Rinsho Shinkeigaku (Clinical Neurology)

Case Report

Intravenous recombinant tissue plasminogen activator therapy in a 14-week pregnant woman with embolic stroke due to protein S deficiency

Hiroko Hori, M.D.1), Fumio Yamamoto, M.D.1), Yasuyuki Ito, M.D.1), Yoichiro Hashimoto, M.D.1), Teruyuki Hirano, M.D., Ph.D.2) and Makoto Uchino, M.D., Ph.D2)3)

1)Department of Neurology, Kumamoto City Hospital
2)Department of Neurology, Kumamoto University Hospital
3)Present Address: Jonan Hospital

When cerebral infarction develops during pregnancy, treatment without adverse effects must be considered not only for the mother but also for the fetus. Because pregnant women were excluded from many clinical trials, clear treatment guidance for them is not shown in the package inserts or guidelines of many drugs. We report the case of a 35-year-old woman (gravida 3, para 2) who developed sudden onset of left visual field defect, left hemiparesis, and dysesthesia over the left forearm during her fourth month of pregnancy. Brain diffusion-weighted MRI showed high intensity areas in the right occipital lobe, and magnetic resonance angiography revealed an occlusion of the right posterior cerebral artery. She was treated with an intravenous injection of recombinant tissue plasminogen activator 2 h 55 min after symptom onset, and the visual field and sensorimotor deficits improved. MRA obtained 3 days after the onset showed recanalization of the right posterior cerebral artery. We also conducted electrocardiography, neck vascular ultrasound, cardiovascular ultrasound, transcranial Doppler recordings from the temple area, and laboratory examinations for complete blood count, biochemistry, coagulation factors, endocrine secretion, and autoantibodies. Reduced protein S activity (35%) along with high intensity transient signals on transcranial Doppler indicated microemboli to be the embolic source. All other tests were negative. Anticoagulation therapy was initiated to prevent recurrence. She was initially given intravenous heparin, and then switched to warfarin therapy at 15 weeks of gestation. The patient delivered a healthy infant via caesarean section. Although reports and experiences of thrombolytic therapy with injection of recombinant tissue plasminogen activator during pregnancy remain scant, this therapy might be carefully used, especially after due consideration and understanding of the risks and benefits for both mother and fetus.
Full Text of this Article in Japanese PDF (1946K)

(CLINICA NEUROL, 53: 212－216, 2013)
key words: protein S deficiency, cerebral embolism, pregnancy, rt-PA, warfarin

(Received: 31-Jan-12)