Stroke 2013 July-10

 

Systemic thrombolysis for stroke in pregnancy

Am J Emerg Med. 2013 Feb;31(2):448.e1-3.

Rossana Tassi1, M.D.; Maurizio Acampa1, M.D.; Giovanna Marotta1, M.D.; Samuele Cioni2, M.D.; Francesca Guideri1, M.D.; Simone Rossi3, M.D.; Alfonso Cerase 2, M.D.; Giuseppe Martini1, M.D.

 1 Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte”, Siena, Italy.

2 Unit NINT Neuroimaging and Neurointervention, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte”, Siena, Italy.

3 Unit Neurology Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte”, Siena, Italy.

 

Corresponding author:

Rossana Tassi, MD

Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte”, Viale Mario Bracci, 16, 53100 Siena, Italy – Phone: +390577585217 – Fax: +390577585307 – Email: r.tassi@ao-siena.toscana.it

Abstract:

Pregnancy is an exclusion criteria for all clinical trials that validates alteplase in acute stroke, so our knowledge about its use in this condition is relative only to case reports and case series. Herein we report the successful use of intravenous rtPA in a pregnant women with acute stroke. The patient was a 28-year old who was 16 weeks pregnant. She presented to our hospital one hour after a sudden onset of mothor aphasia, hemiparesis and hypoesthesia on the right side due to incipient ischemia in the left cerebral hemisphere resulting from ipsilateral middle cerebral artery subocclusion demonstrated by MRI. After intravenous rTPA administration, she improved within a few hours, persisting only a slight motory aphasia. A transesophageal echocardiography showed a large patent foramen ovale with right to left shunt. Although the probable origin of stroke secondary to paradoxical embolism, we decided to treat the patient with acetilsalicilic acid. After the discharge, pregnancy was regular and the patient delivered an healthy term infant without complications and the puerperium was normal.

To date only seven patients treated with intravenous alteplase for stroke has been reported. The fetal outcome was good in 5 cases, while in two patients were recorded minor hemorrhagic episodes and one patient died from dissection during angioplasty. With one exception, mothers recovered well from their strokes.

Based on our case and reports obtained from literature, it seems that pregnant women generally can be safely treated with rt-PA systemic thrombolisys having a good outcome.

 

REFERENCES

1. Treadwell SD, Thanvi B, Robinson TG. Stroke in pregnancy and the puerperium. Postgrad Med J 2008; 84: 238-245

2. Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133: 630S-669S.

3. Cronin CA, Weisman CJ, Llinas RH. Stroke Treatment. Beyond the three hour window and in the pregnant patient. Ann NY Acad Sci 2008; 1142: 159-178.

4. Del Zotto E, Giossi A, Volonghi I, et al. Ischemic stroke during pregnancy and puerperium. Stroke Res Treat 2011: 606780.

5. Yamaguchi, Kondo T, Ihara M, et al. Intravenous recombinant tissue plasminogen activator in a 18-week pregnant women with embolic stroke. Rinsho Shinkeigaku 2010; 50: 315-9.

6. LI Y, Margraf J, Kluck B, et al. Thrombolityc therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: a case report and literature review. Neurologist 2012;18

 

 Rossana TassiFIGURE 1

Magnetic resonance imaging and angiography (MRA).

At admission (a,b), serial nonconsecutive fluid-attenuated inversion recovery (FLAIR) and b: 1000 s/mm2 isotropic diffusion-weighted (DW) axial images (a) showed areas of restricted diffusion and incipient signal alteration in the left middle cerebral artery (MCA) territories (anterior cortex in the plan passing for basal ganglia and lateral territory in a rostral plan), insular cortex, lentiform nucleus, and posterior portion of caudate nucleus head. This resulted from of left MCA M1 segment focal narrowing (long arrow), and M2 segments low signal flow intensity, at anteroposterior view retropojection from time of flight (TOF) MRA. Minimum apparent diffusion coefficient of the ischemic areas was 287+/-12 mm2 /sec. One day later (c, d), the ischemic areas are frankly evident and only slightly enlarged at FLAIR and DW images (c), and TOF MRA showed clearcut improvement of left MCA flow, and especially M1 segment caliber. Note also a subtle lowintensity signal on FLAIR images (asterisk, and arrowheads) in the ischemic subcortical white matter, consistent with abnormal iron deposition from disruption of iron axonal transport or free radicals production.

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