Mechanical Thrombectomy as Stroke Management in Pregnancy: A Systematic Review

Abstract

BACKGROUND:

To assess the safety, efficacy, and maternal and fetal outcome of mechanical thrombectomy (MT) for ischemic stroke in pregnancy, given the increased risk due to physiological cardiovascular and coagulation changes.

METHODS:

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered in the International Prospective Register of Systematic Reviews. Studies were sourced from PubMed, Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, and Excerpta Medica Database, including records up to May 2024. All relevant studies reporting on pregnant patients diagnosed with ischemic stroke and treated with MT, either alone or in combination with thrombolytics (tPA [tissue-type plasminogen activator]), were included regardless of study design. Endovascular MT techniques, including stent retrievers and aspiration thrombectomy, were evaluated. Patient demographics and procedural characteristics were extracted and analyzed. Primary maternal stroke–related outcomes included functional independence at 90 days, defined by a modified Rankin Scale (mRS) score of ≤2, and successful recanalization based on a modified Treatment in Cerebral Infarction score of ≥2B. Maternal safety outcomes assessed the occurrence of any complications (deep vein thrombosis/pulmonary embolism and intracranial hemorrhage) and mortality. Neonatal outcomes were evaluated based on mortality and overall health at follow-ups.

RESULTS:

The database search initially identified 785 records. After removal of duplicates, 143 studies remained for screening. Of these, 46 full-text articles were assessed for eligibility, yielding 16 studies that met the inclusion criteria. Cumulatively, the study included 26 cases, with a mean maternal age of 32.6 years. Stroke occurred most frequently in the first and third trimesters (each n=11/26; 42.3% [95% CI, 23.4–63.1]), followed by the second trimester (n=4/26; 15.4% [95% CI, 4.4–34.9]). MT was performed using various techniques, including a combination of stent retrievers and aspiration thrombectomy (n=11/25; 44.0% [95% CI, 24.4–65.1]), stent retrievers alone (n=5/25; 20.0% [95% CI, 6.8–40.7]), and aspiration thrombectomy alone (n=9/25; 36.0% [95% CI, 18.0–57.5]). Successful recanalization (modified Treatment in Cerebral Infarction score ≥2B) was achieved in 21 of 23 cases (91.3% [95% CI, 72.0–98.9]), with 7 achieving complete reperfusion (modified Treatment in Cerebral Infarction score, 3). No maternal deaths were reported; minor residual neurological symptoms (mRS score, 1) and slight disabilities (mRS score, 2) were observed in 11 cases, while 9 patients had no symptoms at follow-up (mRS score, 0). Among patients with reported follow-up mRS scores, functional independence (mRS score, 0–2) was achieved in 20 of 20 cases (100.0% [95% CI, 83.2–100.0]). Fetal outcomes included 16 of 24 successful pregnancies (66.7% [95% CI, 44.7–84.4]), 3 of 24 healthy ongoing pregnancies (12.5% [95% CI, 2.7–32.4]), 3 of 24 elective terminations (12.5% [95% CI, 2.7–32.4]), and 2 of 24 pregnancy losses (8.3% [95% CI, 1.0–27.0]), including 1 abortion due to an obstetric factor and 1 spontaneous abortion.

CONCLUSIONS:

MT is a viable treatment for ischemic stroke in pregnancy, balancing maternal benefits against fetal risks, including radiation exposure and anticoagulation considerations. Careful patient selection and procedural modifications are essential. Despite limited data, MT demonstrates favorable maternal and fetal outcomes. More systematic reporting and larger studies are needed to develop standardized guidelines, ensuring the safety of both mother and neonate.

CLINICAL PERSPECTIVE.

What Is New?

• This study reinforces that pregnancy should not be an absolute contraindication for mechanical thrombectomy.

• This study highlights the need for individualized patient selection and procedural adjustments to minimize fetal risks.

What Are the Clinical Implications?

• Mechanical thrombectomy can be performed safely in pregnant patients with ischemic stroke, with favorable maternal and fetal outcomes.

• Radiation exposure remains a concern but can be minimized with proper precautions.

• Most patients achieved successful reperfusion.

