Table 1.6.
Reported cases of thrombolysis and thrombectomy in pregnancy
| Author (year) | Maternal age (year) | Gestational age | Signs/symptoms | Risk factors/comorbidities | Imaging | Thrombolysis and/or thrombectomy (time after symptom onset) | Potential complications | Secondary prevention | Mode of delivery | Maternal outcome | Fetal outcome |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Rodrigues et al. (2019) | 29 | 27 weeks | R-sided weakness/numbness, hemianopsia, and aphasia | NA | Stroke code CTH/CTA: unremarkable Follow-up CTH: L MCA/ACA stroke |
IV tPA | NA | Aspirin and LMW heparin | C-section | Persistent expressive aphasia and R-sided weakness | Healthy |
| Blythe et al. (2019) | 29 | 39 weeks | L-sided weakness and neglect | Factor XI deficiency, gestational thrombocytopenia | CTA with R M1/2 occlusion | Thrombectomy (no tPA due to low platelets) | NA | Not reported | C-section | Asymptomatic | Healthy |
| Peksa et al. (2019) | 35 | 9 weeks | L-sided weakness and L visual field deficit and neglect | Prior history of preeclampsia, GDM | CTH with hyperdense R MCA, CTA with M1 occlusion | IV tPA | NA | Aspirin and LMW heparin | Vaginal | Mild residual symptoms (NIHSS 0, mRS 0) | Healthy |
| Watanabe et al. (2019) | 36 | 21 weeks | R-sided weakness, dysarthria, headache | NA | MRA: L ICA occlusion | IV tPA+ thrombectomy | NA | Not reported | Not reported | Mild residual weakness | Healthy |
| Landais et al. (2018) | 32 | 13 weeks | Aphasia and R-hand numbness | NA | MRI DWI restriction in L MCA territory and chronic R MCA stroke | IV tPA | NA | Aspirin, transitioned to warfarin postpartum | Vaginal | Residual aphasia | Healthy |
| Zhu et al. (2018) | 28 | 9 weeks | R-sided weakness and numbness and dysarthria | Previous miscarriage | CTH: early L MCA infarct signs and hyperdense MCA CTA: L MCA occlusion |
IV tPA+ thrombectomy | NA | LMW heparin | Vaginal | Asymptomatic at 1 year follow-up | Healthy |
| Shah et al. (2018) | 37 | 9 weeks | Recurrent L-sided weakness and R gaze preference 2 days apart | Hypertension, hyperlipidemia, and dilated cardiomyopathy | (1) CTH: early loss of gay-white differentiation in R MCA territory and hyperdense R MCA CTA: inferior M2 cutoff (2) CTH/CTA: R proximal M1 cutoff |
(1) Initial occurrence tPA with improvement (2) Thrombectomy after recurrence 2 days later |
NA | LMW heparin | Published prior to delivery | Mild residual weakness | Fetus healthy at follow-up |
| Jiang and Hu (2018) | 26 | 31 weeks | R-sided weakness and dysarthria | History of rheumatic fever with mitral regurgitation and prolapse | CTH: unremarkable MRI: multiple bilateral acute infarcts (R caudate, L BG, L CR) |
IV tPA | Small L cerebellar and R temporal hemorrhage | LMW heparin, then long-term warfarin | Vaginal | Asymptomatic | Healthy |
| Bhogal et al. (2017)(A) | 38 | 24 weeks | R-sided weakness/numbness, L gaze deviation, and aphasia | Drug abuse, PFO | CTH: hyperdense L MCA MRI: L lentiform nucleus and insular diffusion restriction Angio: terminal L ICA occlusion |
Thrombectomy (outside tPA window once transferred to referral center) | NA | Clopidogrel + aspirin for 3 month and then aspirin indefinitely | Vaginal | Mild residual weakness | Healthy |
| Bhogal et al. (2017) (B) | 36 | 25 weeks | Headache, nausea and vomiting, progressing to stupor | Prior type A aortic dissection | CTH: dense basilar CTA: distal basilar occlusion |
IV tPA + thrombectomy | NA | Ticagrelor+aspirin, then switched to prasugrel+aspirin | Published prior to delivery | Internuclear ophthalmoplegia only | Fetus healthy at follow-up |
