Oral Contraceptives as Predictor of Ischemic Stroke in a Young Primigravida: a Case Report From Khz Musthafa General Hospital, Tasikmalaya
DOI:
https://doi.org/10.29313/bcsms.v5i3.21656Keywords:
Ischemic stroke, Oral contraceptives, Pregnancy, Young womenAbstract
Abstract. Oral contraceptives (OC) are a recognized risk factor for stroke in young women. Combined oral contraceptives (COCs) containing estrogen and progesterone increase the risk of thrombus formation up to threefold compared to non-users, especially during the first year of use. Pregnancy also constitutes a risk factor due to physiological changes in hemodynamics, blood viscosity, connective tissue, and the immune system. The coexistence of both factors may further elevate the risk of cerebrovascular events. OC use may impair arterial elasticity and endothelial function, thereby predisposing to thrombosis. Pregnancy amplifies this risk through a procoagulant–anticoagulant imbalance, hemodynamic overload, and immune-mediated vascular changes that facilitate thrombus formation. The synergistic effect of these mechanisms likely contributed to ischemic stroke in this patient. Further research is needed, as this represents only a single case report. Stroke in young pregnant women may occur as a consequence of oral contraceptive use as a primary risk factor, although other vascular risk factors such as dyslipidemia and obesity cannot be excluded as potential contributors.
References
1. Correia P, Machado S, Meyer I, Amiguet M, Eskandari A, Michel P. Ischemic stroke on hormonal contraceptives: Characteristics, mechanisms and outcome. Eur Stroke J [Internet]. 2021 Jun 1 [cited 2025 Aug 13];6(2):205. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8370064/
2. Bukhari S, Yaghi S, Bashir Z. Stroke in Young Adults. J Clin Med [Internet]. 2023 Aug 1 [cited 2025 Aug 14];12(15):4999. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10420127/
3. Chang BP, Wira C, Miller J, Akhter M, Barth BE, Willey J, et al. Neurology Concepts: Young Women and Ischemic Stroke—Evaluation and Management in the Emergency Department. Academic Emergency Medicine [Internet]. 2018 Jan 1 [cited 2025 Aug 2];25(1):54–64. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13243
4. Eng PC, Tan LLY, Kimball TN, Prapiadou S, Tan BYQ. Ischemic Stroke in Women: Understanding Sex-Specific Risk Factors, Treatment Considerations, and Outcomes. Journal of Cardiovascular Development and Disease 2024, Vol 11, Page 382 [Internet]. 2024 Nov 29 [cited 2025 Aug 6];11(12):382. Available from: https://www.mdpi.com/2308-3425/11/12/382/htm
5. Badan Kependudukan dan Keluarga Berencana Nasional (BKKBN). Prevalensi kontrasepsi modern (mCPR) berdasarkan provinsi: hasil pemutakhiran PK-23. 2023;
6. Edris FE, Alasiri RAA, Albukhari AF, Sadiq MA, Alahmadi WM, Alruwaili AR, et al. Assessment of Women’s Awareness of the Possible Risk of Stroke Associated with the Use of Oral Contraceptives Pills in Saudi Arabia: A Cross-Sectional Study. Medicina (B Aires) [Internet]. 2025 Feb 1 [cited 2025 Aug 17];61(2):259. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11857735/
7. Brabaharan S, Veettil SK, Kaiser JE, Raja Rao VR, Wattanayingcharoenchai R, Maharajan M, et al. Association of Hormonal Contraceptive Use With Adverse Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials and Cohort Studies. JAMA Netw Open [Internet]. 2022 Jan 14 [cited 2025 Aug 17];5(1):e2143730. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8760614/
8. Cooper DB, Patel P. Oral Contraceptive Pills. A History of Intellectual Property in 50 Objects [Internet]. 2024 Feb 29 [cited 2025 Aug 15];224–31. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430882/
9. Yonis H, Lokkegaard E, Kragholm K, Granger CB, Moller AL, Morch LS, et al. Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study. BMJ [Internet]. 2025 Feb 12 [cited 2025 Aug 2];388. Available from: https://www.bmj.com/content/388/bmj-2024-082801
