Stroke treatment: beyond the three-hour window and in the pregnant patient

Microarray Data Analysis of Molecular Mechanism Associated with Stroke Progression

This study aimed to explore the molecular mechanism of stroke and provide a new target in the clinical management. The miRNA dataset GSE97532 (3 blood samples from middle cerebral artery occlusion (MCAO) and 3 from sham operation) and mRNA dataset GSE97533 (3 blood samples from MCAO and 3 from sham operation) were obtained from GEO database. Differentially expressed mRNA (DEGs) and miRNAs (DEMIRs) were screened out between MCAO and sham operation groups. Then, DEMIR-DEG interactions were explored and visualized using Cytoscape software. Moreover, the enrichment analysis was performed on these DEMIRs and DEGs. Furthermore, protein-protein interaction (PPI) network was constructed. Finally, the DEG-target transcription factors (TFs) were investigated using the WebGestal software. The current bioinformatics analysis revealed 38 DEMIRs and 546 DEGs between MCAO and sham operation groups. The DEMIR-DEG analysis revealed 370 relations, such as miR-107-5p-Furin. The top 10 up- and downregulated DEMIRs were mainly enriched in pathways like cAMP signaling pathway. The PPI network analysis revealed 2 modules. The target DEGs of the 10 up- and downregulated DEMIRs in 2 modules were mainly assembled in functions like ATP binding and pathway including ABC transporters. Furthermore, the DEG-TF network analysis identified 5 outstanding TFs including androgen receptor (AR). miR107-5p might take part in the progression of stroke via inhibiting the expression of Furin. TFs like AR might be used as a novel gene therapy target for stroke. Furthermore, cAMP signaling pathway and ATP binding function might be a novel breakthrough for stroke treatment.

Uneventful Pregnancy and Delivery after Thrombolysis Plus Thrombectomy for Acute Ischemic Stroke: Case Study and Literature Review

BACKGROUND

Intravenous thrombolysis with recombinant tissue plasminogen activator and endovascular mechanical thrombectomy are known to be the most effective treatments in the acute phase of ischemic stroke. However, the safety of intravenous systemic thrombolysis with recombinant tissue plasminogen and endovascular mechanical thrombectomy during pregnancy is not well-confirmed. We describe a case of an uneventful pregnancy and delivery after thrombolysis plus endovascular mechanical thrombectomy for acute ischemic stroke.

MATERIALS AND METHODS

The patient's medical records were reviewed retrospectively. A comprehensive systemic literature search of the PubMed database was conducted.

CASE PRESENTATION

A 36-year-old woman at 21 weeks gestation presented with a sudden headache, dysarthria, and right hemiparesis. Magnetic resonance angiography revealed occlusion of the left internal carotid artery. Recombinant tissue plasminogen activator was administered intravenously 193 minutes after symptom onset, and endovascular mechanical thrombectomy was started immediately. Recanalization of her left internal carotid artery was achieved. The patient continued to experience mild hemiparesis after the initial treatment and started rehabilitation. The fetus remained in satisfactory condition during the pregnancy and was delivered at 38 weeks without obvious maternal or neonatal complications. No apparent abnormality has been observed in the newborn in the first year of life.

CONCLUSIONS

Intravenous recombinant tissue plasminogen and endovascular mechanical thrombectomy could be considered as treatment for acute ischemic stroke during pregnancy unless high risks of hemorrhage or preterm labor are expected.

Neuroendocrinal, Neurodevelopmental, and Embryotoxic Effects of Recombinant Tissue Plasminogen Activator Treatment for Pregnant Women with Acute Ischemic Stroke

Thrombolysis with recombinant tissue plasminogen activator (rTPA) was the first evidence-based treatment approved for acute stroke. Ischemic stroke is relatively uncommon in fertile women but treatment is often delayed or not given. In randomized trials, pregnancy has been an exclusion criterion for thrombolysis. Physiologic TPA has been shown to have neuroendocrine effects namely in vasopressin secretion. Important TPA effects in brain function and development include neurite outgrowth, migration of cerebellar granular neurons and promotion of long-term potentiation, among others. Until now, no neuroendocrine side-effects have been reported in pregnant women treated with rTPA. The effects of rTPA exposure in the fetus following intravenous thrombolysis in pregnant women are still poorly understood. This depends on low case frequency, short-duration of exposure and the fact that rTPA molecule is too large to pass the placenta. rTPA has a short half-life of 4–5 min, with only 10% of its concentration remaining in circulation after 20 min, which may explain its safety at therapeutically doses. Ischemic stroke during pregnancy occurs most often in the third trimester. Complication rates of rTPA in pregnant women treated for thromboembolic conditions and ischemic stroke were found to be similar when compared to non-pregnant women (7–9% mortality). In embryos of animal models so far, no indications of a teratogenic or mutagenic potential were found. Pregnancy is still considered a relative contraindication when treating acute ischemic stroke with rTPA, however, treatment risk must be balanced against the potential of maternal disability and/or death.

Pregnancy and stroke risk in women

Stroke, the sudden onset of brain dysfunction from a vascular cause, is one of the most common causes of long-term disability. Although rare during childbearing years, stroke is even more devastating when it occurs in a young woman trying to start a family. Pregnancy and the postpartum period are associated with an increased risk of ischemic stroke and intracerebral hemorrhage, although the incidence estimates have varied. There are several causes of stroke that are in fact unique to pregnancy and the postpartum period, such as preeclampsia and eclampsia, amniotic fluid embolus, postpartum angiopathy and postpartum cardiomyopathy. Data regarding these individual entities are scant. Most concerning is the lack of data regarding both prevention and acute management of pregnancy-related stroke. The purpose of this article is to summarize existing data regarding incidence, risk factors and potential etiologies, as well as treatment strategies for stroke in pregnancy.