Several recent randomised control trials have shown adjunctive endovascular mechanical thrombectomy to be an effective and safe treatment for acute stroke superior to medical therapy alone. Despite this, questions remain over certain groups of patients that have been excluded from these studies, such as pregnant women. We believe this is a topic of increasing clinical significance with minimal data in the literature. In this article we discuss stroke in pregnancy and highlight the important technical considerations of endovascular mechanical thrombectomy, including minimising radiation exposure to the mother and fetus.
Miller EC and Leffert L. Stroke in pregnancy: a focused update. Anesth Analg. 2020; 130: 1085–1096.
2.
SwartzRCayleyMLFoleyN, et al.The incidence of pregnancy-related stroke: a systematic review and meta-analysis. Int J Stroke2017; 12: 687–697.
3.
CauldwellMRuddANelson-PiercyC. Management of stroke and pregnancy. Eur Stroke J2018; 3: 227–236.
4.
MoattiZGuptaMYadavaR, et al.A review of stroke and pregnancy: incidence, management and prevention. Eur J Obstet Gynecol Reprod Biol2014; 181: 20–27.
5.
ScottCABewleySRuddA, et al.Incidence, risk factors, management, and outcomes of stroke in pregnancy. Obstet Gynecol2012; 120: 318–324.
6.
McLeanKCushmanM. Venous thromboembolism and stroke in pregnancy. Hematology Am Soc Hematol Educ Program2016; 2016: 243–250.
7.
BarghouthiTBushnellC. Prevention and management of stroke in obstetrics and gynecology. Clin Obstet Gynecol2018; 61: 235–242.
8.
PowersWJ, et al.2018 guidelines for the early management of patients with acute ischaemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2018; 49: e46–e110.
9.
National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16 s: diagnosis and initial management. Available at: https://www.nice.org.uk/guidance/NG128. May 2019. (accessed 9 November 2019).
10.
Turc G, Bhogal P, Fischer U, et al. European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg. Epub ahead of print 26 February 2019. doi: 10.1136/neurintsurg-2018-014569.
11.
LandaisAChaumontHDellisR. Thrombolytic therapy of acute ischaemic stroke during early pregnancy. J Stroke Cerebrovasc Dis2018; 27: e20–e23.
12.
KhanAHosseiniPNevajdaB, et al.Lesson of the month 2: use of thrombolysis for ischaemic stroke in pregnancy – a case report and review of literature. Clin Med (Lond)2017; 17: 581–583.
13.
NogueiraRGLutsepHLGuptaR, et al.Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet2012; 380: 1231–1240.
14.
BerkhemerOAFransenPSBeumerD, et al.A randomized trial of intraarterial treatment for acute ischaemic stroke. N Engl J Med2015; 372: 11–20.
15.
JovinTGChamorroACoboE, et al.Thrombectomy within 8 hours after symptom onset in ischaemic stroke. N Engl J Med2015; 372: 2296–2306.
16.
CampbellBCMitchellPJKleinigTJ, et al.Endovascular therapy for ischaemic stroke with perfusion-imaging selection. N Engl J Med2015; 372: 1009–1018.
17.
SaverJLGoyalMBonafeA, et al.Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med2015; 372: 2285–2295.
18.
GoyalMDemchukAMMenonBK, et al.Randomized assessment of rapid endovascular treatment of ischaemic stroke. N Engl J Med2015; 372: 1019–1030.
19.
BracardSDucrocqXMasJL, et al.Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol2016; 15: 1138–1147.
20.
MoccoJZaidatOOvon KummerR, et al.Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone. Stroke2016; 47: 2331–2338.
21.
MuirKWFordGAMessowCM, et al.Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. J Neurol Neurosurg Psychiatry2017; 88: 38–44.
22.
KhouryNNDarsautTEGhostineJ, et al.Endovascular thrombectomy and medical therapy versus medical therapy alone in acute stroke: a randomized care trial. J Neuroradiol2017; 44: 198–202.
23.
PalaniswamiMYanB. Mechanical thrombectomy is now the gold standard for acute ischaemic stroke: implications for routine clinical practice. Interv Neurol2015; 4: 18–29.
24.
SmithWS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischaemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol2006; 27: 1177–1182.
25.
GoyalMMenonBKvan ZwamWH, et al.Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet2016; 387: 1723–1731.
26.
SlawskiDSalahuddinHShawverJ, et al.Mechanical thrombectomy in elderly stroke patients with mild-to-moderate baseline disability. Intervent Neurol2018; 7: 246–255.