10. Miller EC, Gatollari HJ, Too G, Boehme AK, Leffert L, Elkind MSV, et al. Risk of Pregnancy-Associated Stroke Across Age Groups in New York State. JAMA Neurol [Internet]. 2016 Dec 1 [cited 2025 Aug 2];73(12):1461–7. Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2570547
11. Miller EC, Leffert L. Stroke in Pregnancy: A Focused Update. Anesth Analg [Internet]. 2020 Apr 1 [cited 2025 Aug 4];130(4):1085. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7035913/
12. Elgendy IY, Bukhari S, Barakat AF, Pepine CJ, Lindley KJ, Miller EC. Maternal Stroke: A Call for Action. Circulation [Internet]. 2021 Feb 16 [cited 2025 Aug 2];143(7):727–38. Available from: https://pubmed.ncbi.nlm.nih.gov/33587666/
13. Ouerdiene A, Messelmani M, Mansour M, Zaouali J, Mrissa R. Early pregnancy‐associated ischemic stroke during first trimester in a young woman: A case report. Clin Case Rep [Internet]. 2021 Sep 1 [cited 2025 Aug 2];9(9):e04736. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8405521/
14. Salehi Omran S, Parikh NS, Poisson S, Armstrong J, Merkler AE, Prabhu M, et al. Association Between Pregnancy and Cervical Artery Dissection. Ann Neurol [Internet]. 2020 Sep 1 [cited 2025 Aug 2];88(3):596. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10001425/
15. Jx S, David M, Werring J. Stroke: causes and clinical features. 2020;561–6.
16. The Main Periods of Human Life | Enhanced Reader.
17. Johansson T, Fowler P, Ek WE, Skalkidou A, Karlsson T, Johansson A. Oral Contraceptives, Hormone Replacement Therapy, and Stroke Risk. Stroke [Internet]. 2022 Oct 1 [cited 2025 Aug 2];53(10):3107–15. Available from: https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.038659
18. Xu Z, Yue Y, Bai J, Shen C, Yang J, Huang X, et al. Association between oral contraceptives and risk of hemorrhagic stroke: a meta-analysis of observational studies. Arch Gynecol Obstet [Internet]. 2018 May 1 [cited 2025 Aug 4];297(5):1181–91. Available from: https://pubmed.ncbi.nlm.nih.gov/29460112/
19. Okoth K, Chandan JS, Marshall T, Thangaratinam S, Thomas GN, Nirantharakumar K, et al. Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review. The BMJ [Internet]. 2020 Oct 7 [cited 2025 Aug 4];371:m3502. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7537472/
20. Li F, Zhu L, Zhang J, He H, Qin Y, Cheng Y, et al. Oral Contraceptive Use and Increased Risk of Stroke: A Dose–Response Meta-Analysis of Observational Studies. Front Neurol [Internet]. 2019 Sep 23 [cited 2025 Aug 24];10:993. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6767325/
21. Williams JS, MacDonald MJ. Influence of hormonal contraceptives on peripheral vascular function and structure in premenopausal females: A review. Am J Physiol Heart Circ Physiol [Internet]. 2021 Jan 1 [cited 2025 Aug 16];320(1):H77–89. Available from: https://journals.physiology.org/doi/10.1152/ajpheart.00614.2020
22. Reed S, Koro C, DiBello J, Becker K, Bauerfeind A, Franke C, et al. Prospective controlled cohort study on the safety of a monophasic oral contraceptive containing nomegestrol acetate (2.5mg) and 17β-oestradiol (1.5mg) (PRO-E2 study): risk of venous and arterial thromboembolism. European Journal of Contraception and Reproductive Health Care [Internet]. 2021 [cited 2025 Aug 17];26(6):439–46. Available from: https://www.tandfonline.com/action/journalInformation?journalCode=iejc20
23. Sharma R, Gupta P, Mahajan N. Pregnancy, Ischemic Stroke and Heart Disease: A Rare Clinical Scenario. J Obstet Gynaecol India [Internet]. 2019 Aug 1 [cited 2025 Aug 2];70(4):321. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7381533/
24. Ban L, Sprigg N, Sultan AA, Nelson-Piercy C, Bath PM, Ludvigsson JF, et al. Incidence of First Stroke in Pregnant and Nonpregnant Women of Childbearing Age: A Population‐Based Cohort Study From England. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease [Internet]. 2017 Apr 5 [cited 2025 Aug 2];6(4):e004601. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5532991/
