Mechanical Thrombectomy as Stroke Management in Pregnancy: A Systematic Review

To assess the safety, efficacy, and maternal and fetal outcome of mechanical thrombectomy (MT) for ischemic stroke in pregnancy, given the increased risk due to physiological cardiovascular and coagulation changes.

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered in the International Prospective Register of Systematic Reviews. Studies were sourced from PubMed, Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, and Excerpta Medica Database, including records up to May 2024. All relevant studies reporting on pregnant patients diagnosed with ischemic stroke and treated with MT, either alone or in combination with thrombolytics (tPA [tissue-type plasminogen activator]), were included regardless of study design. Endovascular MT techniques, including stent retrievers and aspiration thrombectomy, were evaluated. Patient demographics and procedural characteristics were extracted and analyzed. Primary maternal stroke-related outcomes included functional independence at 90 days, defined by a modified Rankin Scale (mRS) score of ≤2, and successful recanalization based on a modified Treatment in Cerebral Infarction score of ≥2B. Maternal safety outcomes assessed the occurrence of any complications (deep vein thrombosis/pulmonary embolism and intracranial hemorrhage) and mortality. Neonatal outcomes were evaluated based on mortality and overall health at follow-ups.

The database search initially identified 785 records. After removal of duplicates, 143 studies remained for screening. Of these, 46 full-text articles were assessed for eligibility, yielding 16 studies that met the inclusion criteria. Cumulatively, the study included 26 cases, with a mean maternal age of 32.6 years. Stroke occurred most frequently in the first and third trimesters (each n=11/26; 42.3% [95% CI, 23.4-63.1]), followed by the second trimester (n=4/26; 15.4% [95% CI, 4.4-34.9]). MT was performed using various techniques, including a combination of stent retrievers and aspiration thrombectomy (n=11/25; 44.0% [95% CI, 24.4-65.1]), stent retrievers alone (n=5/25; 20.0% [95% CI, 6.8-40.7]), and aspiration thrombectomy alone (n=9/25; 36.0% [95% CI, 18.0-57.5]). Successful recanalization (modified Treatment in Cerebral Infarction score ≥2B) was achieved in 21 of 23 cases (91.3% [95% CI, 72.0-98.9]), with 7 achieving complete reperfusion (modified Treatment in Cerebral Infarction score, 3). No maternal deaths were reported; minor residual neurological symptoms (mRS score, 1) and slight disabilities (mRS score, 2) were observed in 11 cases, while 9 patients had no symptoms at follow-up (mRS score, 0). Among patients with reported follow-up mRS scores, functional independence (mRS score, 0-2) was achieved in 20 of 20 cases (100.0% [95% CI, 83.2-100.0]). Fetal outcomes included 16 of 24 successful pregnancies (66.7% [95% CI, 44.7-84.4]), 3 of 24 healthy ongoing pregnancies (12.5% [95% CI, 2.7-32.4]), 3 of 24 elective terminations (12.5% [95% CI, 2.7-32.4]), and 2 of 24 pregnancy losses (8.3% [95% CI, 1.0-27.0]), including 1 abortion due to an obstetric factor and 1 spontaneous abortion.

MT is a viable treatment for ischemic stroke in pregnancy, balancing maternal benefits against fetal risks, including radiation exposure and anticoagulation considerations. Careful patient selection and procedural modifications are essential. Despite limited data, MT demonstrates favorable maternal and fetal outcomes. More systematic reporting and larger studies are needed to develop standardized guidelines, ensuring the safety of both mother and neonate.