Stroke code in a term pregnant woman: a case report.

Technical Summary: Stroke in a Term Pregnant Woman: A Case Report

Problem Statement
Stanford type A acute aortic dissection (AAD) during pregnancy is a rare, life-threatening condition with high maternal and fetal mortality, particularly when presenting with atypical symptoms. While the classic presentation involves sudden chest pain, up to 20–30% of women may present without pain or with atypical features. In 10–15% of AAD cases, involvement of the supra-aortic trunks (SAT) leads to neurological manifestations, such as acute ischemic stroke, as the initial presentation. This atypical onset often delays diagnosis, especially when clinical suspicion focuses on isolated cerebrovascular events. Furthermore, while computed tomography angiography (CTA) is the diagnostic gold standard, it can fail in complex hemodynamic settings due to suboptimal vascular opacification, leading to missed diagnoses in critical scenarios.

Methodology
This study presents a single-case report of a 38-year-old primiparous woman at 40 weeks of gestation who presented with acute ischemic stroke. The diagnostic and therapeutic approach involved:

• Diagnostic Imaging: The patient underwent two initial CTAs which failed to provide adequate vascular opacification, hindering the identification of the dissection. A bedside transthoracic echocardiography (TTE) was subsequently performed in the interventional neuroradiology suite. A final CTA with adequate contrast distribution was obtained post-diagnosis to confirm anatomical details.
• Multidisciplinary Management: A "pregnancy heart team" comprising cardiac surgery, cardiology, neurology, gynecology, anesthesiology, and intensive care specialists coordinated the care.
• Surgical Strategy: The team executed an urgent, sequential intervention: emergency cesarean delivery followed immediately by aortic repair.
  • Obstetric Phase: A transverse hysterotomy was performed with specific hemostatic measures (Posadas technique uterine artery ligation, Bakri balloon, vaginal packing) to minimize bleeding prior to heparinization.
  • Cardiac Phase: The patient underwent median sternotomy, evacuation of hemopericardium, and cardiopulmonary bypass under moderate hypothermia (26°C). The procedure involved aortotomy confirming a primary intimal tear in the distal ascending aorta and a bicuspid aortic valve with a coaptation defect. The valve was replaced with a 21-mm mechanical prosthesis, and the ascending aorta was reconstructed with a 32-mm graft under selective cerebral perfusion.

Key Results

• Diagnosis: The diagnosis of Stanford type A AAD with hemopericardium and extension into the SAT was initially missed by CTA but successfully identified via bedside TTE, which revealed the bicuspid valve, dissection flap, and hemopericardium.
• Maternal Outcome: The mother survived the procedure with a favorable postoperative course, including early extubation and withdrawal of vasoactive support. She was discharged after 17 days. While she experienced persistent left hemiparesis, hemisensory loss, and homonymous hemianopia due to the established cerebral infarction, she remained asymptomatic from a cardiovascular standpoint during follow-up.
• Fetal/Neonatal Outcome: A live newborn was delivered via cesarean section and remained clinically stable without complications.
• Imaging Confirmation: Postoperative CTA confirmed patency of the supracoronary graft, though it noted persistent residual dissection of the aortic arch and brachiocephalic trunk, along with chronic right carotid occlusion.

Significance and Claims
The paper asserts that this case highlights three critical clinical lessons:

1. Clinical Suspicion: There is a need for a high index of suspicion for AAD in pregnant patients presenting with acute neurological symptoms, even in the absence of typical chest pain.
2. Diagnostic Limitations and Alternatives: The case underscores the limitations of CTA in complex hemodynamic states where contrast distribution may be suboptimal. It emphasizes the decisive role of bedside TTE as a rapid, accessible, and non-invasive diagnostic tool in emergency settings, particularly when findings such as bicuspid aortic valve disease, aortic regurgitation, or hemopericardium are present.
3. Multidisciplinary Coordination: The successful outcome is attributed to the urgent, coordinated management by a cardio-obstetric team. This approach allowed for individualized decision-making regarding the sequencing of cesarean delivery and aortic repair, as well as the careful balancing of neurological, surgical, obstetric, thrombotic, and hemorrhagic risks.

The authors conclude that early recognition and this specific multidisciplinary strategy are essential to optimize maternal and fetal survival in such high-risk scenarios.