25. MF Ubaid ASSFZARAMS. Stroke in Early Postpartum Period in a Young Woman: A Case Study. J Clin Case Rep. 2019;(01).
26. Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, et al. Preeclampsia and future cardiovascular health. Circ Cardiovasc Qual Outcomes [Internet]. 2017 Feb 1 [cited 2025 Aug 4];10(2). Available from: https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.116.003497
27. Thomas Q, Crespy V, Duloquin G, Ndiaye M, Sauvant M, Béjot Y, et al. Stroke in women: When gender matters. Rev Neurol (Paris) [Internet]. 2021 Oct 1 [cited 2025 Aug 4];177(8):881–9. Available from: https://pubmed.ncbi.nlm.nih.gov/34172293/
28. Aoyama K, Ray JG. Pregnancy and Risk of Intracerebral Hemorrhage. JAMA Netw Open. 2020;3(4):202844.
29. Van Alebeek ME, De Heus R, Tuladhar AM, De Leeuw FE. Pregnancy and ischemic stroke: a practical guide to management. Curr Opin Neurol [Internet]. 2018 Feb 1 [cited 2025 Aug 11];31(1):44–51. Available from: https://pubmed.ncbi.nlm.nih.gov/29120921/
30. Sanders BD, Davis MG, Holley SL, Phillippi JC. PREGNANCY-ASSOCIATED STROKE. J Midwifery Womens Health [Internet]. 2018 Jan 1 [cited 2025 Aug 11];63(1):23. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7608605/
31. Wang J, Gao Y, Yuan Y, Wang H, Wang Z, Zhang · Xiangjian. Th17 Cells and IL-17A in Ischemic Stroke. 2035 [cited 2025 Aug 17];61:2411–29. Available from: https://doi.org/10.1007/s12035-023-03723-y
32. Troiano NH. Physiologic and Hemodynamic Changes During Pregnancy. AACN Adv Crit Care [Internet]. 2018 Sep 15 [cited 2025 Aug 24];29(3):273–83. Available from: https://dx.doi.org/10.4037/aacnacc2018911
33. Quiñones-Ossa GA, Lobo C, Garcia-Ballestas E, Florez WA, Moscote-Salazar LR, Agrawal A. Obesity and Stroke: Does the Paradox Apply for Stroke? Neurointervention [Internet]. 2021 Mar 1 [cited 2025 Aug 12];16(1):9. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7946563/
34. Tham KW, Abdul Ghani R, Cua SC, Deerochanawong C, Fojas M, Hocking S, et al. Obesity in South and Southeast Asia—A new consensus on care and management. Obesity Reviews [Internet]. 2022 Feb 1 [cited 2025 Aug 14];24(2):e13520. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10078503/
35. Goldstein LB. Weighing the Effect of Overweight/Obesity on Stroke Risk. Stroke [Internet]. 2024 Jul 1 [cited 2025 Aug 13];55(7):1866–8. Available from: http://ahajournals.org
36. Mikkola U, Rissanen I, Kivelä M, Rusanen H, Kajantie E, Miettunen J, et al. Overweight in Adolescence and Young Adulthood in Association with Adult Cerebrovascular Disease: The NFBC1966 Study. Stroke. 2024 Jul 1;55(7):1857–65.
