Oral Contraceptives and Ischemic Stroke Risk
A 27-year-old, previously healthy woman with no history of migraine presented to the emergency department with sudden-onset left hemiparesis. Her only stroke risk factor was oral contraceptive use for the past several months. She awoke in normal health but soon developed left-sided weakness. On arrival to the emergency department, she had a blood pressure of 126/73 and a heart rate of 88. National Institutes of Health Stroke Scale was 5 for a left facial droop, hemiparesis, and dysarthria. Her computed tomography head was normal. She received intravenous tPA (tissue-type plasminogen activator) at her local hospital and was transferred to a comprehensive stroke center. On arrival, she had improved to a National Institutes of Health Stroke Scale of 2 for left facial droop and left arm drift. Magnetic resonance imaging of the brain revealed diffusion restriction within the right insula, putamen, and caudate (Figure [A] and [B]). Magnetic resonance angiography of the head and neck showed no intracranial or extracranial stenosis (Figure [C] and [D]). Fat-saturated imaging was considered but not done because she had widely patent arteries and no symptoms suggestive of dissection, such as headache or neck pain. She underwent an extensive workup, including transesophageal echocardiogram with bubble study, cardiac monitoring for paroxysmal atrial fibrillation, hemoglobin A1c, lipid panel, lupus anticoagulant, anticardiolipin antibodies, antinuclear antibodies, antithrombin-3, β-2 glycoprotein, homocysteine, protein C and S, and genetic testing for prothrombin gene mutation and Factor V Leiden. All testing was negative for a potential cause of stroke. She was diagnosed with cryptogenic stroke and discharged on aspirin and statin. Her oral contraceptive pills (OCPs) were stopped.
This case illustrates a common scenario where the only potential risk factor for …