Struggling with acute stroke in pregnancy
Year: 2026
Type: article
Abstract: Introduction: Acute ischemic stroke in pregnancy is rare, but it is a neurological emergency that can cause serious morbidity and mortality for both mother and fetus. The hypercoagulability, hemodynamic changes, and vascular adaptations that accompany pregnancy increase the risk of cerebrovascular events. Although mechanical thrombectomy is one of the standard reperfusion therapies in acute ischemic stroke due to large vessel occlusion, evidence on the efficacy and safety of treatment in this patient group is limited because pregnant women are underrepresented in randomized controlled trials. Nevertheless, current guidelines state that pregnancy alone is not a contraindication to mechanical thrombectomy and that endovascular treatment can be applied in suitable patients after multidisciplinary evaluation. This report presents the clinical course and treatment approach of a patient who underwent mechanical thrombectomy twice, in two different trimesters of the same pregnancy, for acute ischemic stroke due to large vessel occlusion.Case: A twenty-one-year-old woman with a mechanical heart valve replacement, at 10 weeks of gestation, presented with acute-onset aphasia and right hemiparesis while on low-molecular-weight heparin (LMWH). The initial NIHSS score was 9 and the initial mRS score was 0. To reduce radiation exposure because of the pregnancy, brain diffusion MRI and MR angiography were used. Mechanical thrombectomy was performed after a large vessel occlusion was found in the left MCA M1 segment. About three months later, at 31 weeks of gestation, the patient presented again with right hemiparesis and speech disturbance. The NIHSS score was 16. MRI showed acute ischemic changes in the territory of the inferior division of the left MCA M2, and because of clinical-radiological mismatch, endovascular treatment was planned again. At the first presentation, MR angiography had shown an occlusion at the left MCA M1 level and diffusion MRI the corresponding acute ischemic area. Systemic intravenous r-tPA was not given in early pregnancy. Lead shielding was applied over the abdomen and chest for fetal protection. In the mechanical thrombectomy performed under conscious sedation, TICI 3 recanalization was achieved at first pass using a combination of retrievable stent and aspiration. After the procedure, the patient was followed on LMWH and ASA. The mother was discharged with NIHSS 0 and mRS 0, and the fetus was healthy. About three months later, at 31 weeks of gestation, a second acute ischemic stroke occurred. MRI showed acute ischemic changes in the territory of the inferior division of the left MCA M2. Mechanical thrombectomy was performed because of clinical-radiological mismatch. TICI 3 recanalization was achieved using a two-pass combined stent-retriever and thromboaspiration technique. For the distal bed, 5 mg of intra-arterial tPA was given from the proximal left MCA. Histochemical examination of the retrieved thrombus was consistent with fibrinoid material. No intracranial hemorrhage occurred after the procedure. The patient was followed on LMWH and ASA; because she was in the third trimester, she was switched back to warfarin. The patient, discharged with an NIHSS of 0, had her pregnancy ended by elective cesarean section at 39 weeks.Discussion/Conclusion: Cardioembolism, cervical artery dissection, and prothrombotic states are among the important causes of ischemic stroke in pregnancy. Anticoagulation management in patients with mechanical heart valves requires balancing the maternal risk of thromboembolism against fetal safety. In our patient, the use of LMWH instead of warfarin in early pregnancy and the switch back to warfarin in the third trimester show the importance of an anticoagulation strategy tailored to gestational age. In the management of acute large vessel occlusion in pregnancy, it is important to reduce fetal radiation exposure as much as possible. In our patient, an MRI-based approach was preferred for brain and vascular imaging, abdominal lead shielding was used during the endovascular procedures to protect the fetus from radiation, and the procedure was completed as quickly as possible. In the first thrombectomy only mechanical reperfusion was used, whereas intra-arterial tPA was used during the second procedure, and successful TICI 3 recanalization was achieved in both interventions. Because the current evidence on mechanical thrombectomy in pregnancy consists largely of case reports and small series, sharing experience can contribute to clinical practice. This case shows that mechanical thrombectomy can be performed successfully in two separate large vessel occlusions that developed in the first and third trimesters of the same pregnancy. TICI 3 recanalization was achieved in both interventions, the mother recovered fully neurologically, and the pregnancy ended healthily. Pregnancy should not be regarded as a contraindication to mechanical thrombectomy on its own when there is an appropriate indication. A multidisciplinary approach by neurology, interventional neuroradiology, obstetrics and gynecology, cardiology, and anesthesia teams is essential for ensuring maternal and fetal safety in these patients.Keywords:
Language: English
Subfield: Clinical Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7225777068
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