MRI of the brain without contrast is an alternative. The use of MRI should not delay treatment of patients who are eligible for IV TPA, with the same goal of door-to-interpretation in 45 minutes.

Other useful diagnostic tests include:

• Intracranial and extracranial vessel imaging (CTA of the brain and neck, MRA of the brain and neck, carotid ultrasound, transcranial Doppler, cerebral arteriogram).
• Echocardiogram or TEE.
• Venous Doppler ultrasound.
• Basic diagnostics, including EKG (for arrhythmias such as atrial fibrillation), CBC, chemistries, INR.
• Hypercoagulability work-up.

Management

Well-planned protocols should be in place that have been coordinated with the consulting team, including OB, vascular neurology, medicine, neurosurgery, interventional, and other appropriate services. As previously noted, rapid identification of stroke type is critical to proper management. As with most management decisions concerning pregnant patients, maternal stabilization is the priority. While the mother is being stabilized, also monitor the fetus.

A good overall reference for SAH management in all patients was published in 2011.⁸ While specifics for pregnancy were not covered, the diagnostic and therapeutic approaches should be applied to pregnant patients.

Ischemic Stroke

IV TPA and mechanical thrombectomy have been used successfully in pregnancy. As with any treatment, risks and benefits should be weighed.^9-13 Because vaso-occlusive stroke may have cardiac or systemic disease–associated etiologies, these should be evaluated and treated. Most of this will usually occur post-ED care. In some cases, chronic anticoagulation treatments should be considered to prevent recurrence.¹⁴

Intracranial and Subarachnoid Hemorrhage

SAH is the most frequent cause of intracranial bleeds during pregnancy.^15-17

Many patients may have a recent history of a warning leak (sentinel bleed) with symptoms that appear and resolve prior to a major SAH. The leak may present with any of the listed clinical findings. Early identification and treatment can prevent a subsequent fatal bleed.

A patient on anticoagulant therapy requires reversal therapy. Significant thrombocytopenia would generally require platelet transfusion.

Use of hemostatic drugs such as epsilon-aminocaproic acid (EACA) and recombinant activated factor VII have not been clearly shown to affect outcomes.¹⁸ Drugs increasing clotting tendency may put pregnant patients at risk for embolic complications and probably should be avoided.

Nimodipine may be considered after a discussion with consultants. It is category C. Nimodipine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Mannitol can cause fluid shifts away from the fetus, leading to fetal circulation problems. It may be considered after discussion with consultants, with active monitoring for a viable fetus.