Stroke in pregnancy can lead to devastating maternal and neonatal complications. Although stroke rarely occurs during pregnancy, pregnant women are at a significantly higher risk of developing ischemic or hemorrhagic stroke compared with the general population.¹ Population-level data indicate that ischemic stroke complicates ≈5 and 35 per 100 000 pregnancies.² In women of childbearing age, large-vessel occlusions account for a minority of ischemic strokes, and the proportion is likely even lower during pregnancy.² Several cardiovascular and hemodynamic changes in physiology could contribute to this increased risk.³

In stroke management, the primary objective is to restore blood flow to the brain, achievable through thrombolytic therapy or mechanical thrombectomy (MT). Intravenous thrombolysis with tPA (tissue-type plasminogen activator) and endovascular MT are the most effective treatments for acute ischemic stroke. Published literature indicates that data on the safety of tPA use during pregnancy are limited, and its safety remains uncertain.⁴ When thrombolysis is contraindicated, it poses a significant challenge for obstetric care providers in determining the optimal treatment approach. It is also important to consider the risks of fetal radiation exposure when addressing MT in early pregnancy.⁵

Although pregnancy should not be considered an absolute contraindication for MT, the decision to withhold standard therapy must be carefully considered due to the substantial risk associated with nonintervention.⁶ Supporting this, a large-scale US claims analysis found MT to be safe and effective in pregnant and postpartum women with acute ischemic stroke, with lower complication rates than in nonpregnant patients and no in-hospital maternal or fetal deaths.⁷ A prospective study by Cai et al⁸ has shown that radiation exposure during cerebral artery angiography may have harmful effects on the human body. Therefore, minimizing the use of ionized radiation and iodinated contrast agents is a crucial consideration, especially for pregnant women. In addition, a systematic review by Gomes et al⁹ demonstrated that the risks associated with using thrombolytics during pregnancy seem justified, given the increased risk of mortality.

Despite various studies evaluating the efficacy of MT and intravenous thrombolysis, there is a notable lack of inclusion of pregnant women. The management of ischemic stroke in pregnant women remains a topic of ongoing debate and investigation. The aim of this study is to give cohesive insights into the outcomes of the use of MT in pregnant individuals.

Methods

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Search Strategy

According to the guidelines set in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 framework for conducting systematic reviews,¹⁰ we executed a comprehensive systematic review of the use of MT in acute ischemic stroke management in pregnancy (Supplemental Material). The registration of this review can be found in the International Prospective Register of Systematic Reviews registry (Unique identifier: CRD42024556204). Systematic search of the PubMed, Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, and Excerpta Medica Databases was utilized from inception until May 2024. Key terms used for the systematic search included a comprehensive variation of MeSH terms tailored to stroke, pregnancy, thrombectomy, and tPA. References cited within the included studies were manually screened to identify relevant literature, which might have been overlooked. Authors independently completed the primary screening of titles and abstracts and subsequently finished the secondary screening. In case of conflicting opinions, authors would resolve them through discussion. The inclusion criteria for this review encompass studies from any publication date, which are in English, including pregnant patients, and report relevant clinical outcomes.

The review accepts all eligible studies involving the use of MT in pregnancy, regardless of study design, gestational age at presentation, stroke subtype, MT technique, or clinical outcome, to provide a comprehensive overview of current practices, therapeutic approaches, and maternal-fetal outcomes reported in the literature. Exclusion criteria eliminate studies not in English, those excluding pregnant populations, those lacking relevant outcomes, and patients not using tPA or MT, or nonoriginal articles.

Data Extraction and Management

Data were independently extracted by the authors from the text, tables, and figures of the included studies using a standardized, predesigned extraction form. Extracted data included variables related to maternal, neonatal, and stroke outcomes. Due to the qualitative nature and small sample sizes of the included studies, primarily case reports and case series, no meta-analytical statistical methods were applied. Instead, we conducted a descriptive synthesis of the data. Frequencies and proportions were used to summarize categorical variables, such as comorbidities, procedural details, and outcomes. Exact binomial 95% CIs (Clopper-Pearson) were calculated for proportions. Continuous variables, such as maternal age and National Institutes of Health Stroke Scale (NIHSS) scores, were reported as means or ranges where available. Given the inherent heterogeneity and limited reporting across studies, no comparative or inferential statistics were performed.

