To describe a case of successful use of intravenous tissue plasminogen activator (IV-tPA) in a pregnant woman presenting with severe aphasia and a large vessel occlusion (LVO).

The efficacy and safety of IV-tPA in pregnancy is unknown. Potential obstetric complications from acute thrombolytic therapy include placental abruption, uterine bleeding, premature labor, and even fetal demise. Currently, pregnancy is considered a relative contraindication to IV-tPA based on stroke expert consensus/guidelines, but with no large trial data to support its use.

A 35-year-old woman who was 11 weeks pregnant and with no significant past medical history presented with fluctuating inability to speak and right arm weakness. Upon evaluation, she had a NIH Stroke Scale (NIHSS) of a 4: Severe expressive more than comprehensive aphasia and no motor deficits. MR angiography showed an abrupt left middle cerebral artery M1 segment occlusion and an MRI Brain was normal. A careful discussion of risks and benefits of IV-tPA in the setting of pregnancy was done with the patient and family and after their consent, IV-tPA was initiated ~ 3 hours from symptom onset. Less than an hour post tPA initiation, her symptoms completely resolved with a NIHSS of 0. She continued to remain asymptomatic throughout hospitalization and had no obstetric complications. A repeat MRA performed at 24 hours post thrombolytic therapy showed a complete resolution of the left MCA LVO and a repeat MRI Brain only showed a tiny punctate left parietal stroke and no hemorrhage.

Our case demonstrates an excellent outcome with thrombolysis in a pregnant woman with acute ischemic stoke and a complete resolution of a large vessel occlusion with no early or in-hospital complications. Pregnant patients with life threatening or potentially debilitating symptoms from acute ischemic strokes should be considered for thrombolytic therapy.