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Ouerdiene A, Messelmani M, Mansour M, Zaouali J, Mrissa R. Early pregnancy-associated ischemic stroke during first trimester in a young woman: A case report. Clin Case Rep 2021; 9:e04736. [PMID: 34484770 PMCID: PMC8405521 DOI: 10.1002/ccr3.4736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 07/30/2021] [Accepted: 08/09/2021] [Indexed: 11/07/2022] Open
Abstract
Pregnancy-associated ischemic stroke is rare. The degree of the risk is the highest in the third trimester, but clinicians should be also wary from the beginning of the pregnancy as the risk still exists like demonstrated by our case.
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Affiliation(s)
- Asma Ouerdiene
- Department of NeurologyMilitary Hospital of Instruction of TunisTunisTunisia
| | - Mariem Messelmani
- Department of NeurologyMilitary Hospital of Instruction of TunisTunisTunisia
| | - Malek Mansour
- Department of NeurologyMilitary Hospital of Instruction of TunisTunisTunisia
| | - Jamel Zaouali
- Department of NeurologyMilitary Hospital of Instruction of TunisTunisTunisia
| | - Ridha Mrissa
- Department of NeurologyMilitary Hospital of Instruction of TunisTunisTunisia
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Proença F, Guerreiro C, Sá G, Reimão S. Neuroimaging safety during pregnancy and lactation: a review. Neuroradiology 2021; 63:837-845. [PMID: 33704518 DOI: 10.1007/s00234-021-02675-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/07/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Imaging studies are crucial adjuncts when studying acute and chronic diseases, so pregnant and lactating women are as likely to be evaluated with one of the available imaging modalities. Due to the specific condition of the mother and child in this time period it is crucial to make an appropriate selection of imaging studies. METHODS We review the existing literature and analyse the latest evidence and guidelines regarding neuroimaging safety during pregnancy and lactation, proposing an algorithm of action based on risk/benefits assessment. RESULTS Choosing the most appropriate neuroimaging modality implicates assessing the pretest pertinence of the study-the possibility of a serious treatable neurologic disease, pondering what is the most useful imaging modality for the diagnosis and evaluating the associated risks. Among physicians (and patients), however, the risk component is perhaps the least well understood, with misperceptions regarding safety and potential hazards. Computed tomography (CT) risks are principally related to ionizing radiation and intravenous (IV) administration of iodinated contrast. However, as very low risks for the mother and foetus have been reported and CT remains the most available tool for initial rapid diagnosis of acute neurological conditions, it should not be withheld in urgent situations. Magnetic resonance imaging (MRI), unlike CT, does not use ionizing radiation or iodinated contrast mediums, having the best anatomical detail possible. However, there are some usage safety concerns regarding the magnetic field strength and gadolinium-based contrast use. CONCLUSION There are lacking longitudinal and prospective studies to sustain evidence based choices of imaging studies during pregnancy and lactation. Ultimately the decision should be based on the risk/benefit, taking into account the patient's safety, care and outcomes. However, using a specific algorithm can guide decisions in daily clinical practice.
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Affiliation(s)
- F Proença
- Serviço de Imagiologia Neurológica, CHULN - Hospital Santa Maria, Lisbon, Portugal
| | - C Guerreiro
- Serviço de Imagiologia Neurológica, CHULN - Hospital Santa Maria, Lisbon, Portugal
| | - G Sá
- Serviço de Imagiologia Neurológica, CHULN - Hospital Santa Maria, Lisbon, Portugal
| | - S Reimão
- Serviço de Imagiologia Neurológica, CHULN - Hospital Santa Maria, Lisbon, Portugal.
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Moriyama T, Sugiura Y, Hayashi Y, Kinoshita F, Yamamura R, Moriya M, Tatsumi C, Yokoe M, Nagatsuka K, Ishihara M, Goto T, Nishio M, Watanabe Y. Thrombolysis and Mechanical Thrombectomy for Acute Ischemic Stroke in Pregnancy: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:124-128. [PMID: 37502798 PMCID: PMC10370802 DOI: 10.5797/jnet.cr.2020-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/15/2020] [Indexed: 07/29/2023]
Abstract
Objective Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT) are effective treatments for acute ischemic stroke (AIS). However, the treatment for AIS in pregnancy is not established because no clinical trials have included pregnant patients. We present a case of middle cerebral artery (MCA) M2 segment occlusion in pregnancy treated with IV thrombolysis and endovascular therapy. Case Presentation A 36-year-old woman being 6 weeks pregnant presented with right-sided hemiparesis and aphasia. MRI showed a high-intensity area on diffusion-weighted imaging of the left parietal lobe, and MRA showed left MCA M2 segment occlusion. She underwent IV rt-PA and MT and achieved thrombolysis in cerebral infarction 2b revascularization without complications. The protein S concentration was lower than that in the physiological changes during pregnancy. She was diagnosed with embolic stroke related to coagulopathy in pregnancy, and she underwent anticoagulation. At the 3-month follow-up, the modified Rankin Scale was 0. She miscarried at 4 months, and the fetal death was presumed to be obstetric cause. Conclusion IV rt-PA and MT may be effective and safe treatments for pregnant patients. Estimated fetal radiation exposure during MT is low and is presumed not to affect fetal development. We should mitigate the radiation dose and reduce the dose of iodinated contrast agents, particularly in pregnant patients.
