Background Stroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely. Aims A systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted. Summary of review Eleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8-47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7-36.9) and from hemorrhage 12.2 (95% confidence interval 6.4-23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7-22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3-18.9), and hemorrhage (12.2, 95% confidence interval 6.4-23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9-28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3-26.1). Conclusions Stroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.

Stroke can cause neurological impairment ranging from mild to severe, but the impact of stroke extends beyond the initial brain injury to include a complex interplay of devastating comorbidities including: post-stroke depression, obstructive sleep apnea, and cognitive impairment ("DOC"). We reviewed the frequency, impact, and treatment options for each DOC condition. We then used the Ottawa Model of Research Use to examine gaps in care, understand the barriers to knowledge translation, identification, and addressing these important post-stroke comorbidities. Each of the DOC conditions is common and result in poorer recovery, greater functional impairment, increased stroke recurrence and mortality, even after accounting for traditional vascular risk factors. Despite the strong relationships between DOC comorbidities and these negative outcomes as well as recommendations for screening based on best practice recommendations from several countries, they are frequently not assessed. Barriers related to the nature of the screening tools (e.g., time consuming in high-volume clinics), practice environment (e.g., lack of human resources or space), as well as potential adopters (e.g., equipoise surrounding the benefits of treatment for these conditions) pose challenges to routine screening implementation. Simple, feasible approaches to routine screening coupled with appropriate, evidence-based treatment protocols are required to better identify and manage depression, obstructive sleep apnea, and cognitive impairment symptoms in stroke prevention clinic patients to reduce the impact of these important post-stroke comorbidities. These tools may in turn facilitate large-scale randomized controlled treatment trials of interventions for DOC conditions that may help to improve cardiovascular outcomes after stroke or TIA.

Cognitive screening in patients with stroke is endorsed by Best Practice Recommendations, 7 and rapid cognitive assessments are widely used in clinic settings to understand patient function and tailor appropriate therapy. The Montreal CognitiveBackground and Purpose-The Montreal Cognitive Assessment (MoCA) is used commonly to identify cognitive impairment (CI), but there are multiple published cut points for normal and abnormal. We seek to validate a pragmatic approach to screening for moderate-severe CI, by classifying patients into high-, intermediate-, and low-risk categories. Methods-A total of 390 participants attending an academic Stroke Prevention Clinic completed the MoCA and more detailed neuropsychological testing. Between April 23, 2012 and April 30, 2014, all consecutive new referrals to the regional Stroke Prevention Clinic who were English-speaking, not severely aphasic, and could see and write well enough to complete neuropsychological testing were assessed for inclusion, and consenting patients were enrolled. CI was defined as ≥2 SDs below normal for age and education on at least 2 cognitive subtests. A single cut point for CI was compared with 2 cut points (high sensitivity and high specificity) generated using receiver operator characteristic and area under the curve analyses. The intermediate-risk group contained those scoring between the 2 cut points. Results-Thirty-four percent of participants had a symptomatic or silent stroke, 34% were seen for possible or probable transient ischemic attack, and 32% were diagnosed with other vascular or nonvascular conditions. Using a single cut point, sensitivity and specificity were optimal with MoCA ≤22, (sensitivity=60.4%, specificity=89.9%, area under the curve=0.801, positive predictive value=48.5%, negative predictive value=93.5%, positive likelihood ratio=6, and negative likelihood ratio=0.4). Using 2 cut points, sensitivity was optimal with MoCA ≥28 (sensitivity=96.2%, negative predictive value =97.6%, and negative likelihood ratio=1.27), and specificity was optimal with MoCA ≤22 (specificity=89.9%, positive predictive value=48.5%, and positive likelihood ratio=6). 9 There is considerable variability in the diagnostic characteristics of the MoCA within the population with stroke (Table I in the online-only Data Supplement); most commonly, a cut point of ≥26 is considered normal, whereas ≤25 is considered impaired. Conclusions-Stratifying8 This dichotomization stems from the statistical approach to receiver-operating curves, but contradicts clinical thought processes in which screening questions are used throughout a clinical encounter to decide serious concern, no concern, or possible concern and guide further questioning or appropriate actions. The MoCA has been shown to be more sensitive to vascular CI than other quick screens (eg, the Folstein Mini-Mental State Examination), but less specific. [10][11][12] However, this reflects the use of a single cut point. In both clinical practice and research, the MoCA is often used as a surrogate for CI...