Maternal Variables

Data extracted for maternal variables included age (in years) and the presence or absence of conditions such as hypertension, hyperlipidemia, diabetes, cardioembolism, unspecified comorbidities, coagulopathies, and prior stroke.

Stroke-Related Variables

Stroke-related variables extracted included the type of presentation (direct admission or transfer). MT-specific data encompassed access routes (femoral or radial), device selection (eg, stent retrievers such as Trevo or Solitaire, aspiration systems such as Penumbra, and adjunctive tools such as balloon guide catheters), technique used, number of passes, and anesthesia use. These device-related parameters were treated as variables of interest given their potential influence on recanalization success, complication rates, and overall procedural safety. Timing metrics (door-to-needle and door-to-recanalization time, in minutes) were also collected. Neurological outcomes were assessed using NIHSS score at presentation,¹¹ posttreatment, and at discharge, as well as the modified Thrombolysis in Cerebral Infarction (mTICI) scores following thrombolysis and thrombectomy.¹² Additional procedural details recorded included occlusion site and occurrence of complications, such as intracranial hemorrhage or venous thromboembolism (deep vein thrombosis [DVT]/pulmonary embolism [PE]).

Primary Maternal Outcomes

Successful maternal outcomes were assessed using functional independence at 90 days poststroke onset, defined by a modified Rankin Scale (mRS) score of ≤2 and successful recanalization as indicated by an mTICI grade of ≥2B.¹³ Other functional outcomes included mortality at 90 days poststroke onset, occurrence of intracranial hemorrhage, residual stroke symptoms, in-hospital mortality, length of stay, and post-MT prophylaxis.

Neonatal Variables

Data included fetal outcomes, gestational age at the moment of stroke, gestational age during birth, mode of delivery, and details of pregnancy termination (gestational week and reason for termination), as well as status on follow-up and duration or end point.

Results

Patients’ Demographics, Comorbidities, and Relevant Medical History

We initially identified a total of (n=785) records. Following the evaluation of titles, abstracts, full-text reports, and the subsequent removal of duplicates, 16 eligible studies met our inclusion criteria. We analyzed 12 case reports and 4 case series detailing the demographics, comorbidities, and relevant medical history of pregnant individuals undergoing MT for stroke management (Table 1).

Table 1.

Patients’ Demographics, Comorbidities, and Relevant Medical History

The combined case reports and series comprised 26 female patients who underwent MT, with a mean age of 32.56 years. Regarding comorbidities, hypertension was reported in 4 case reports.^20,24,27 Limaye et al²⁷ also reported one case with comorbid diabetes. A total of 4 patients had previously experienced a stroke.^24,27 Other notable comorbidities included protein S deficiency, ovarian hyperstimulation syndrome, rheumatic heart disease, patent foramen ovale, and others, as shown in Table 1.

Stroke Presentation and Management

Among the cases summarized in Table 1, patients presented across all trimesters, with equal frequency in the first and third trimesters (n=11; 42.3% [95% CI, 23.4–63.1]) and fewer in the second trimester (n=4; 5.4% [95% CI, 4.4–34.9]).

Anesthesia use varied among patients; 6 cases were given conscious sedation, 5 cases were performed under general anesthesia, and 5 cases had local anesthesia alone, as shown in Table 2. Patient presentation was evenly split between direct admissions and transfers, with 13 cases in each group. Femoral access was the most common method used (18 cases), with NIHSS scores at presentation ranging from 2 to 28 with a mean of 15.2. Only Shah et al²⁴ utilized radial access. tPA was administered in 13 cases, with the time to administration generally exceeding 1 hour (Table 2).

Table 2.