37. Pirau L, Lui F. Vertebrobasilar Insufficiency. Equilibrium Research [Internet]. 2023 Jul 17 [cited 2025 Aug 14];73(3):117–26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482259/
38. Moors C, Stapleton C. Signs and symptoms of vertebrobasilar insufficiency secondary to atherosclerosis: A systematic review. Journal of Osteopathic Medicine [Internet]. 2025 Mar 28 [cited 2025 Aug 14];1–14. Available from: https://www.degruyterbrill.com/document/doi/10.1515/jom-2024-0203/html?srsltid=AfmBOooBF6fU_O4lgQO0ghvzXgv7BQHbnUz8A1HYaAx_087s0AdlakMT
39. Gowda SN, Munakomi S, Jesus O De. Brainstem Stroke. StatPearls [Internet]. 2024 Feb 25 [cited 2025 Aug 3]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK560896/
40. Almohammedi RM, Almutairi H, Alhoussien RO, Alotayan MT, Almutairi AK, Bafail WO, et al. Brainstem hemorrhage is uncommon and is associated with high morbidity, mortality, and prolonged hospitalization. Neurosciences [Internet]. 2020 Apr 1 [cited 2025 Aug 3];25(2):91. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8015522/
41. Wieruszewski ED. Brain Stem Stroke: A Complex Neurological Event. J Exp Stroke Transl Med [Internet]. 2024 Dec 31 [cited 2025 Aug 29];16(6):283–4. Available from: https://www.openaccessjournals.com/articles/brain-stem-stroke-a-complex-neurological-event-18443.html
42. Malla G, Jillella D V. Pontine Infarction. StatPearls [Internet]. 2023 May 29 [cited 2025 Aug 3]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK554418/
2. Bukhari S, Yaghi S, Bashir Z. Stroke in Young Adults. J Clin Med [Internet]. 2023 Aug 1 [cited 2025 Aug 14];12(15):4999. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10420127/
3. Chang BP, Wira C, Miller J, Akhter M, Barth BE, Willey J, et al. Neurology Concepts: Young Women and Ischemic Stroke—Evaluation and Management in the Emergency Department. Academic Emergency Medicine [Internet]. 2018 Jan 1 [cited 2025 Aug 2];25(1):54–64. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13243
4. Eng PC, Tan LLY, Kimball TN, Prapiadou S, Tan BYQ. Ischemic Stroke in Women: Understanding Sex-Specific Risk Factors, Treatment Considerations, and Outcomes. Journal of Cardiovascular Development and Disease 2024, Vol 11, Page 382 [Internet]. 2024 Nov 29 [cited 2025 Aug 6];11(12):382. Available from: https://www.mdpi.com/2308-3425/11/12/382/htm
5. Badan Kependudukan dan Keluarga Berencana Nasional (BKKBN). Prevalensi kontrasepsi modern (mCPR) berdasarkan provinsi: hasil pemutakhiran PK-23. 2023;
6. Edris FE, Alasiri RAA, Albukhari AF, Sadiq MA, Alahmadi WM, Alruwaili AR, et al. Assessment of Women’s Awareness of the Possible Risk of Stroke Associated with the Use of Oral Contraceptives Pills in Saudi Arabia: A Cross-Sectional Study. Medicina (B Aires) [Internet]. 2025 Feb 1 [cited 2025 Aug 17];61(2):259. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11857735/
7. Brabaharan S, Veettil SK, Kaiser JE, Raja Rao VR, Wattanayingcharoenchai R, Maharajan M, et al. Association of Hormonal Contraceptive Use With Adverse Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials and Cohort Studies. JAMA Netw Open [Internet]. 2022 Jan 14 [cited 2025 Aug 17];5(1):e2143730. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8760614/
8. Cooper DB, Patel P. Oral Contraceptive Pills. A History of Intellectual Property in 50 Objects [Internet]. 2024 Feb 29 [cited 2025 Aug 15];224–31. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430882/
9. Yonis H, Lokkegaard E, Kragholm K, Granger CB, Moller AL, Morch LS, et al. Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study. BMJ [Internet]. 2025 Feb 12 [cited 2025 Aug 2];388. Available from: https://www.bmj.com/content/388/bmj-2024-082801
10. Miller EC, Gatollari HJ, Too G, Boehme AK, Leffert L, Elkind MSV, et al. Risk of Pregnancy-Associated Stroke Across Age Groups in New York State. JAMA Neurol [Internet]. 2016 Dec 1 [cited 2025 Aug 2];73(12):1461–7. Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2570547
11. Miller EC, Leffert L. Stroke in Pregnancy: A Focused Update. Anesth Analg [Internet]. 2020 Apr 1 [cited 2025 Aug 4];130(4):1085. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7035913/
12. Elgendy IY, Bukhari S, Barakat AF, Pepine CJ, Lindley KJ, Miller EC. Maternal Stroke: A Call for Action. Circulation [Internet]. 2021 Feb 16 [cited 2025 Aug 2];143(7):727–38. Available from: https://pubmed.ncbi.nlm.nih.gov/33587666/
13. Ouerdiene A, Messelmani M, Mansour M, Zaouali J, Mrissa R. Early pregnancy‐associated ischemic stroke during first trimester in a young woman: A case report. Clin Case Rep [Internet]. 2021 Sep 1 [cited 2025 Aug 2];9(9):e04736. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8405521/
14. Salehi Omran S, Parikh NS, Poisson S, Armstrong J, Merkler AE, Prabhu M, et al. Association Between Pregnancy and Cervical Artery Dissection. Ann Neurol [Internet]. 2020 Sep 1 [cited 2025 Aug 2];88(3):596. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10001425/
