Journal Reading

Alteplase Therapy for Acute Ischemic

Stroke in Pregnancy: Two Case Reports
and a Systematic Review of the Literature

Presented by:
dr. Banu Eko Susanto
Supervisor:
dr. Rivan danuaji, Sp. N (K). M. Kes
 ABSTRACT
• Intravenous alteplase is the only medication approved for hyperacute
treatment of AIS (Acute Ischemic Stroke)  it has not been evaluated
prospectively in pregnancy (exclusion criterion)  safety in pregnant
patients is not well established
• Pregnancy recently removed as a relative contraindication in the 2018
AHA/ASA guidelines.
• This review report the use of intravenous alteplase for AIS in two
pregnant patients  clinical improvement and without complications
(mother or fetus).
• This review summarize a systematic review of the literature for both
intravenous and intra-arterial alteplase use for AIS in pregnant patients.
 INTRODUCTION

• The risk of stroke during pregnancy is roughly three

times greater than in similar nonpregnant patients.
Prevalence AIS accounts for 30–50% of all stroke subtypes in
pregnant patients and is responsible for 7% of
maternal deaths in the United States.

• Given the already low proportion of patients

with AIS eligible for definitive therapies 
Urgency appropriate to consider the use of alteplase in
pregnant women who do not have additional
contraindications
 CASE REPORT 1

ONSET 60’ ONSET 90’ ONSET 120’ TREATMENT EVALUATIO

N
• G2P1, 12 • Complete • Reccurent • IV alteplase • 3 days: no
weeks, 26- resolution symptoms 58 mg (0.9 residual
year-old, of • NIHSS mg/kg): deficits, no
64.4-kg symptoms score: 4. bolus 10%, , ICH on
• Left MCA • Brain MRI: 90% repeat
syndrome acute left infused neuroimagin
• NIHSS posterior over 60’ g
score: 29 frontal lobe • Evaluation: • Gave birth at
• CT Scan: no cortical no 34 weeks
acute infarct, no hypercoagu without
pathology, ICH. lable complication
no ICH conditions/ s
clear during
etiology for delivery and
AIS no birth
defect.
 CASE REPORT 2

CLINICAL TREATMENT EVALUATION EVALUATION

MANIFESTATIONS

• G2P0, 24-year- • CT scan: no • MRA: right • Discharged

old, 30 weeks acute MCA M2 after 4 days on
pregnant pathology, no branch therapeutic
• NIHSS score: ICH. occlusion. enoxaparin
12. • IV alteplase • MRI given (history
• Medical had been perfusion:area of DVT)
history: initiated prior of infarction • Neurologic
obesity, to transfer to without improvement
spontaneous stroke center significant and no ICH on
miscarriage, ischemic repeat
DVT lower penumbra neuroimaging
extremity, • Delivered at
smoking. 39 weeks
without
complications
METHODS

• The PubMed, EMBASE, and Ovid databases were searched for

combinations of the following medical subject heading (MeSH)
terms: fibrinolytic agents, alteplase, tPA, pregnancy, and
stroke.
• Titles of the articles identified were reviewed, and relevant
abstracts were reviewed to determine inclusion.
RESULT OF LITERATURE REVIEW
 RESULT OF LITERATURE REVIEW

FIRST TRIMESTER
 RESULT OF LITERATURE REVIEW

SECOND TRIMESTER
 RESULT OF LITERATURE REVIEW
THIRD TRIMESTER
 DISCUSSION

Adverse Effect
• There are five case reports with negative outcomes in the mother, fetus, or both after
the administration of alteplase.
• Three published reports of hemorrhagic transformation in the mother have been
documented with alteplase administration for AIS; however, all had complete or near
complete recovery
• In most published cases (n=13) alteplase was administered in the first trimester of
pregnancy. None of these cases reported teratogenic effects of alteplase, which is
pregnancy category C due to embryocidal effects in rabbits at doses of 3 mg/kg.
However, it is a large molecule and is unlikely to cross the human placenta.
 DISCUSSION

Intra Vena vs Intra Arterial

• Both IV and intra-arterial (IA) alteplase have been used for AIS in pregnancy  25
patients received IV alteplase and 6 received IA alteplase.
• There is insufficient evidence to make a recommendation for one route of administration
over another, and the level of evidence is unlikely to improve for this patient population.
• The decision should be guided by relevant patient characteristics, relative
contraindications, cerebral artery and territory effected, time of presentation, and level of
functional deficit.
 DISCUSSION

Evidence Based and

Recomendation

• Alteplase use in pregnant patients appears to be safe for both the mother and fetus
 paucity of data  precluded evidence-based risk/benefit.
• Based on evidence from case reports, the American Heart Association/American
Stroke Association recommends administering alteplase in pregnant patients with
AIS when anticipated benefits outweigh anticipated risks of bleeding 
recommendation grade is low, and the level of evidence is poor (class IIb; level of
evidence C)
CONCLUSION

• Alteplase was safely administered in our two pregnant patients

for the treatment of AIS without complications to either the
mother or fetus.
• Alteplase may be considered in pregnancy and should not be
withheld in the setting of strokesolely due to pregnancy
THANK YOU