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Neurological Rehabilitation

(Kiosk 3) A Case of Stroke Presentation Following Oral Contraceptive Initiation

Thursday, November 16, 2023
12:45 PM – 2:15 PM CT

    Co-Author(s)

  • Matthew A. Cascio, DO

    Resident Physician
    Nassau University Medical Center PM&R Program
    East Meadow, New York

  • Corey Spector, DO

    Resident Physician
    Nassau University Medical Center PM&R Program
    East Meadow, New York

  • Kanwardeep Singh, MD

    Resident Physician
    Nassau University Medical Center PM&R Program
    East Meadow, New York

  • JL

    Jack Leal, DO

    Resident Physician
    Nassau University Medical Center PM&R Program
    East Meadow, New York

  • RC

    Ricardo Cruz, MD

    Attending Physician
    Nassau University Med Center
    East Meadow, New York

    • Primary Author(s)

  • Diane Moya, DO

    Resident Physician
    Nassau University Medical Center PM&R Program
    East Meadow, New York

Case Diagnosis: Stroke presentation following oral contraceptive initiation

Case Description or Program Description: A 29-year-old female without medical history, who started oral contraceptives (Levonorgestrel-Ethinyl Estradiol) one week prior, was holding her baby when she noted sudden left arm weakness. She looked in the mirror and noticed left sided facial droop. She called her mother who noted slurred speech and took the patient to the emergency department. NIHSS in the emergency department was 3 for dysarthria, left arm weakness, and facial paralysis. CT head and perfusion studies were negative, and she was given TPA two hours after symptom onset. MRI obtained later that day demonstrated no acute pathology.

Setting: Tertiary care teaching hospital

Assessment/Results: She was evaluated by a physiatrist the following day, with her facial droop, dysarthria, and weakness resolved. Full stroke and hypercoagulability workup were unrevealing and the patient’s only apparent stroke risk factor was recent oral contraceptive (OCP) initiation. She was cleared by physiatry and discharged home with outpatient follow-up.

Discussion (relevance): Approximately 10.7 million women aged 15 to 44 in the United States use OCP’s. OCP’s are associated with increased procoagulant factors including prothrombin, fibrinogen, and factors VII and VIII, as well as decreased tissue factor pathway inhibitor and antithrombin levels. Studies performed in the 1970’s linked high-dose estrogens from OCP’s to increased ischemic strokes; however, these formulations are no longer used. While studies have shown progestin-only OCP’s to not increase stroke risk, combination OCP’s have shown some risk for ischemic stroke. This risk is typically confounded by other issues including OCP formulation, hypertension, smoking, age, and presence of migraine with aura.

Conclusions: Our patient experienced acute neurologic deficits one week after combination OCP initiation. Prompt symptom recognition allowed for treatment with TPA. In the absence of other apparent risk factors for stroke or hypercoagulability, it is important to consider OCP initiation as a potential inciting factor.