15. Jx S, David M, Werring J. Stroke: causes and clinical features. 2020;561–6.
16. The Main Periods of Human Life | Enhanced Reader.
17. Johansson T, Fowler P, Ek WE, Skalkidou A, Karlsson T, Johansson A. Oral Contraceptives, Hormone Replacement Therapy, and Stroke Risk. Stroke [Internet]. 2022 Oct 1 [cited 2025 Aug 2];53(10):3107–15. Available from: https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.038659
18. Xu Z, Yue Y, Bai J, Shen C, Yang J, Huang X, et al. Association between oral contraceptives and risk of hemorrhagic stroke: a meta-analysis of observational studies. Arch Gynecol Obstet [Internet]. 2018 May 1 [cited 2025 Aug 4];297(5):1181–91. Available from: https://pubmed.ncbi.nlm.nih.gov/29460112/
19. Okoth K, Chandan JS, Marshall T, Thangaratinam S, Thomas GN, Nirantharakumar K, et al. Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review. The BMJ [Internet]. 2020 Oct 7 [cited 2025 Aug 4];371:m3502. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7537472/
20. Li F, Zhu L, Zhang J, He H, Qin Y, Cheng Y, et al. Oral Contraceptive Use and Increased Risk of Stroke: A Dose–Response Meta-Analysis of Observational Studies. Front Neurol [Internet]. 2019 Sep 23 [cited 2025 Aug 24];10:993. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6767325/
21. Williams JS, MacDonald MJ. Influence of hormonal contraceptives on peripheral vascular function and structure in premenopausal females: A review. Am J Physiol Heart Circ Physiol [Internet]. 2021 Jan 1 [cited 2025 Aug 16];320(1):H77–89. Available from: https://journals.physiology.org/doi/10.1152/ajpheart.00614.2020
22. Reed S, Koro C, DiBello J, Becker K, Bauerfeind A, Franke C, et al. Prospective controlled cohort study on the safety of a monophasic oral contraceptive containing nomegestrol acetate (2.5mg) and 17β-oestradiol (1.5mg) (PRO-E2 study): risk of venous and arterial thromboembolism. European Journal of Contraception and Reproductive Health Care [Internet]. 2021 [cited 2025 Aug 17];26(6):439–46. Available from: https://www.tandfonline.com/action/journalInformation?journalCode=iejc20
23. Sharma R, Gupta P, Mahajan N. Pregnancy, Ischemic Stroke and Heart Disease: A Rare Clinical Scenario. J Obstet Gynaecol India [Internet]. 2019 Aug 1 [cited 2025 Aug 2];70(4):321. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7381533/
24. Ban L, Sprigg N, Sultan AA, Nelson-Piercy C, Bath PM, Ludvigsson JF, et al. Incidence of First Stroke in Pregnant and Nonpregnant Women of Childbearing Age: A Population‐Based Cohort Study From England. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease [Internet]. 2017 Apr 5 [cited 2025 Aug 2];6(4):e004601. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5532991/
25. MF Ubaid ASSFZARAMS. Stroke in Early Postpartum Period in a Young Woman: A Case Study. J Clin Case Rep. 2019;(01).
26. Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, et al. Preeclampsia and future cardiovascular health. Circ Cardiovasc Qual Outcomes [Internet]. 2017 Feb 1 [cited 2025 Aug 4];10(2). Available from: https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.116.003497
27. Thomas Q, Crespy V, Duloquin G, Ndiaye M, Sauvant M, Béjot Y, et al. Stroke in women: When gender matters. Rev Neurol (Paris) [Internet]. 2021 Oct 1 [cited 2025 Aug 4];177(8):881–9. Available from: https://pubmed.ncbi.nlm.nih.gov/34172293/
