Unenhanced CT, CT angiogram and CT perfusion on presentation. A, Unenhanced CT scan of the head demonstrates early ischemic change in the insular cortex and lentiform nucleus, giving an ASPECTS score of 8. B, Contrast-enhanced CT angiogram shows occlusion of the left middle cerebral artery in the mid-M1 segment. C, Cerebral blood volume is decreased in the region of the lentiform nucleus, consistent with the hypodensity seen on unenhanced CT. D, Mean transit time is prolonged throughout the left MCA territory. CT indicates computed tomography; ASPECTS, Alberta Stroke Program Early CT Score; MCA, middle cerebral artery. 

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... stroke is fortunately a rare occurrence in pregnancy. However, when it does occur, neurologists can be faced with difficult therapeutic decisions. Specifically, how should neurologists select among therapeutic options when clinical trial data are lacking? In this article, we report a case of acute stroke in pregnancy successfully treated with intravenous (IV) thrombolysis and stent-retriever thrombectomy, the first reported case of which we are aware. We briefly review the literature on acute stroke treatment in pregnancy and consider the way therapeutic decision making occurs in the absence of evidence from randomized clinical trials (RCTs). Mrs R is a 32-year-old woman, Gravida 4 Para 2 (G4P2), at 37 weeks gestation who arrived in the emergency department approximately 50 minutes after developing right-sided weak- ness and global aphasia. The heart rate was 127, and the blood pressure was 134/87. Neurological examination demonstrated that the patient was mute but was able to follow some com- mands, with right hemiparesis and hemisensory loss. Her initial National Institutes of Health Stroke Scale (NIHSS) score was 16, consistent with a significant clinical deficit. A review of her past medical history revealed hypothyroid- ism, obesity, and obstructive sleep apnea. Her only medication was levothyroxine. She had no known allergies. Laboratory studies were normal. The unenhanced computed tomography (CT) scan of the head demonstrated a hyperdense left middle cerebral artery (MCA) sign with early ischemic changes in the left lentiform nucleus and insular cortex. The Alberta Stroke Program Early CT Score (ASPECTS) was 8, suggesting minimal completed infarction. A CT angiogram demonstrated a sharp occlusion in the first (M1) segment of the left MCA with good collateral circulation (Figure 1). The incidence of ischemic stroke in pregnancy is difficult to quantify, with estimates varying from 4 to 40 per 100 000 pregnancies. 1 It is controversial to what degree pregnancy should be considered a risk factor for stroke in and of itself. 2,3 Mechanisms of stroke in pregnancy and the puerperium may reflect common processes (smoking and hypertension) or rarer processes such as postpartum cardiomyopathy, coagulopa- thies, and vasculopathies. 4 Therapeutic options for ischemic stroke in pregnancy are similarly controversial. Seminal trials that investigated the use of tissue plasminogen activator (tPA), the only therapy cur- rently approved for acute ischemic stroke, explicitly excluded pregnant patients. 5 The major complication associated with the use of thrombolytics is hemorrhage, be it intracranial, gas- trointestinal, or intrauterine. Tissue plasminogen activator does not cross the placenta but may precipitate placental hemorrhage, which would be the major complication specific to a pregnant patient population. 1 To date, only a small number of reported cases have detailed the use of IV tPA in pregnancy and the puerperium. 6,7,8,9 Of 6 reported cases, 1 patient died, 1 had minor hemorrhagic transformation of the infarct, and 1 had an intrauterine hema- toma; in 3 cases the pregnancy was lost or was terminated. 1 Among 28 pregnant patients who received thrombolysis for any thromboembolic process, the cumulative risk of death was 7 % and the risk of fetal demise for any reason was 24 % . 9 Despite the absence of randomized trial data to support the use of thrombolytics in pregnancy, several leading experts have advocated that ‘‘thrombolysis should be considered for all potentially disabling strokes during pregnancy,’’ (p. 88) arguing that the ‘‘risk is low and the likelihood of benefit from IV tPA significant.’’ 10 Pregnant patients have also been excluded from recent and ongoing trials of intra-arterial stroke therapy (thrombolysis and mechanical thrombectomy), and there are no published experiences on the use of modern mechanical thrombectomy devices for ischemic stroke during pregnancy. 11,12,13,14 However, endovascular therapy can be successful with lower doses of thrombolytic agents or none at all, 15 as in the case of the latest generation of stent retrievers. Several case reports have outlined the uses of intra-arterial thrombolytics for the treatment of stroke in pregnancy without complications. 16,17,18 However, endovascular management is not without risk, and 1 pregnant patient is reported to have died due to iatrogenic intracranial dissection during attempted administration of intra-arterial tPA. 8 At the time of this patient’s presentation, no positive clinical trials had yet been published to support stent-retriever thrombectomy, though the clinicians involved had been active recruiters into several endovascular trials. Therapeutic options in this case included no acute therapy, IV thrombolysis with tPA, intra-arterial clot removal with a modern stent retriever, or a combination of IV and intra-arterial therapies. The obstetrical team was consulted, and they advised that medical management should prioritize the moth- er’s health. The initial reaction of the neurologist on call was to prefer intra-arterial over IV therapy in this case, reflecting the lack of randomized trial data for IV tPA in pregnancy and concerns about hemorrhage related to the use of systemic thrombolytics in this population. Granted, there was an equiv- alent lack of clinical trial evidence for the use of intra-arterial thrombectomy in pregnancy. Moreover, there was as yet no randomized trial data supporting endovascular stroke therapy at the time this decision was being made. In addition, both neuroangiography suites in the institution were occupied by patients undergoing procedures, and the start of an intervention on Mrs R would be delayed. The inter- ventional neuroradiologists consulted on the case anticipated that the procedure would be challenging, given the patient’s body habitus and the anatomy of her aortic arch. Therefore, the neurologist on call considered administering IV tPA while awaiting endovascular therapy. This option was discussed with a second staff neurologist and with Mrs R.’s husband. He was distressed but agreed to pursue both therapies should they be necessary. Intravenous tPA was administered 49 minutes after the patient’s arrival in the emergency department and 1 hour 39 minutes after symptom onset. Endovascular therapy began during the tPA infusion, and partial recanalization of the occluded MCA was achieved after the first pass of a Trevo stent retriever approximately 2.5 hours after symptom onset. After a second pass with the device, an excellent angiographic result (Tici-3a flow) was obtained (Figure 2). Immediately postprocedure, Mrs R demonstrated only mild right facial droop, with an NIHSS score of 1. A fetal ultrasound was normal. The patient was admitted to the ...