Stroke in pregnancy

Spontaneous haemorrhagic stroke complicating severe pre-eclampsia in pregnancy: a case report in a resource-limited setting in Cameroon

BACKGROUND

Spontaneous intracerebral haemorrhage is a rare complication of preeclampsia during pregnancy associated with a high morbidity and mortality. Compared with the non-pregnant women stroke rates are relatively rare during pregnancy.

CASE PRESENTATION

We report the case of a 32-year-old female Cameroonian gravida 4 para 3 who presented at 34 weeks of gestation with sudden onset of right sided hemiplegia associated with headache, blurred vision and a blood pressure of 182/126. Cerebral CT scan confirmed a left parietal spontaneous haemorrhage. Emergency caesarean delivery was done and the recovery uneventful.

CONCLUSION

This case highlights the importance of good neurological examination in pregnant women presenting with neurological symptoms as well as the place of multidisciplinary management in severe life threatening conditions.

Cerebrovascular emergencies in pregnancy

Caring for pregnant and postpartum patients with neurological disease carries specific challenges. In performing a diagnosis, it is often difficult to differentiate between true pathology and neurological symptoms resulting from normal pregnancy physiology. Treating the pregnant patient can be problematic as well. Providers need to be aware of the possible untoward effects of maternal treatments on the developing fetus, but not withhold therapies that reduce disease-related morbidity and mortality. Given the complexities of conducting trials during pregnancy, few treatments are based on high-quality data; observational data and clinical expert opinion often guide treatments. With the exception of preeclampsia/eclampsia, neurological diseases typically do not warrant early delivery in the absence of fetal distress. Multidisciplinary care, utilizing the expertise of anesthesiology, critical care medicine, emergency medicine, maternal-fetal medicine, neurology, and radiology, is essential in ensuring prompt diagnosis and treatment.

Spontaneous hemorrhagic strokes during pregnancy: case report and review of the literature

Hemorrhagic stroke is responsible for significant morbidity and mortality. Postpartum and pregnancy are risk period. Only urgent care in intensive care units may improve prognosis. We report the case of 22 years old's Morrocan, who presented to our department with an intense headache headset followed a few hours later by consciousness disorder. Clinical examination at admission has objectified a woman obsessed with a GCS 13, normotensive, the labstix is negative. A brain scan was performed showing left temporal intra parenchymal hematoma with ventricular flooding and subfalcine herniation. An external ventricular shunt was made. The patient was extubated on day 2 of hospitalization, with progressive neurological improvement. Concerning obstetrical care, the pregnancy has evolved harmoniously without any growth retardation or other abnormalities, with full-term vaginal delivery of a healthy 3kg200 baby. although Hemorrhagic stroke during pregnancy is rare, the prognosis is reserved. An adequate care in intensive care unit is required.

Thrombolytic therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: a case report and literature review

INTRODUCTION

Thrombolysis for acute ischemic stroke has been rarely administrated during pregnancy. Paradoxical embolism through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation (AVM) is an identified risk factor for ischemic stroke.

CASE REPORT

We report a 24-year-old woman at 11 weeks gestation who developed a sudden onset of dysarthria, hemiparesis, and hemisensory loss. She was diagnosed as having an ischemic stroke in the left middle cerebral artery (MCA) territory. She was treated with intra-arterial recombinant tissue plasminogen activator with subsequent resolution of her neurological deficits. Further workup revealed the presence of a PFO with a large right-to-left shunt. After being put on antithrombotic therapy, she presented again at 13 gestational weeks with a new ischemic infarction in the vertebrobasilar territory. Her PFO was closed percutaneously under ultrasonic guidance but the right-to-left shunt persisted. After a normal delivery, she was found to have a large pulmonary AVM which was successfully resected without complication.

CONCLUSIONS

This report describes the successful usage of intra-arterial tissue plasminogen activator for acute ischemic stroke during early pregnancy. In patients with presumed paradoxical embolism, careful attention should be paid to rule out a coexistence of PFO and pulmonary AVM.

Antepartum intracranial hemorrhage due to unrecognized unilateral moyamoya disease: a case report

PURPOSE

Moyamoya (meaning a "hazy puff of smoke" in Japanese) disease is a rare cerebrovascular occlusive disease. Moyamoya disease may become symptomatic for the first time during pregnancy. We report a case of antepartum intracranial hemorrhage due to unrecognized unilateral moyamoya disease, which was subsequently diagnosed as HELLP syndrome during the postpartum period.

STUDY DESIGN

A case report of a 29-year-old Japanese primigravida who was transported to our hospital at 39 weeks of gestation because of sudden loss of consciousness and left hemiplegia. On arrival, her blood pressure was 143/94 mmHg with 1+ proteinuria by dipstick. Brain computed tomography revealed a right putaminal hemorrhage with intraventricular hemorrhage. The patient delivered a neonate by emergency cesarean section, and an intracranial hematoma was subsequently evacuated. Approximately 3 h postoperatively, she was diagnosed with HELLP syndrome and the following were initiated: IV magnesium sulfate, antihypertensive agents, and transfusion of 10 units of platelets. Angiographic findings were consistent with unilateral moyamoya disease.

CONCLUSIONS

Moyamoya disease is a rare entity that must be considered in the differential diagnosis of hemorrhagic stroke during pregnancy. It is important to perform careful monitoring and adequate management with cooperation between obstetricians and other specialists when serious complications arise.

Moyamoya-disease-related ischemic stroke in the postpartum period

Stroke during pregnancy or the puerperium is an extremely rare yet serious cause of perinatal morbidity and mortality. Moyamoya disease, a cerebrovascular occlusive pathology with a female predominance, may become symptomatic for the first time in association with pregnancy. A 36-year-old woman with postpartum pre-eclampsia suddenly developed hemiparesis in the left arm with dysarthria after the initiation of antihypertensive measures. Cranial magnetic resonance imaging and angiography revealed acute ischemic lesions in the right hemisphere along with the steno-occlusive lesions of bilateral terminal portions of the internal carotid artery, indicating Moyamoya disease. With anti-platelet medication, the patient recovered gradually and was diagnosed as having Moyamoya disease using conventional angiography 3 months postpartum. In this case, the fluctuations in blood pressure in association with pre-eclampsia appear to have exacerbated the clinical symptoms of Moyamoya disease. As such, Moyamoya disease should be considered as an underlying disease of ischemic stroke associated with pregnancy.

Intravenous recombinant tissue plasminogen activator in a pregnant woman with cardioembolic stroke

BACKGROUND AND PURPOSE

Historically, the use of tissue plasminogen activator (tPA) thrombolysis in pregnancy has been regarded as relatively contraindicated. Underlying this stance has been the concern over the risk of bleeding complications in both mother and child.

SUMMARY OF CASE

We report the successful use of intravenous recombinant tPA (rtPA) thrombolysis in a pregnant woman with acute cardioembolic stroke.

CONCLUSIONS

The patient improved clinically, did not develop complications after receiving rtPA, and at 37 weeks' gestation, delivered a healthy infant, demonstrating that rtPA thrombolysis may be used safely in pregnant women.