Stroke Presentation and Management

Time to revascularization was averaged at ≈4.5 hours. As shown in Table 2, MT was performed using a combination of stent retrievers and aspiration thrombectomy in about 44% of cases (n=11; 44.0% [95% CI, 24.4–65.1]), occasionally with the aid of a balloon guide catheter for enhanced clot removal, as mentioned in Deshmukh et al¹⁷ and Limaye et al.²⁷

Aspiration thrombectomy alone was utilized in 9 cases (36.0% [95% CI, 18.0–57.5]), while stent retrievers alone were used in 5 procedures (20.0% [95% CI, 6.8–40.7]), indicating its continued relevance as an independent treatment option (Table 2). A variety of MT devices and adjunctive systems were used across procedures. Commonly used stent retrievers included the Solitaire FR (Medtronic), used in 3 cases,^14,17,26 and Trevo stent retrievers (Stryker), used in 4 cases (Table 2).

The Penumbra aspiration system was used in 7 procedures.^{4,21,24–26,28} Additional adjunctive tools, including the FlowGate 8F balloon guide catheter (Stryker) and the Sofia distal access catheter (MicroVention), were also mentioned. In one case, a pREset 4 × 20 mm stent retriever (Phenox GmbH) was used.²⁶

In the case described by Zhang et al,¹⁹ the specific thrombectomy device was not mentioned; however, the authors reported using a 5F intermediate catheter for thrombus aspiration. Studies that did not specify MT device types or techniques are summarized in Table 2.

The number of passes ranged from 1 to 5. Revascularization was achieved on the first pass in 8 patients and on the third pass in 6 patients (Table 2). Reported radiation doses in MT vary widely depending on the measurement used. The included studies variably reported maternal radiation exposure using absorbed dose,^21,27 effective dose,²⁸ or dose-area product.²⁶ However, none provided direct estimates of fetal absorbed dose relevant to conceptus safety.

As shown in Table 2, post-MT mTICI scores demonstrated successful reperfusion (mTICI score ≥2b) in 21 of 23 cases (91.3% [95% CI, 72.0–98.9]) with available data. Specifically, complete reperfusion (mTICI score 3) was achieved in 7 cases (30.4%), near-complete reperfusion (mTICI score 2c) in 3 cases (13.0%), and substantial reperfusion (mTICI score 2b) in 11 cases (47.8%). Partial reperfusion (mTICI score 2a) was observed in 2 cases (8.7%), and 3 cases did not report mTICI scores.

The vessel most commonly occluded was the middle cerebral artery (M1 segment). All other documented occlusions were from the anterior circulation, except for the basilar occlusion reported in the study by Bhogal et al.²⁶ Although it represents a single case, it achieved excellent post-MT recanalization (mTICI score, 3), with minor residual symptoms. As for the cause of the strokes among the patients, cardioembolism was identified in 6 cases, while cryptogenic strokes were reported in 15 cases. All the patients who had a cardioembolic stroke had valvular heart disease,^19,25 septal defects,^21,26 or cardiomyopathy.²⁴

Maternal and Fetal Outcomes

Among all 26 cases, no patient experienced intracranial hemorrhage or DVT/PE. However, 2 cases describe hemorrhagic transformation of infarction (hemorrhagic infarction type 1).^22,27 NIHSS score at discharge varied, but most reported scores revealed minor (9 cases) to no (4 cases) stroke symptoms (Table 3). Less desirable scores indicating moderate stroke were noted in 4 cases.^14,15,22,27

Table 3.

Maternal and Fetal Outcomes

Table 3 shows how the length of hospital stay varied significantly across cases, averaging ≈8 days. Residual symptoms varied across the reported cases. The majority of patients either had no deficits documented or none reported. Among those with persisting symptoms, most were mild, including minor upper limb weakness,²³ subtle facial droop,²⁸ slight dysphasia,²⁸ mild hand paresis,²⁶ or minimal spasticity.¹⁵ A few cases noted functional limitations such as ambulation with a walker,²⁴ mild internuclear ophthalmoplegia,²⁶ or a general description of slight disability, as shown in Table 3. Only 1 patient was reported to have a moderate deficit, presenting with aphasia.¹⁴ Overall, residual impairments were generally minor, with complete or near-complete recovery being the predominant outcome.