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Affiliation(s)
- Takuya Moriyama
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yuri Sugiura
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yuto Hayashi
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Fukuaki Kinoshita
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Ryohei Yamamura
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masayuki Moriya
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Chikao Tatsumi
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masaru Yokoe
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masahiro Ishihara
- Department of Neurosurgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Tetsu Goto
- Department of Neurosurgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masami Nishio
- Department of Neurosurgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yuko Watanabe
- Department of Obstetrics and Gynecology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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Bulwa Z, Dresser LP, Clarke J, Mendelson S. Mystery Case: Clinical Reasoning: Recurrent cerebral ischemia during pregnancies. Neurology 2020; 95:e2453-e2457. [PMID: 32907962 DOI: 10.1212/wnl.0000000000010829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Zachary Bulwa
- From the Department of Neurology (Z.B., L.P.D., S.M), University of Chicago, IL; and Leonard M. Miller School of Medicine (J.C.), University of Miami, FL.
| | - Laura P Dresser
- From the Department of Neurology (Z.B., L.P.D., S.M), University of Chicago, IL; and Leonard M. Miller School of Medicine (J.C.), University of Miami, FL
| | - Jamie Clarke
- From the Department of Neurology (Z.B., L.P.D., S.M), University of Chicago, IL; and Leonard M. Miller School of Medicine (J.C.), University of Miami, FL
| | - Scott Mendelson
- From the Department of Neurology (Z.B., L.P.D., S.M), University of Chicago, IL; and Leonard M. Miller School of Medicine (J.C.), University of Miami, FL
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Kozberg MG, Camargo EC. Management of Maternal Stroke and Mitigating Risk. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:72. [DOI: 10.1007/s11936-019-0770-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ryman KM, Pace WD, Smith S, Fontaine GV. Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature. Pharmacotherapy 2019; 39:767-774. [PMID: 31077601 DOI: 10.1002/phar.2278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute ischemic stroke (AIS) during pregnancy is a rare but serious complication. Intravenous alteplase is the only medication approved for hyperacute treatment of AIS; however, it has not been evaluated prospectively in pregnancy. Pregnancy was an exclusion criterion in prospective AIS studies and was only recently removed as a relative contraindication in the 2018 American Heart Association/American Stroke Association Stroke guidelines. Due to the exclusion of pregnant women from randomized controlled trials, the safety of fibrinolytic therapy in pregnant patients is not well established. In this review, we report the use of intravenous alteplase for AIS in two pregnant patients, with temporally associated clinical improvement and without complications to either the mother or fetus. Additionally, we summarize a systematic review of the literature for both intravenous and intra-arterial alteplase use for AIS in pregnant patients. A total of 31 cases met inclusion criteria for this review of assessment of safety and efficacy of alteplase use in pregnancy. Existing case reports and guidelines support the use of alteplase for AIS in pregnant patients without contraindications.
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Affiliation(s)
- Klayton M Ryman
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
- Department of Pharmacy, Baylor University Medical Center, Dallas, Texas
| | - Wilson D Pace
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
| | - Shawn Smith
- Department of Neurology, Intermountain Medical Center, Murray, Utah
- Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Gabriel V Fontaine
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
- Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah
- Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
- Roseman University College of Pharmacy, South Jordan, Utah
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Rodrigues R, Silva R, Fontão L, Ruano L, Roriz JM. Acute Ischemic Stroke in Pregnancy. Case Rep Neurol 2019; 11:37-40. [PMID: 31543784 PMCID: PMC6739700 DOI: 10.1159/000496386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/17/2018] [Indexed: 12/26/2022] Open
Abstract
Stroke is an uncommon but serious potential complication of pregnancy. The management of acute ischemic stroke in pregnant women remains a complex challenge that extends beyond the limits of clinical trial evidence. Patient 1 was a 29-year-old woman 27 weeks into her first pregnancy, without remarkable past medical history or vascular risk factors. She was admitted 1 h after sudden onset of a left total anterior circulation syndrome (National Institute of Health Stroke Scale [NIHSS] score of 23). CT and angio-CT scans were normal. Thrombolysis was performed, with mild clinical improvement. Brain MRI showed multi-territorial embolic events. Extended blood panel, cervical-transcranial ultrasound, 48-h ECG monitoring, and transthoracic echocardiogram were unremarkable. She was started on aspirin and low-molecular-weight heparin (LMWH), giving birth to a healthy child 10 weeks later. Patient 2 was a 45-year-old woman 34 weeks into her pregnancy, without remarkable past medical history or vascular risk factors. She was admitted 30 min after sudden onset of a left partial anterior circulation syndrome, already partially recovered (NIHSS score of 4). The CT scan showed only a subacute right incidental middle cerebral artery infarct, while the angio-CT confirmed a left M3 branch occlusion. Thrombolysis and thrombectomy were contraindicated by the recent contralateral infarct, mild deficits, and distal occlusion site. Brain MRI also suggested an embolic etiology and LMWH was started. Extended blood panel, 48-h ECG monitoring, and transthoracic echocardiogram were normal. She gave birth to a healthy baby 4 weeks later. These cases emphasize the growing real-world evidence of the emergent use of CT, IV contrast, and recombinant tissue plasminogen activator in pregnant women with acute stroke, while also illustrating the importance of an individualized management, accounting for the safety of both mother and child.
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Affiliation(s)
- Rita Rodrigues
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Renata Silva
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Luís Fontão
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Luís Ruano
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal.,Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - José Mário Roriz
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
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Shah SS, Snelling BM, Brunet MC, Sur S, McCarthy DJ, Stein A, Khandelwal P, Starke RM, Peterson EC. Transradial Mechanical Thrombectomy for Proximal Middle Cerebral Artery Occlusion in a First Trimester Pregnancy: Case Report and Literature Review. World Neurosurg 2018; 120:415-419. [DOI: 10.1016/j.wneu.2018.09.095] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 11/16/2022]
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