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      Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system

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          Abstract

          Even though intravenous thrombolysis with tissue plasminogen activator (IV tPA) is the standard of care in acute ischemic stroke, its use in pregnancy is not clearly defined. Mechanical thrombectomy devices can be an option; however, literature on the use of such mechanical devices in stroke in pregnancy is lacking. Here we describe two cases that developed acute embolic stroke during pregnancy who were successfully treated by mechanical clot retrieval using the Penumbra system 28 (Penumbra Inc., Alameda, California, USA). To the best of our knowledge, these are the only case reports on the use of the Penumbra device in pregnant patients with acute ischemic stroke.

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          Thrombolytic therapy in pregnancy.

          Michael Buerke, G Leonhardt, H Nietsch … (2006)
          Pregnancy due to its physiological changes is a procoagulant state. The rate of cardiac valve prosthesis thrombosis, deep venous thrombosis and pulmonary embolism are all increased. Thrombolytic therapy with tissue plasminogen activator (rt-PA) is an approved therapy for ischemic stroke, myocardial infarction, pulmonary embolism and thrombosis of cardiac valve prosthesis. However, there are no data from controlled randomized trials in pregnant patients. Thrombolytic therapy has been rarely used in pregnancy with only 28 cases of rt-PA thrombolysis reported in the literature so far. Indications for rt-PA thrombolysis were stroke (n = 10), thrombosis of cardiac valve prosthesis (n = 7), pulmonary embolism (n = 7), deep venous thrombosis (n = 3), and myocardial infarction (n = 1). Remarkably, all thrombosis of cardiac valve prostheses occurred after switching from warfarin to heparin in order to prevent teratogenicity and fetal loss. Two patients died (7%) and three suffered from complications that were managed conservatively (11%). In another three patients thrombolysis was not successful. Thrombolysis complication rates were similar compared to non-pregnant patients for the above mentioned indications. Six out of the 26 fetus from surviving mothers died (23%), three of them after induced abortion for maternal reasons (12%). A likely causal relation to the prior thrombolysis could only be established in two fetal fatalities (8%). None of the live born children suffered a permanent deficit. Considering that rt-PA does not cross the placenta and taking into account that the complication rates do not exceed those of large randomised controlled trials thrombolytic therapy should not be withheld in pregnant patients in case of life-threatening or potentially debilitating thrombembolic disease.
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            Thrombolytic therapy of acute ischemic stroke during pregnancy.

            John McAllen, Steven Wechsler, H S Starkman … (2006)
            The authors report eight pregnant women with acute ischemic stroke treated with thrombolysis (rt-PA [recombinant human tissue plasminogen activator] or urokinase). Seven women recovered. Two extracranial and two asymptomatic intracranial hemorrhages complicated treatment; one woman died of arterial dissection complicating angiography. Three patients had therapeutic abortions, two fetuses were miscarried, and two babies were delivered healthy. Although pregnant women may be treated safely with thrombolytics, risks and benefits to mother and fetus must be carefully weighed.
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              Use of thrombolytics for the treatment of thromboembolic disease during pregnancy.

              M Turrentine, G A Braems, M. Ramírez (1995)
              The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the world's literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Ann Indian Acad Neurol
                Journal ID (iso-abbrev): Ann Indian Acad Neurol
                Journal ID (publisher-id): AIAN
                Title: Annals of Indian Academy of Neurology
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 0972-2327
                ISSN (Electronic): 1998-3549
                Publication date (Print): Apr-Jun 2016
                Volume: 19
                Issue: 2
                Pages: 261-263
                Affiliations
                [1]Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
                [1 ]Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
                Author notes
                For correspondence: Prof. Mathew Alexander, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu, India. E-mail: mathewalex@ 123456cmcvellore.ac.in
                Article
                Publisher ID: AIAN-19-261
                DOI: 10.4103/0972-2327.173302
                PMC ID: 4888695
                PubMed ID: 27293343
                SO-VID: 9524b467-634e-4aeb-b8c0-c0936013cb15
                Copyright © Copyright: © Annals of Indian Academy of Neurology
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution NonCommercial ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                History
                Date received : 31 January 2015
                Date revision received : 13 April 2015
                Date accepted : 29 May 2015
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Neurology
                Keywords: mechanical thrombectomy in pregnancy,penumbra system,stroke in pregnancy
                Data availability:
                ScienceOpen disciplines: Neurology
                Keywords: mechanical thrombectomy in pregnancy, penumbra system, stroke in pregnancy

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