Fetal outcomes were available for 24 of 26 cases (92.3%), with 2 cases lacking fetal status reporting. Among the 24 cases with available data, outcomes were largely positive, with the majority resulting in successful term deliveries (n=16; 66.7% [95% CI, 44.7–84.4]), and 3 pregnancies (12.5% [95% CI, 2.7–32.4]) were ongoing at the time of data cutoff. Elective terminations due to maternal wishes or concerns over MT adverse effects occurred in 3 cases (12.5% [95% CI, 2.7–32.4]) reported by Yoshida et al,¹⁴ Zhang et al,¹⁹ and Morello et al.²⁰ Spontaneous first-trimester abortions occurred in 2 cases (8.3% [95% CI, 1.0–27.0]) as reported by Moriyama et al²¹ and Limaye et al.²⁷ Moriyama et al²¹ presumed to be due to an obstetric factor causing intrauterine fetal demise at 13 weeks of gestation. The mother wished to proceed with delivering the fetus at 15 weeks of gestation.²¹

Follow-up durations ranged from 1 month to 8 years. Neonate exams, midwife follow-ups, and long-term follow-ups demonstrated 12 documented positive outcomes^{4,15–18,23,25,26,28} in addition to 3 healthy ongoing pregnancies.^22,24,26 During this period, approximately half of the patients received post-MT prophylaxis, most commonly in the form of oral antiplatelet or anticoagulant therapy, or subcutaneous low-molecular-weight heparin. As shown in Table 3, follow-up mRS scores were available for 20 of 26 patients (76.9%), with 6 cases not reporting mRS scores. Among the 20 patients with available data, all (100.0% [95% CI, 83.2–100.0]) achieved functional independence (mRS score ≤2). Specifically, mRS scores of 0, 1, and 2 were observed in 9 (45.0%), 7 (35.0%), and 4 (20.0%) cases, respectively.

Discussion

In our study, we reviewed 26 cases, focusing on key aspects of the therapeutic approach for pregnant patients with stroke to guide physicians. Unlike large population-based studies, which show that most pregnancy-associated strokes occur in the second trimester (20.6%) and postpartum (45.4%), when hypercoagulability, vascular stress, and rising blood volume peak,^3,29 our series differed in that cases were more common in the first and third trimesters. This pattern may reflect selection differences and reporting bias but also the presence of additional risk factors in early and late pregnancy, such as structural heart disease and underlying hypercoagulable states, which likely contributed to the clustering of first and third trimester events. Importantly, these findings underscore that stroke can occur at any stage of pregnancy and should remain a diagnostic consideration even early on.

When considering the potential consequences of physiological hypercoagulability, other conditions such as MI, DVT, and PE also warrant attention. Pregnant individuals are notably more susceptible to these conditions.^30,31 In our study, patients already diagnosed with thrombophilic disorders (protein S deficiency, factor V Leiden mutation, and ovarian hyperstimulation syndrome) likely experienced an exacerbation of their condition due to the aforementioned pregnancy-related changes. To address the minority of patients in our review who experienced hemorrhagic infarction type 1 hemorrhagic transformation (n=2), it is noteworthy that both had received tPA.^22,27 Whether pregnancy-related hypercoagulability alters the risk of hemorrhagic transformation after reperfusion therapy remains uncertain; physiological hypercoagulation could theoretically mitigate bleeding, yet pregnancy-related hemodynamic changes (such as increased blood volume and cardiac output) and hormonal effects on vascular reactivity, together with the use of tPA in select patients, may conversely increase susceptibility.

We predominantly observed anterior circulation occlusions, with only a single case involving the basilar artery.²⁶ The limited number of reported posterior circulation strokes may be related to physiological changes associated with pregnancy. Larger studies are needed to confirm whether this association truly exists. In addition, the variability in NIHSS scores reflects the diverse presentation of stroke severity and outcomes, emphasizing the need for individualized treatment approaches. The use of post-MT prophylaxis in several cases underscores its importance in preventing recurrent thrombotic events, aligning with standard clinical practices. Studies have demonstrated that such prophylaxis significantly reduces the risk of subsequent strokes and other thromboembolic events, thereby improving maternal outcomes.³² Implementing individualized anticoagulation strategies post-MT is, therefore, necessary in this high-risk group.

