the hospital or at a follow-up clinic.

Of the total population that had been referred to at-home rehabilitation services (n = 115), only 43.5% actually received the service. Those referred to outpatient clinics (n = 85) fared even worse, with only 34.1% of patients receiving the recuperation services.

When the data was analyzed for subgroups, it showed that after adjusting for age, severity, and disability, non-white patients were 78% less likely to receive rehabilitation services than white patients.

These studies were released concurrently with the American Heart Association/American Stroke Association’s release of updated stroke guidelines, which “detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks.”

The first study, “Secular increases in spontaneous subarachnoid hemorrhage during pregnancy,” was presented at the American Stroke Association’s International Stroke Conference 2018 in Los Angeles, California.

The second study, “The comprehensive post-acute stroke services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial,” was also presented at the conference, and published in BMC Neurology.

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