28. Aoyama K, Ray JG. Pregnancy and Risk of Intracerebral Hemorrhage. JAMA Netw Open. 2020;3(4):202844.
29. Van Alebeek ME, De Heus R, Tuladhar AM, De Leeuw FE. Pregnancy and ischemic stroke: a practical guide to management. Curr Opin Neurol [Internet]. 2018 Feb 1 [cited 2025 Aug 11];31(1):44–51. Available from: https://pubmed.ncbi.nlm.nih.gov/29120921/
30. Sanders BD, Davis MG, Holley SL, Phillippi JC. PREGNANCY-ASSOCIATED STROKE. J Midwifery Womens Health [Internet]. 2018 Jan 1 [cited 2025 Aug 11];63(1):23. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7608605/
31. Wang J, Gao Y, Yuan Y, Wang H, Wang Z, Zhang · Xiangjian. Th17 Cells and IL-17A in Ischemic Stroke. 2035 [cited 2025 Aug 17];61:2411–29. Available from: https://doi.org/10.1007/s12035-023-03723-y
32. Troiano NH. Physiologic and Hemodynamic Changes During Pregnancy. AACN Adv Crit Care [Internet]. 2018 Sep 15 [cited 2025 Aug 24];29(3):273–83. Available from: https://dx.doi.org/10.4037/aacnacc2018911
33. Quiñones-Ossa GA, Lobo C, Garcia-Ballestas E, Florez WA, Moscote-Salazar LR, Agrawal A. Obesity and Stroke: Does the Paradox Apply for Stroke? Neurointervention [Internet]. 2021 Mar 1 [cited 2025 Aug 12];16(1):9. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7946563/
34. Tham KW, Abdul Ghani R, Cua SC, Deerochanawong C, Fojas M, Hocking S, et al. Obesity in South and Southeast Asia—A new consensus on care and management. Obesity Reviews [Internet]. 2022 Feb 1 [cited 2025 Aug 14];24(2):e13520. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10078503/
35. Goldstein LB. Weighing the Effect of Overweight/Obesity on Stroke Risk. Stroke [Internet]. 2024 Jul 1 [cited 2025 Aug 13];55(7):1866–8. Available from: http://ahajournals.org
36. Mikkola U, Rissanen I, Kivelä M, Rusanen H, Kajantie E, Miettunen J, et al. Overweight in Adolescence and Young Adulthood in Association with Adult Cerebrovascular Disease: The NFBC1966 Study. Stroke. 2024 Jul 1;55(7):1857–65.
37. Pirau L, Lui F. Vertebrobasilar Insufficiency. Equilibrium Research [Internet]. 2023 Jul 17 [cited 2025 Aug 14];73(3):117–26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482259/
38. Moors C, Stapleton C. Signs and symptoms of vertebrobasilar insufficiency secondary to atherosclerosis: A systematic review. Journal of Osteopathic Medicine [Internet]. 2025 Mar 28 [cited 2025 Aug 14];1–14. Available from: https://www.degruyterbrill.com/document/doi/10.1515/jom-2024-0203/html?srsltid=AfmBOooBF6fU_O4lgQO0ghvzXgv7BQHbnUz8A1HYaAx_087s0AdlakMT
39. Gowda SN, Munakomi S, Jesus O De. Brainstem Stroke. StatPearls [Internet]. 2024 Feb 25 [cited 2025 Aug 3]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK560896/
40. Almohammedi RM, Almutairi H, Alhoussien RO, Alotayan MT, Almutairi AK, Bafail WO, et al. Brainstem hemorrhage is uncommon and is associated with high morbidity, mortality, and prolonged hospitalization. Neurosciences [Internet]. 2020 Apr 1 [cited 2025 Aug 3];25(2):91. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8015522/
41. Wieruszewski ED. Brain Stem Stroke: A Complex Neurological Event. J Exp Stroke Transl Med [Internet]. 2024 Dec 31 [cited 2025 Aug 29];16(6):283–4. Available from: https://www.openaccessjournals.com/articles/brain-stem-stroke-a-complex-neurological-event-18443.html
42. Malla G, Jillella D V. Pontine Infarction. StatPearls [Internet]. 2023 May 29 [cited 2025 Aug 3]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK554418/
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