A subset of patients, as shown in Table 1, displayed a variety of structural heart diseases (n=7), such as atrial septal defect, mitral valve replacement, patent foramen ovale, rheumatic heart disease, and dilated cardiomyopathy. Given that structural heart disease is a well-established risk factor for stroke,³³ this underscores the necessity for careful anticoagulation prophylaxis in this patient population.³⁴ Notably, 3 patients with mechanical mitral valves developed cardioembolic strokes despite being on low-molecular-weight heparin prophylaxis.^19,25 In 2 cases, oral anticoagulants had been recently transitioned to low-molecular-weight heparin before stroke onset.²⁵ These events underscore the importance of standard prophylactic strategies in mitigating thromboembolic risk during the hypercoagulable state of pregnancy. In addition, the physiological strain and hypercoagulability of pregnancy in patients with underlying cardiac disease and thrombophilic diseases may contribute to residual symptoms observed in some of the cases^{14,15,19,21,23–27}; however, further studies are required to clarify and establish this relationship.

It is worth mentioning that failure of prophylaxis in conditions requiring anticoagulation, such as PE and DVT, occurs in ≈2.5% of pregnant women.³⁵ Factors contributing to these failures may include nonadherence, incorrect dosing, drug-drug interactions, and other variables.

Our results demonstrated an almost equal reliance on aspiration alone (n=9) and combined aspiration-stent retriever techniques (n=11). This distribution aligns with growing evidence that aspiration is a valid first-line option. Randomized trials, such as ASTER (2017; Aspiration Versus Stent Retriever for Successful Revascularization) and COMPASS (2019; Comparing the Penumbra System Aspiration Thrombectomy With Stent Retriever Thrombectomy), showed that direct aspiration achieved comparable rates of successful revascularization and functional outcomes to stent retrievers, with 90-day independence (mRS score, 0–2) occurring in roughly half of patients in both groups.^36,37

When combining aspiration with a stent retriever (eg, Solumbra or CAPTIVE techniques), randomized data suggest no clear superiority over single-device strategies. The ASTER2 trial (2021; Aspiration Plus Stent Retriever Versus Stent Retriever Alone) reported similar near-complete reperfusion rates (mTICI score 2c/3 in 64.5% versus 57.9%) and equivalent 90-day functional independence and safety outcomes between combination therapy and stent retriever alone.³⁸ Thus, while combination approaches may provide procedural flexibility in complex cases, current evidence supports both aspiration-first and stent retriever-first strategies as effective standalone options, with no consistent advantage demonstrated for routine dual-device use.

The diversity of devices noted (multiple stent retriever brands, various aspiration catheters, and so on) underscores an important aspect of current endovascular therapy: no single device or technique fits every scenario. Interventionalists often prepare a toolbox of catheters and retrievers, selecting or combining them based on clot location, vessel size, and clot characteristics. For example, large-bore aspiration catheters (such as ACE 68 or Sofia) can directly ingest clots when positioned at the occlusion, while stent retrievers are excellent for ensnaring clots, especially in tortuous distal vessels or when aspiration alone is insufficient. The concurrent use of balloon guide catheters (eg, FlowGate) in some procedures is noteworthy. By inflating a balloon in the carotid during thrombectomy, forward blood flow is temporarily halted, which markedly reduces the risk of distal embolization and can improve the success of the first pass.³⁹

The number of passes required to achieve successful recanalization varied significantly, with some cases achieving success on the first pass, while others required multiple attempts. Achieving recanalization on the first pass often resulted in a favorable mTICI score of 3, which aligns with existing literature, suggesting that first-pass success is associated with better clinical outcomes and reduced procedural time.⁴⁰ However, it is essential to note that cases requiring multiple passes in our study also showed acceptable outcomes upon follow-up.

