Critique of “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature”

We recently read with great interest the article by Ryman et al entitled “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature.” We would like to congratulate the authors for achieving a successful outcome in such a high-risk patient for acute ischemic stroke (AIS) during pregnancy, and we want to share our experience in pregnant women with prosthetic valve thrombosis (PVT) who underwent AIS during thrombolytic therapy (TT). A prosthetic heart valve is highly thrombogenic and increases the risk of thrombosis up to 10% (especially a mechanical prosthetic valve) with the procoagulant condition of pregnancy. We previously reported that a low-dose slow infusion of tissue-type plasminogen activator (tPA [alteplase]) with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of PVT in pregnant women and that TT should be considered firstline therapy in pregnant patients with PVT. The most feared complication is the risk of cerebral embolism that can be up to 5–6% for left-sided PVT. The first 6 hours after cerebral thromboembolism are crucial, and early diagnosis and exclusion of hemorrhage by multidetector computed tomography is very important. Although the recommended dose of alteplase according to the stroke guideline is 0.9 mg/kg (maximum dose 90 mg) for 60 minutes for AIS according to current guidelines, with 10% of the dose given as a bolus for 1 minute, we used lower doses for safety concerns. Our success reported in our case reports may have been due to the early diagnosis and fresh nature of the thrombus. 4 Faster TT regimens may induce new thromboembolisms in patients with concomitant PVT. In conclusion, low-dose and slow-infusion TT is effective and safe in AIS during PVT treatment.