| Khan et al. (2017) | 33 | 9 weeks | R-sided weakness/numbness and visual field cut | Prior miscarriages (11), tobacco and substance use disorder | CTH: unremarkable Repeat CTH: PCA infarct |
IV tPA | Fetal hemorrhage/demise | Aspirin, then long-term clopidogrel | D&C | Residual visual symptoms and weakness | First trimester loss |
| Reining-Festa et al. (2017) | 37 | 5 weeks | L-sided weakness | HTN, obesity, history of rheumatic fever, prior second semester miscarriage | MRI: R MCA diffusion restriction | IV tPA | NA | Aspirin, then LMW heparin | C-section | Residual sensory symptoms | Healthy |
| Tversky et al. (2016) | 31 | 5 weeks | R-sided weakness and dysarthria | Protein C and S deficiencies, DVT, PFO (presumed paradoxical embolism) | CTH unremarkable, MRI with L thalmocapsular DWI restriction | IV tPA | NA | LMW heparin | NA (published prior to delivery) | Asymptomatic at discharge | No evidence of abnormalities in second trimester |
| Bereczki Jr et al. (2016) | 40 | 2 weeks postpartum | R-sided weakness and aphasia | Cervical artery dissection, migraine, childhood epilepsy | CTH: R MCA hyperdensity CTA: RM1 occlusion, b/l ICA dissections |
IV tPA + thrombectomy (and stended R ICA) | NA | LMW heparin and clopidogrel | Vaginal | Asymptomatic at 6 weeks | Healthy |
| Boyko et al. (2016) | 32 | 37 weeks | R-sided weakness/numbness and aphasia | Hypothyroidism, obesity, and obstructive sleep apnea | CTH: hyperdense L MCA with early loss of gray-white differentiation CTA: L M1 occlusion |
IV tPA + thrombectomy | Asymptomatic hemorrhage | Aspirin | C-section | Residual facial droop | Healthy |
| Aaron et al. (2016) (A) | 24 | Third trimester | L-sided weakness | Rheumatic fever, mitral valve replacement (on LMWH) | MRI/A: diffusion restriction involving lateral lenticulostriate territory; R M1 occlusion | Thrombectomy | NA | Oral anticoagulation | Vaginal | Mild residual weakness | Healthy |
| Aaron et al. (2016) (B) | 28 | 37 weeks | L-sided weakness | Rheumatic fever, mitral valve replacement (on LMWH), severe IUGR | MRI/A: diffusion restriction in R putamen and R M1 occlusion | Thrombectomy | NA | LMW heparin, then oral anticoagulants postpartum | C-section | Residual weakness | Healthy |
| Pongracz et al. (2015) | 21 | 21 weeks | L-sided weakness | Tobacco use | CTH: unremarkable CTA: R M1 cutoff |
IA tPA | NA | LMW heparin | C-section | Mild residual weakness | Healthy |
| Ritchie et al. (2015) | 28 | 39 weeks | L-sided weakness/numbness | NA | MRI: small R MCA stroke | IV tPA | NA | Aspirin until delivery, clopidogrel and tinzaparin postpartum | Vaginal (forceps-assisted) | Full recovery at 8 months | Healthy |
| Ritter et al. (2014) | 32 | 36 weeks | R-sided weakness/numbness, dysarthria, neglect | Migraine with aura | CTA: L lower M2 occlusion | IV tPA | NA | Aspirin until delivery, clopidogrel postpartum | C-section | Residual weakness | Healthy |
| Tassi et al. (2013) | 28 | 16 weeks | R-sided weakness/numbness and aphasia | PFO, factor V Leiden | MRI/A: L MCA territory ischemic stroke | IV tPA | NA | Aspirin | Vaginal | Mild residual deficits | Healthy |
| Hori et al. (2013) | 35 | 13 weeks | L-sided weakness and visual field cut | Protein S deficiency | R PCA occlusion | IV tPA | NA | IV heparin—> warfarin at 15 weeks | C-section (w/general anesthesia) | Residual visual deficits | Healthy |
| Li et al. (2012) | 24 | 11 and 13 weeks | R-sided weakness and dysarthria at 11 weeks and facial numbness at 13 weeks | PFO, pulmonary AVM | L MCA ischemic stroke at 11 weeks and vertebrobasilar territory at 13 weeks | IA tPA | NA | Aspirin and enoxaparin | Vaginal | Residual weakness | Healthy |