For pregnant patients, minimizing fetal radiation remains a primary goal. Yet, across the available reports, radiation data were limited to maternal exposure metrics (absorbed dose, effective dose, or dose-area product), without fetal dose assessment. Because fetal risk thresholds are expressed in absorbed dose (50–100 mGy),⁴¹ the absence of such data precludes direct evaluation of fetal safety in these cases. Nonetheless, strategies such as minimizing fluoroscopy time, optimizing collimation, applying abdominal shielding, and carefully selecting procedural approaches remain essential to reduce exposure.⁴²

While femoral access is typically favored in emergencies, radial access may reduce scatter to the pelvis and, thus, offer an advantage in pregnancy. Nonetheless, consistent with prior reports,⁴³ concerns about fetal harm remain central to patient decision-making, even when physicians emphasize the relative safety of fluoroscopy.⁴⁴ For instance, Zhang et al¹⁹ described a patient who elected pregnancy termination despite reassurances, underscoring the importance of accurate counseling and public awareness to reduce anxiety surrounding radiation risks. The variability in reported exposure during MT highlights the influence of operator technique and case complexity. Studies in nonpregnant patients demonstrate that radiation dose increases with each additional pass, doubling by the third and tripling by the fifth, illustrating how procedural factors shape overall exposure.⁴⁵ Ultimately, balancing the maternal benefit of MT against fetal radiation risk requires not only technical precautions but also thoughtful, evidence-based counseling to support informed decision-making.

Despite incomplete dosimetry, our pooled outcomes support MT as a safe and effective reperfusion strategy in pregnancy when clinically indicated, aligning with current literature.⁶ Positive outcomes were seen throughout the study, with high rates of successful maternal and fetal outcomes. When comparing the gestational age during pregnancy and delivery, it can be seen that the earlier the presentation of stroke, the more likely the pregnancy was to be electively terminated. In 2 full-term pregnancies, the authors mention a 10- and 5-day period between stroke onset and delivery,^18,25 both of whom went on to have favorable fetal and maternal outcomes. One remarkable case of stroke, 18 days post-in vitro fertilization, managed to complete her pregnancy to term with only minor residual upper limb weakness.²³ The occurrence of stroke as a result of assisted reproductive technologies is rare, with only a few cases reported in the literature.

The absence of reported complications such as intracerebral hemorrhage or venous thromboembolism (DVT/PE) in these cases is consistent with existing literature, supporting the safety of MT in pregnancy. Goyal et al⁴⁶ support this claim, demonstrating the efficacy and safety of MT in clinical practice, with a low rate of adverse events, including intracranial hemorrhage and DVT/PE. The wide range of follow-up durations demonstrates the need for long-term patient monitoring to ensure ongoing health and manage any delayed complications. However, more studies are needed to confidently state specifics regarding the follow-up protocol. Our data were cut short with missing variables that could have added more depth to the stroke presentation and management. Variables such as the mRS score and periodic monitoring of NIHSS scores were sparsely documented.

Limitations

A significant limitation is the risk of bias due to the type of studies included being mostly case reports and series. These studies were also missing data in several key areas. First, there was a lack of detailed information on radiation exposure during MT, making it difficult to accurately assess fetal risk, despite the well-established concerns surrounding ionizing radiation in pregnancy. In addition, incomplete reporting of the thrombectomy devices used and the number of retrieval attempts limited assessment of procedural performance and success. Furthermore, the absence of outcome measures, such as more detailed mRS and NIHSS scores recording, combined with inconsistent long-term follow-up, hinders a comprehensive assessment of functional outcomes and the long-term safety of MT for both the mother and fetus. Our smaller sample size limits the ability to generalize findings to the broader obstetric population. A larger sample size would provide more robust insights into highlighting the diverse stroke presentations and procedural techniques, and hopefully highlight efforts to standardize comparisons and identify best practices.

Conclusions

This systematic review reveals the complexities of managing ischemic stroke in pregnant women who face increased risks due to cardiovascular and coagulation changes. MT, although practical, necessitates careful patient selection and consideration of fetal risks, such as radiation exposure. By emerging evidence and with meticulous planning, MT can lead to highly favorable outcomes. The review emphasizes how physicians planned and managed to achieve the best possible outcomes involving both the mother and neonate. Overall, MT is a viable option for acute ischemic stroke in pregnancy; however, decisions must be case-specific, balancing benefits and risks. Comprehensive data and systematic reporting are needed to establish official guidelines and ensure maternal and fetal safety.

ARTICLE INFORMATION

Sources of Funding

None.

Disclosures

None.

Supplemental Material

PRISMA 2020 Flow Diagram