Thrombolytic Dilemma: A Case Report of Early Puerperium Ischemic Stroke Treated With Intravenous Thrombolysis

Abstract

A 25-year-old woman was admitted to the obstetrics ward when presented with a sudden onset of expressive aphasia and minor right facial palsy 48 hours after forceps-assisted delivery. The intrahospital emergency team was immediately mobilized. The patient had a blood pressure (BP) of 119/79 mmHg, heart rate of 114 bpm, O₂ saturation of 97%, and blood glucose level of 136 mg/dL. Trauma and toxic exposure were ruled out. A rapid EKG was performed with no significant changes. Assuming an acute stroke, the patient immediately underwent brain CT (approximately 15 minutes after the beginning of the symptoms), which revealed no signs of hemorrhage, an ischemic area, or masses. Brain CT angiography was then performed; however, no major brain artery obstruction was found. With brain hemorrhage ruled out and persistent neurologic deficits, the case was discussed between the emergency team doctor and the patient's obstetrician, and intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) was started approximately 45 minutes after the onset of symptoms. After treatment completion, the patient had a complete resolution of the neurological deficits. The patient remained under strict observation at the acute stroke unit (ASU), and no secondary brain hemorrhage or post-partum-related complications were noted.

Keywords: early puerperium thrombolysis; ischemic stroke; postpartum complication; thrombolytic therapy; tissue plasminogen activator.

Figure 1. Brain magnetic resonance imaging

MRI revealing a median pontine rounded lesion (yellow arrows) without mass effects, with slight T1 signal attenuation (A - axial T1; B - sagital T1), T2 hypersignal (C - axial T2; D - sagital T2; F - coronal T2) and hyperintensity on fluid-attenuated inversion recovery (FLAIR) imaging (E - axial FLAIR) suggestive of late subacute ischemic etiology.

Figure 2. Transoesophageal echocardiography

2D transoesophageal echocardiography image (A) of a patent foramen ovale (yellow arrows), with evident shunting on the color flow doppler (B). RA: right atrium; LA: left atrium.