Table 1.3.

Principles of acute ischemic stroke management in pregnancy

Management step	General population	Additional considerations due to pregnancy status
Initial history	• Last known well • Brief history focusing on tPA exclusion criteria	•Determine gestational age •Early involvement of obstetrics team
Initial studies	• Blood glucose by fingerstick • Complete blood count, basic metabolic panel, and coagulation studies • EKG and troponin Note: only blood glucose by fingerstick is needed prior to tPA unless there is suspicion for thrombocytopenia or coagulopathy	• Urine or serum beta-HCG test (for all women of childbearing age) • Fetal monitoring when >24 weeks gestation (particularly when abnormal maternal blood pressure)
Other considerations		• Magnesium sulfate administration in cases of severe preeclampsia
tPA candidates	• Clinical diagnosis of stroke with disabling deficits • Defined onset and able to start treatment within 4.5h of onset • Brain imaging without evidence of hemorrhage, most commonly by noncontrast head CT • No contraindications to tPA by history and labs	• No additional inclusion or exclusion criteria • CT head without contrast acceptable with counseling on imaging-associated risks • MRI also acceptable, but imaging modality should be determined by whichever modality most readily available
Thrombectomy	• Vessel imaging, most commonly by CT angiography, showing a large vessel occlusion • Defined onset and able to start treatment within 6h of onset • If onset within 6–24 h, perfusion imaging showing a large area of salvageable brain tissue relative to the core infarct (with additional criteria per DEFUSE-3 and DAWN studies)	• CT angiography (head and neck) acceptable vessel imaging • MRA also acceptable, but imaging modality should be determined by whichever imaging modality most readily available • If perfusion imaging required for extended-window thrombectomy eligibility, CT perfusion should be used rather than MR perfusion to avoid use of gadolinium contrast