Thrombolysis and thrombectomy in a first trimester stroke: expanding the evidence for acute ischemic stroke management in pregnancy. Illustrative case.

backgroundStroke is the leading cause of disability and the fifth leading cause of death nationwide, with large-vessel occlusions (LVOs) contributing significantly to this burden. The risk of LVO increases in hypercoagulable states such as pregnancy; however, LVOs in pregnancy are rare. Management of this condition lacks well-established guidelines due to the exclusion of pregnant women from clinical trials. Case reports of alteplase and mechanical thrombectomy (MT) use during pregnancy suggest therapeutic potential; however, there is less evidence for agents such as tenecteplase (TNK). OBSERVATIONS: The authors present the case of a 27-year-old woman, G5P2A2, at 4 weeks' gestation who presented with seizure-like activity, expressive aphasia, and right-sided hemiparesis, NIH Stroke Scale score of 21. The patient was diagnosed with an ischemic stroke. TNK was administered without symptom resolution, and the patient was transferred to the authors' center. Imaging demonstrated left M2 occlusion, and MT was performed successfully. The patient carried the pregnancy to term and delivered a healthy infant at 37 weeks. LESSONS: To the authors' knowledge, this represents the first formally reported case of LVO treated with TNK and MT in the first trimester of pregnancy. More data are needed to determine whether these interventions are safe for patients with LVOs during the first trimester of pregnancy. https://thejns.org/doi/10.3171/CASE25126.