How should a 36‑week pregnant woman with acute right‑sided numbness from face to foot be managed emergently?

Emergency Management of Acute Right-Sided Numbness in a 36-Week Pregnant Woman

This patient requires immediate emergency evaluation for acute ischemic stroke with urgent neuroimaging (MRI preferred), and if large vessel occlusion is confirmed, mechanical thrombectomy should be strongly considered as it can be performed safely in pregnancy and offers the best chance to prevent permanent disability. 1

Immediate Assessment and Stabilization

Treat This as a Stroke Emergency

• Activate stroke team immediately – stroke in pregnancy is rare (4.3 to 210 per 100,000 gestations) but the third trimester carries the highest risk, and time-critical interventions can prevent devastating permanent neurological deficits 1
• Obtain vital signs with particular attention to blood pressure (severe preeclampsia/eclampsia can present with focal neurological deficits and must be ruled out) 1
• Check fingerstick glucose immediately to exclude hypoglycemia as a stroke mimic 2
• Establish IV access with large-bore catheter (18-gauge or larger) 3

Critical Time-Sensitive Questions

• Determine exact time of symptom onset or last known well – this drives all treatment decisions for both IV thrombolysis (4.5-hour window) and mechanical thrombectomy (up to 24-hour window in select cases) 1, 2
• Assess severity using NIH Stroke Scale – unilateral face-to-foot numbness suggests large territory involvement 2
• Rule out seizure activity or postictal state (eclampsia can present with focal deficits) 1

Urgent Neuroimaging

MRI is Preferred Over CT

• Obtain MRI of the brain and spine immediately – MRI is the preferred imaging modality for suspected neurological complications in pregnancy and does not involve ionizing radiation 1
• If MRI is not immediately available, non-contrast CT head is acceptable to rule out hemorrhage, but has lower sensitivity for acute ischemic stroke 2, 4
• Obtain vascular imaging (MRA or CTA) to identify large vessel occlusion – this determines eligibility for mechanical thrombectomy 1, 2
• Iodinated contrast is category B in pregnancy; animal studies show no teratogenic effects and the benefit of diagnosing treatable stroke far outweighs theoretical risks 1

Treatment Considerations

IV Thrombolysis (tPA)

• If within 4.5 hours of symptom onset and no contraindications, strongly consider IV alteplase – the AHA/ASA guidelines recommend IV tPA be considered when benefits of treating potentially debilitating stroke outweigh the risk of uterine bleeding 1
• Alteplase does not cross the placenta (molecule too large) and systematic review of tPA use in pregnancy for neurological indications showed no maternal deaths, no major bleeding events, and only 3 fetal losses (none attributed to tPA) 1
• Complication rates are comparable to non-pregnant patients: maternal mortality 1%, maternal hemorrhage 8%, fetal loss 6% 1

Mechanical Thrombectomy

• If large vessel occlusion is confirmed on vascular imaging, proceed urgently with mechanical thrombectomy – this can be performed up to 24 hours from last known well in select cases and offers superior outcomes for large vessel occlusions 1, 2
• Radiation exposure during thrombectomy is typically well below 50 mGy (the threshold considered negligible for fetal risk), and the most sensitive period for radiation effects is 8-15 weeks gestation (this patient is at 36 weeks) 1
• Consult anesthesiology early – neurointerventionalists should have low threshold for anesthesia consultation, especially for complex cases or agitated patients 1

Rule Out Pregnancy-Specific Causes

Severe Preeclampsia/Eclampsia

• Check blood pressure – if SBP ≥160 mmHg or DBP ≥110 mmHg persisting >15 minutes, initiate antihypertensive treatment immediately 1
• Obtain urine protein, complete blood count, liver enzymes, creatinine 1
• If severe preeclampsia with clinical signs of severity, administer magnesium sulfate 4-6g IV loading dose to prevent eclamptic seizures 1, 5

Cerebral Venous Thrombosis

• Pregnancy and postpartum period increase risk of cerebral venous thrombosis 1
• MRI with venography can diagnose this condition 1

Multidisciplinary Coordination

Immediate Consultations Required

• Neurology/stroke team (for thrombolysis and thrombectomy decisions) 1, 5
• Obstetrics (for fetal monitoring and delivery planning) 5, 3
• Maternal-fetal medicine (for high-risk pregnancy expertise) 6, 5
• Anesthesiology (if procedural sedation or airway management needed) 1, 5

Fetal Monitoring

• Initiate continuous fetal heart rate monitoring at 36 weeks gestation 5
• Do not delay maternal stroke treatment for fetal concerns – optimizing maternal neurological outcome is the priority, and maternal brain perfusion directly affects fetal well-being 1

Critical Pitfalls to Avoid

Do Not Delay Imaging or Treatment

• The most common error is failing to recognize stroke as an emergency in pregnancy – every minute of delay results in loss of 1.9 million neurons 7
• Do not withhold IV contrast or radiation-based imaging when clinically indicated – the risk of untreated stroke far exceeds theoretical risks to the fetus at 36 weeks 1

Do Not Assume Symptoms Are "Just Pregnancy-Related"

• While pregnancy increases risk of certain conditions (preeclampsia, venous thrombosis), acute unilateral numbness from face to foot is a stroke until proven otherwise 1, 2
• Maintain high index of suspicion even if blood pressure is normal – arterial stroke can occur without hypertension 1

Do Not Place Patient in Left Lateral Position for Imaging

• While left uterine displacement is critical during cardiac arrest, it is not necessary for stroke evaluation and should not delay imaging 1, 5

Disposition

• Admit to stroke unit or neurocritical care unit with obstetric consultation 1, 3
• If thrombectomy is performed, patient requires ICU-level monitoring 3
• Coordinate delivery planning with obstetrics – at 36 weeks, delivery may be indicated after maternal stabilization depending on clinical course 5