Neuroimaging procedures are essential in AIS reperfusion therapy qualification process. In the general population both computed tomography (CT) and magnetic resonance imaging (MRI) are effective in excluding intracerebral hemorrhage (ICH) and the preferred method is chosen based on its local availability to ensure rapid treatment introduction. Similarly, endovascular treatment (EVT) eligibility assessment based on noninvasive cerebral vessel imaging can interchangeably utilize MR angiography (MRA) or CT angiography (CTA) [
7]. In pregnancy, not only the pace of the qualification process, but also fetal safety should be taken into consideration when selecting imaging techniques.
There is also a group of AIS patients beyond the standard time window for reperfusion therapy that could potentially benefit from employment of advanced neuroimaging techniques, such as CTP or MRP imaging. This approach has not been validated in stroke during pregnancy and will be a subject of our theoretical considerations.
Initial Noncontrast Imaging
Noncontrast head CT poses a theoretical risk of fetal adverse events due to radiation exposure; however, its estimated X‑ray dose to an unborn child ranging between 0.001 and 1 mSv is thought to be very low [
9,
10]. As a comparison, the expected cumulative dose of background radiation absorption during the entire pregnancy is about 1 mSv and the typical occupational limit for fetal radiation equals 5 mSv [
11,
12]. Animal studies showed the risk of prenatal death due to irradiation to be highest during the preimplantation period (0–2 weeks) and of congenital anomalies or growth restriction during organogenesis (2–8 weeks). The approximated thresholds for those events are 50–250 mSv. Radiation exposure associated with the significant risk of severe intellectual disability (60–310 mSv) is thought to be much higher than the amount absorbed by fetus during head CT as well [
11,
13]. In fact, there was no abortion, growth restriction or anomalies reported with levels below 50 mSv [
9]. The risk of carcinogenesis is not well evaluated but considered to be very low in case of radiologic examinations above the diaphragm and below the knees [
9]. It rises with the amount of exposure and is estimated to elevate the background rate by less than 1 in 10,000 cases with doses < 1 mGy [
14,
15] and 1 in 2000 with 10–20 mSv [
16,
17]. Given the information above, it should be concluded that the fetal ionizing radiation exposure from noncontrast head CT is probably negligible and concerns of its safety must not preclude prompt utilization of this imaging modality in cases of maternal stroke; however, additional safety measures, such as shielding of the abdomen/pelvis and minimizing scans should be routinely incorporated [
12].
The use of MRI eliminates the roentgen irradiation with all of its potential adverse events. Studies have also failed to show increased risk of stillbirth, neonatal death, neoplasm or congenital abnormalities in infants whose mothers were exposed to MRI during the first trimester [
18]. There are no known biological effects on fetuses during later periods of pregnancy as well [
19]. Therefore, in childbearing women it is considered to be the neuroimaging method of choice [
19,
20]. Its downsides include longer than CT scan duration and limited availability in some centers.
In conclusion, in case of disabling stroke during pregnancy rapid neuroimaging utilizing the readily available method (CT or MRI) should be performed. When both imaging modalities may be applied without significant delay or reperfusion treatment is not considered, MRI should be preferred over CT.
Noninvasive Cerebral Vessel Imaging
Noninvasive vessel imaging should be a part of routine initial AIS evaluation. Its primary objective is to assess for large vessel occlusion (LVO) as a part of EVT qualification process. For this purpose CTA and MRA are considered to be equivalent methods, with the former having slightly higher accuracy than the latter [
7].
During CTA iodinated contrast agent is applied that may bring some fetal safety concerns. Despite crossing the placenta via simple diffusion, in vitro studies have failed to show mutagenic effect of iodinated contrast media and teratogenic effect has not been observed in animal studies [
21‐
24]. Nevertheless, there were no such studies performed in pregnant women and most of iodinated contrast agents are classified as class B by the U.S. Food and Drug Association (FDA) [
25]. There was one study providing data on neurodevelopment after iodinated contrast, which was normal until the last follow-up at the age of 4 months [
26].