| Yamaguchi et al. (2010) | 36 | 18 weeks | R-sided weakness/numbness and aphasia | Hashimoto disease | MRI/A: L MCA occlusion and high intensity areas | IV tPA | NA | Aspirin and heparin | Vaginal | Asymptomatic | Healthy |
| Méndez et al. (2008) | 37 | 15h after delivery | L-sided weakness/numbness, dysarthria and visual field cut | migraine | CTH: unremarkable Angiogram distal R M1 occlusion |
IA urokinase | NA | LMW heparin | C-section | Asymptomatic | Healthy |
| Wiese et al. (2006) | 33 | 13 weeks | R-sided weakness, aphasia | Prosthetic mitral valve thrombois, prior GDM | CTH: L BG/IC hypodensity | IV tPA | NA | LMW heparin | C-section | Residual weakness | Healthy |
| Murugappan et al. (2006) (A) | 37 | 12 weeks | NIHSS = 19 | Mitral valve replacement | R MCA occlusion | IV tPA | Intrauterine hematoma | NA | NA | Healthy | Medical termination of pregnancy |
| Murugappan et al. (2006) (B) | 31 | 4 weeks | Not reported | Protein S deficiency | L MCA occlusion | IV tPA | NA | NA | NA | Healthy | Medical termination of pregnancy |
| Murugappan et al. (2006) (C) | 29 | 6 weeks | NIHSS = 13 | Aortic valve replacement | R MCA occlusion | IV tPA | Arterial dissection during angioplasty | NA | NA | Death | Death |
| Murugappan et al. (2006) (D) | 43 | 37 weeks | NIHSS = 25 | Antithrombin 3, protein C and S deficiencies | L MCA occlusion | IA tPA | NA | NA | Not reported | Healthy | Healthy |
| Murugappan et al. (2006) (E) | 28 | 6 weeks | Not reported | Protein C and S deficiency, PFO | Basilar occlusion | IA urokinase | Buttock hematoma | NA | Not reported | Healthy | Healthy |
| Murugappan et al. (2006) (F) | 40 | 6 weeks | Not reported | PCV, essential thrombolysis | Superior sagittal sinus thrombosis | Local urokinase | Partial recanalization | NA | NA | Healthy | Fetal demise, chromosomal abnormality |
| Murugappan et al. (2006) (G) | 21 | 8 weeks | Not reported | +dRVVT, antiphospholipid antibodies | Cerebral venous thrombosis | Local urokinase | Enlargement of IVC-related hemorrhage | NA | NA | Healthy | Medical termination of pregnancy |
| Murugappan et al. (2006) (H) | 25 | First trimester | Not reported | Bacterial endocarditis | L MCA occlusion | Local urokinase | NA | NA | NA | Healthy | Spontaneous abortion |
| Leonhardt et al. (2006) | 26 | 23 weeks | R-sided weakness | Antiphospholipid syndrome | MRI: L BG diffusion restriction and L M1 occlusion | IV tPA | NA | LMW heparin | Vaginal | Residual weakness | Healthy premature |
| Johnson et al. (2005) | 39 | 37 weeks | L-sided weakness, dysarthria, field cut, and neglect | Chronic hypertension | CTH: unremarkable Angiogram: R M1 occlusion |
IA tPA | NA | Not reported | Vaginal (forceps-assisted) | Asymptomatic | Healthy |
| Weatherby et al. (2003) | 29 | 9 weeks | L-sided weakness and papilledema bilaterally | NA | CTH: increased attenuation of superior sagittal sinus with associated edema MRI/MRV: absence of flow in SSS | Direct thrombolysis | NA | Dalteparin | Vaginal | Asymptomatic | Healthy |
| Elford et al. (2002) | 28 | 3–4 weeks (7 days embryo transfer of IVF) | L-sided weakness, dysarthria | Ovarian hyperstimulation syndrome | CTH: early R perisylvian/frontal/parietal changes CTA: R M1 occlusion |
IA tPA | Small R BG hemorrhage | Dalteparin | Vaginal | Mild residual symptoms | Healthy |
| Dapprich and Boessenecker (2002) | 31 | 12 weeks | R-sided weakness and aphasia | Protein S deficiency | CTH: early L BG hypodensity; TCD w/L M1 occlusion MRI: L BG hemorrhagic transformation |
IV tPA | Small L BG hemorrhage | Aspirin 100mg and LMW heparin | Not reported | Mild residual symptoms | Healthy |