Acute Basilar Artery Occlusion in Pregnancy: Mechanical Thrombectomy in the First Trimester via Radial Access for Fetal Dose Minimization

A 34 year-old female with no significant medical history, who had returned from travels to Thailand 2 weeks prior, woke at 08:00 AM feeling nauseous and vomiting. At 9:30 AM, she suddenly felt more unwell and called for her husband. He found her severely dysarthric, hemiparetic on her left side, vomiting and lethargic. Following admission to the hospital, the patient was found to have a National Institute of Health Stroke Scale (NIHSS) score of 6–7 (5.5 h after symptom onset). Noncontrast cranial computed tomography (NCCT) and computed tomography angiography (CTA) revealed a mid-basilar artery occlusion. The NCCT findings were rated as Alberta Stroke Program Early CT score (ASPECTS) 10. The patient was transferred for emergency endovascular therapy at 2:31 PM (6 h after symptom onset). At this point, the patient’s admission beta-human chorionic gonadotrophin test was returned as positive at 499. General anesthesia was induced, and a transradial approach was selected to minimize the radiation dose to the fetus. After right radial access was established, a Benchmark (Penumbra) and 5F SIM2 Select (Simmons) were navigated into the distal right V2 segment. The Benchmark was then tracked over a 0.035 guidewire (Terumo) into the V4 segment. A contrast medium injection of the right vertebral artery was performed, which confirmed a mid-basilar thrombus with tongues extending into the anterior inferior cerebellar artery bilaterally. A “stent retriever assisted vacuum-locked extraction” (SAVE) technique was employed using pump aspiration (Medela) via a 5F SOFIA catheter (MicroVention), VacLok aspiration (Merit Medical) via the Benchmark, and an EMBOTRAP III (Cerenovus) which was deployed from the right P2 segment into the mid-basilar artery. The clot was allowed to embed for 3 min, following which the stent and SOFIA were retrieved, resulting in TICI 3 recanalization on the first pass at 5:27 PM (8 h after symptom onset). The patient was extubated immediately after endovascular therapy (EVT) and transferred to the hyperacute stroke unit. On arrival to the ward, the patient was NIHSS 0, Glasgow Coma Scale (GCS) 15, and passed a swallow assessment. A cranial MRI performed 19 h after EVT completion demonstrated acute bilateral cerebellar infarcts and suspected right subacute paramedian anteromedial pontine infarct. The patient was discharged the following day. A 90 day follow-up appointment to assess her outcome mRS is awaited. A bubble echocardiogram performed 1 month after the presentation revealed a patent foramen ovale (PFO) with Doppler evidence of a left-to-right shunt at rest. She has been referred to the cardiology team for PFO closure. The patient was informed of her pregnancy status while an inpatient. She had been unaware that she was pregnant. The patient elected for a termination of pregnancy 4 days after presentation. This chapter describes considerations in EVT for posterior circulation LVO in pregnancy, including the use of a transradial approach to reduce scattered radiation.