27.
HilditchCANicholsonPMuradMH, et al.Endovascular management of acute stroke in the elderly: a systematic review and meta-analysis. AJNR Am J Neuroradiol2018; 39: 887–891.
28.
MoccoJTawkRGJahromiBS, et al.Endovascular intervention for acute thromboembolic stroke in young patients: an ideal population for aggressive intervention?J Neurosurg2009; 110: 30–34.
29.
ChalouhiNTjoumakarisSStarkeRM, et al.Endovascular stroke intervention in young patients with large vessel occlusions. Neurosurg Focus2014; 36: E6.
30.
ZanatyMChalouhiNStarkeRM, et al.Endovascular stroke intervention in the very young. Clin Neurol Neurosurg2014; 127: 15–18.
31.
MariniCTotaroRDe SantisF, et al.Stroke in young adults in the community-based L’Aquila registry: incidence and prognosis. Stroke2001; 32: 52–56.
32.
LeysDBanduLHénonH, et al.Clinical outcome in 287 consecutive young adults (15 to 45 years) with ischemic stroke. Neurology2002; 59: 26–33.
33.
VaronaJFBermejoFGuerraJM, et al.Long-term prognosis of ischemic stroke in young adults: study of 272 cases. J Neurol2004; 251: 1507–1514.
34.
ZahnRSchieleRSchneiderS, et al.Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the maximal individual therapy in acute myocardial infarction registry and the myocardial infarction registry. J Am Coll Cardiol2001; 37: 1827–1835.
35.
WhitePMBhallaADinsmoreJ, et al.Standards for providing safe acute ischaemic stroke thrombectomy services (September 2015). Clin Radiol2017; 72: 175.e1–175.e9.
36.
AlbersGWMarksMPKempS, et al.Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med2018; 378: 708–718.
37.
NogueiraRGJadhavAPHaussenDC, et al.Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med2018; 378: 11–21.
38.
SnellingBMcCarthyDJChenS, et al.Extended window for stroke thrombectomy. J Neurosci Rural Pract2019; 10: 294–300.
39.
CampbellBCHillMDRubieraM, et al.Safety and efficacy of Solitaire stent thrombectomy: individual patient data meta-analysis of randomized trials. Stroke2016; 47: 798–806.
40.
GanesalingamJPizzoEMorrisS, et al.Cost-utility analysis of mechanical thrombectomy using stent retrievers in acute ischaemic stroke. Stroke2015; 46: 2591–2598.
SwartzRHLadhaniNNNFoleyN, et al.Canadian stroke best practice consensus statement: secondary stroke prevention during pregnancy. Int J Stroke2018; 13: 406–419.
43.
AaronSShyamkumarNKAlexanderS, et al.Mechanical thrombectomy for acute ischaemic stroke in pregnancy using the penumbra system. Ann Indian Acad Neur2016; 19: 261–263.
44.
BhogalPAguilarMAlMatterM, et al.Mechanical thrombectomy in pregnancy: report of 2 cases and review of the literature. Interv Neurol2017; 6: 49–56.
45.
Szuchy KristiansenEHolm VestergaardHModrauB, et al.Acute ischemic stroke in late pregnancy treated with intravenous thrombolysis and endovascular therapy. Case Rep Neurol2019; 11: 41–46.
46.
WatanabeTTIchijoMKamataT. Uneventful pregnancy and delivery after thrombolysis plus thrombectomy for acute ischemic stroke: case study and literature review. J Stroke Cerebrovasc Dis2019; 28: 70–75.
47.
BlytheRIsmailANaqviA. Mechanical thrombectomy for acute ischemic stroke in pregnancy. J Stroke Cerebrovasc Dis2019; 28: e75–e76.
48.
SidhuMStraussKJConnollyB, et al.Radiation safety in pediatric interventional radiology. Tech Vasc Interv Radiol2010; 13: 158–166.
49.
McColloughCHSchuelerBAAtwellTD, et al.Radiation exposure and pregnancy: when should we be concerned?Radiographics2007; 27: 909–917.
50.
ParryRAGlazeSAArcherBR. The AAPM/RSNA physics tutorial for residents. Typical patient radiation doses in diagnostic radiology. Radiographics1999; 19: 1289–1302.
51.
TseGHBalianVCharalampatouP, et al.Fetal radiation exposure caused by mechanical thrombectomy in large vessel ischaemic stroke in pregnancy. Neuroradiology2019; 61: 443–449.
