[Intravenous recombinant tissue plasminogen activator in an 18-week pregnant woman with embolic stroke].

We are reporting a 36 year-old woman, gravid 3, para 1, aborta 2, who was 18 weeks pregnant and developed a sudden onset of motor aphasia and hemiparesis on the right side. On the initial visit to our hospital, the NIH stroke scale was 6, and the brain MRI revealed high intensity areas in the left insular cortex and the periventricular white matter with occlusion of the left middle cerebral artery (MCA) branches. We diagnosed her as having cerebral embolism, and treated with intravenous recombinant tissue plasminogen activator (rt-PA) with subsequent recanalization of the occuluded left MCA branches. Her motor aphasia and hemiparesis disappeared within a few hours of initiating the therapy. She received aspirin for four months and then heparin until delivery to prevent recurrence. She delivered a healthy term infant without any apparent complications. An 18-week pregnancy itself is not considered a risk factor of stroke, and we ruled out the possibilities of dysfibrinogenemia, homocysteinemia, hereditary or acquired deficiencies of protein C, protein S, and antithrombin III deficiencies, and antiphospholipid antibody syndrome. However, her plasma factor VIII level was significantly elevated to more than 200% (reference for 18-week pregnant woman: 151 +/- 44%), which may have led to her acquired activated protein C resistance or hypercoagulability. As safety of thrombolytic therapy with rt-PA during pregnancy has not been established, this therapy could be carefully used upon due consideration of risks and benefits for both mother and fetus.