Therapeutic management in a pregnant patient with acute ischemic stroke in the revascularization window: A case report

TL;DR

A pregnant woman with a stroke received emergency treatment including cesarean section and mechanical thrombectomy, highlighting the importance of considering genetic and cardiac factors in young stroke patients.

Contribution

This case report highlights the evaluation of inherited genetic thrombophilia and patent foramen ovale in young stroke patients, particularly during pregnancy.

Findings

The patient had a homozygous methylenetetrahydrofolate reductase gene mutation and a heterozygous plasminogen activator inhibitor-1 gene mutation.

A patent foramen ovale was detected with a high risk of paradoxical embolism.

Emergency cesarean section and mechanical thrombectomy were performed within the revascularization window.

Abstract

Pregnancy is considered a relative contraindication for thrombolysis. Moreover, mechanical thrombectomy should be considered for pregnant patients, as it would be indicated in non-pregnant patients. The present study describes the clinical case of a 29-year-old female full-term pregnant patient who presented to the emergency room with a sudden onset symptomatology characterized by pronunciation disorder and motor impairment in the right arm with numbness at the same level, and with a National Institutes of Health Stroke Scale score of 7 points. The patient presented in the revascularization window, and the series of acute medical interventions were as follows: Clinical examination, native head computed tomography (CT) scan, emergency cesarean section, CT angiography of the cerebral arteries, and, eventually, mechanical thrombectomy. A brain MRI revealed a hyperintense lesion in diffusion sequence with low apparent diffusion coefficient correspondence at the frontal level of the left side, affecting the middle and precentral gyrus. A transesophageal ultrasound revealed a small patent foramen ovale with a risk of paradoxical embolism score of 8 points. Usual thrombophilia laboratory test results were negative; however, a homozygous methylenetetrahydrofolate reductase gene mutation and a heterozygous positive plasminogen activator inhibitor-1 gene mutation were detected. On the whole, the present case report emphasizes the importance of evaluating inherited genetic thrombophilia and PFO in young patients suffering a stroke. Moreover, the need for the psychological and psychiatric evaluation for possible reactive depression, anxiety and burnout in young patients suffering a stroke, and particularly in the peripartum period, is highlighted.

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