Thrombolytic therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: a case report and literature review.
BACKGROUND
Thrombolysis for acute ischemic stroke has been rarely administrated during pregnancy. Paradoxical embolism through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation (AVM) is an identified risk factor for ischemic stroke.


METHODS
We report a 24-year-old woman at 11 weeks gestation who developed a sudden onset of dysarthria, hemiparesis, and hemisensory loss. She was diagnosed as having an ischemic stroke in the left middle cerebral artery (MCA) territory. She was treated with intra-arterial recombinant tissue plasminogen activator with subsequent resolution of her neurological deficits. Further workup revealed the presence of a PFO with a large right-to-left shunt. After being put on antithrombotic therapy, she presented again at 13 gestational weeks with a new ischemic infarction in the vertebrobasilar territory. Her PFO was closed percutaneously under ultrasonic guidance but the right-to-left shunt persisted. After a normal delivery, she was found to have a large pulmonary AVM which was successfully resected without complication.


CONCLUSIONS
This report describes the successful usage of intra-arterial tissue plasminogen activator for acute ischemic stroke during early pregnancy. In patients with presumed paradoxical embolism, careful attention should be paid to rule out a coexistence of PFO and pulmonary AVM.
Division of Neurology, Department of Medicine, The Lehigh Valley Health Network, 1250 S. South Cedar Crest Boulevard, Allentown, PA 18103, USA. Yuebing.Li@lvhn.org
Yuebing
Y
Li
John
J
Margraf
Bryan
B
Kluck
Donna
D
Jenny
John
J
Castaldo
D000328:Adult; D001165:Arteriovenous Malformations / Q000150:complications*; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications* / Q000628:therapy; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000150:complications / Q000188:drug therapy*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000628:therapy; D011250:Pregnancy Complications, Hematologic / Q000188:drug therapy*; D011261:Pregnancy Trimester, First; D011651:Pulmonary Artery / Q000002:abnormalities* / Q000000981:diagnostic imaging; D011859:Radiography; D012307:Risk Factors; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014715:Vertebrobasilar Insufficiency / Q000150:complications / Q000188:drug therapy
D010959:Tissue Plasminogen Activator