Mechanical Thrombectomy in Pregnancy: Report of 2 Cases and Review of the Literature

Abstract

Background: Mechanical thrombectomy has recently proved extremely effective in improving the outcome of patients with large vessel occlusion. Despite this, questions still remain over certain cohorts of patients that were excluded from the large randomised controlled trials. One such cohort includes pregnant patients. Although thromboembolic stroke is uncommon in pregnancy, the outcome from this pathology can be devastating. Summary: We present 2 cases of mechanical thrombectomy in pregnancy both of which underwent successful flow restoration without complications. We discuss the incidence of stroke in pregnancy, potential pitfalls of imaging, radiation protection issues, and the role of thrombolysis as well as the available literature on mechanical thrombectomy in this cohort. Key Message: Thrombectomy in pregnancy can be performed safely with no significant changes required to the procedure itself. Radiation exposure during the procedure should be minimised and shielding used to prevent scatter radiation to the fetus; however, given the potential risks of thrombolysis in this cohort of patients, mechanical thrombectomy should be considered in all stages of pregnancy.

Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature

“…Our two pregnant patients with AIS showed short‐term improvement in functional status after receiving IV alteplase. This adds to most of the published case reports (n=27) with documented neurologic improvement and without fetal complications (Table ) . There are five case reports with negative outcomes in the mother, fetus, or both after the administration of alteplase .…”

“…However, it is a large molecule and is unlikely to cross the human placenta . Although most published cases occurred in the first trimester, alteplase appears to be safe in the second and third trimesters as well …”

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

“…An embryo is most susceptible to adverse effects from radiation during organogenesis and the early fetal period. The radiation exposure available from three subjects ranged from 1200 to 3966 mGy to the mother and 4–5 times less than previously reported 19. In addition, all the cases were performed with low-dose fluoroscopy and an abdominal radiation shield to reduce radiation exposure to the fetus (figures 1–3).…”

“…Given the rarity of LVO in pregnancy and due to the exclusion of such patients from clinical trials, data related to the safety and feasibility of EVT are scarce. The reports of EVT exist only from single-center anecdotal case reports 19–23…”

“…There are limited data on the outcome of pregnancy in the setting of LVO stroke. In the literature, a total of seven case reports have been described where a pregnant patient underwent EVT with or without IV t-PA 19–23. All seven case reports in the literature reported good outcomes (mRS ≤2).…”