With a thorough evaluation, most causes of embolism can be identified, although treatment is not always available. Some of these include cardiacassociated embolism, vasculitis, or vasculopathy such as Moyamoya disease (Ishimori, 2006; Miyakoshi, 2009; Simolke, 1991). Outcomes of embolic strokes were reported to be favorable and similar to those of nonpregnant women (Lefert, 2016). hrombolysis for ischemic stroke during pregnancy has been reported (Tversky, 2016).
In reproductive-age women, a significant proportion of pregnancyrelated ischemic strokes are caused by gestational hypertension and preeclampsia (Jeng, 2004; Miller, 2016). s shown in Figure 60-2, areas of subcortical perivascular edema and petechial hemorrhage may progress to cerebral infarction (Aukes, 2007, 2009; Zeeman, 2004a). Although these are usually clinically manifest by an eclamptic convulsion, a few women will sufer a symptomatic stroke from a larger cortical infarction (Chap. 40, p. 734).
Other conditions with findings similar to preeclampsia include thrombotic microangiopathies (Chap. 56, p. 1088) and the reversible cerebral vasoconstriction syndrome (Chap. 40, p. 744). The latter, also termed pospartum angiopathy, can cause extensive cerebral edema with necrosis and widespread infarction with areas of hemorrhage (Edlow, 2013; Katz, 2014; Miller, 2016).
These strokes usually involve the middle cerebral artery (see Fig. 60-2). he diagnosis can be made with conidence only after thrombosis and hemorrhage have been excluded and is more certain if an embolic source is identified. Hemorrhage may be more diicult to exclude because embolization and thrombosis are both followed by hemorrhagic infarction. Paradoxical embolism is an uncommon cause, even considering that more than a fourth of adults have a patent foramen ovale through which right-sided venous thromboemboli are deported (Scott, 2012). Foraminal closure may not improve outcomes in these patients, however, this procedure has been performed during pregnancy (Dark, 2011). Assorted cardioembolic causes of stroke include arrhythmias-especially atrial ibrillation, valvular lesions, mitral valve prolapse, mural thrombus, infective endocarditis, and peripartum cardiomyopathy.
Management of embolic stroke in pregnancy consists of supportive measures and antiplatelet therapy. Thrombolytic therapy and anticoagulation in pregnancy are controversial issues (U,r2012).
Most thrombotic strokes afect older individuals and are caused by atherosclerosis, especially of the internal carotid artery. Many are preceded by one or more TIAs. hrombolytic therapy with a recombinant tissue plasminogen activator (rt-PAj is recommended. Alteplase is one of these and given within the irst 3-hour window if there is measurable neurological deficit and if neuroimaging has excluded hemorrhage. his recombinant enzyme can be used in pregnancy. A principal risk is hemorrhagic transformation of an ischemic stroke in 3 to 5 percent of treated patients (Smith, 2015; van der Worp, 2007).