Endovascular management of acute large vessel occlusion stroke in pregnancy is safe and feasible

Abstract

IntroductionStroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy.MethodsPatients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed.ResultsA total of seven subjects were identified. The average age was 33.2 years (range 25–38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9–28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0–5).ConclusionEVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population.

European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum

“…One patient experienced intrauterine haematoma, which recovered. 25,41,53 (Table 3, Supplementary Table 2) Evidence-based Recommendation Available data do not allow a specific recommendation on IVT in pregnant women with acute ischaemic stroke.…”

“…The remaining 8 patients were treated with a combination of IVT and MT (these subjects have also been taken into consideration for PICO 2.1.). [48][49][50][51][52][53][54][55][56][57][58][59][60] All patients achieved a good outcome according to mRS (mRS 0-2) after 3 months; bleeding complications occurred in two patients only (a small intracerebral haemorrhage in the basal ganglia was observed in one patient receiving MT alone, and a haemorrhagic infarction type 1, that is, petechial haemorrhages at the infarct margins, occurred in one patient treated with bridging therapy); however, both had a favourable outcome. A healthy baby was born to 18 patients; one pregnancy ended in abortion, and in three cases, the birth and child data are missing.…”

A Case of an Early Pregnant Woman with Congenital Protein S Deficiency Who Underwent Mechanical Thrombectomy

“…5) However, the influence of radiation, contrast medium, and drugs, such as heparin, was very small and endovascular treatment could be performed in pregnant women relatively safely according to a report. 6) To our knowledge, there have been only 9 reports (19 patients) in which thrombectomy was performed for LVO in pregnant women [7][8][9][10][11][12][13][14][15] (Table 1). In the present patient, abortion was performed in response to the patient's request, but a favorable outcome was achieved in both mother and fetus in previous reports.…”

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

“…96 The safety and feasibility of EVT of ELVO in pregnancy is based solely on single-center case reports and one small case series, for a total of 14 patients. 95 When examining these historical cases, despite the procedural diversity, 93% (13/14 subjects) achieved a TICI 2b or higher grade of recanalization, and all patients with follow-up data had a mRS score of 0-2 at final follow-up. Delivery outcomes consisted of seven normal full-term deliveries, one spontaneous abortion, two fullterm Cesarean sections, one emergency Cesarean section with delivery of a healthy newborn, and three cases of unknown delivery status.…”