Administration of iodinated contrast media in pregnancy may result in goiter formation and underactive thyroid in neonates, although studies that demonstrated those side effects were performed with liposoluble compounds during amniofetography or hysterosalpingography [
27]. CTA utilizes water-soluble non-ionic media that are considered to have less adverse effects [
28]. In the systematic review of studies including 525 neonates born after maternal contrast agent exposure during CT scanning in pregnancy, the overall proportion of (transient) neonatal thyroid dysfunction was estimated at 0% (95% CI: 0.0–0.02% I
2 = 0%). Transient thyroid dysfunction was found in only 3 out of 525 (0.6%) neonates and resolved spontaneously in all of them [
29]. It is also worth noting that childbearing women with a history of allergic reactions have an increased risk of developing an allergic reaction during pregnancy that may pose some risk for the fetus [
27].
The American College of Obstetricians and Gynecologists stated that despite the lack of known harm, it is generally recommended that contrast only be used if absolutely required to obtain additional diagnostic information that will affect the care of the fetus or woman during the pregnancy [
19]. In cases of disabling AIS the requirement of obtaining additional important information, i.e. presence of the LVO, is certainly met.
Magnetic resonance angiography techniques used in AIS patients include non-contrast time-of-flight MRA (TOF-MRA) and contrast-enhanced MRA (CE-MRA). Despite several disadvantages (e.g. limited field of view that excludes extracranial vessels, long acquisition time with the risk of motion artifacts) TOF-MRA is more widely used in EVT qualification process [
30]. CE-MRA can be superior to TOF-MRA in terms of localizing vessel occlusion and accuracy of collateral status assessment. It also offers shorter acquisition time and larger coverage [
31,
32]; however, it requires gadolinium contrast administration that addresses questions about its safety in pregnancy.
Animal investigations on teratogenic effect of gadolinium-based contrast media have been inconclusive, with some studies showing high and repeated doses to be teratogenic, while others reported no such effects [
27,
33]. Understandably, no trials on pregnant women were conducted. Retrospective studies have presented no significant risk of congenital abnormalities amongst neonates whose mothers were exposed to gadolinium-based contrast [
18,
34]. One large retrospective study assessing long-term safety of MRI exposure during the first trimester of pregnancy showed the risk of rheumatological, inflammatory or infiltrative skin conditions to be increased in gadolinium MRI group compared to no MRI (adjusted hazard ratio, 1.36; 95% CI 1.09–1.69). There was also significantly higher risk of stillbirth and neonatal death in 7 gadolinium MRI-exposed versus 9844 MRI unexposed pregnancies (adjusted relative risk, RR 3.70; 95% CI 1.55–8.85) [
18]. Despite several shortcomings of this study, it may bring the conclusion that MRI with gadolinium contrast enhancement should be used with the highest caution. According to the guidelines of American College of Obstetricians and Gynecologists it should be limited to the instances when it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome [
19]. Given the possibility of TOF-MRA utilization, CE-MRA should not be used as a method of noninvasive cerebral vessel assessment in EVT patient selection during pregnancy.
Considering the abovementioned data and uncertain benefits of EVT treatment of minor AIS, it is reasonable to employ a preimaging selection method based on admission National Institutes of Health Stroke Scale (NIHSS) in pregnant stroke patients. The NIHSS score was found to be the best instrument for LVO prediction, with a threshold of ≥ 6 having the highest sensitivity (87%) and modest specificity (52%). This approach is a valid option in the general population according to AHA/ASA treatment guidelines and might be also reasonable among childbearing women [
7]. A more conservative cut-off NIHSS value of ≥ 10 would provide higher specificity (74%) at the cost of lower sensitivity (73%) [
7,
35].
According to the Canadian Stroke Best Practice Consensus Statement on acute stroke management during pregnancy, in selected cases (e.g. presence of a hyperdense middle cerebral artery on CT), direct digital subtraction angiography (DSA) for potential treatment of LVO may be performed instead of initial noninvasive assessment [
12]. Considering the high specificity of the hyperdense artery sign, this may be a rational approach [
36].
In conclusion, TOF-MRI appears to be the safest noninvasive cerebral vessel imaging method. It should be incorporated into the pregnant AIS patient assessment for LVO when MRI was chosen as the initial imaging modality. It is also reasonable to avoid using CE-MRA in this group of patients. In case of CT being initially selected, CTA should be performed as its fetal adverse effects appear to be negligible. In our opinion, the choice between CT with CTA and MRI with MRA should preferably be made based on availability and pace, rather than safety concerns. It appears reasonable to employ ≥ 6 (or more conservative ≥ 10) NIHSS score threshold for noninvasive cerebral vessel imaging and to abandon the examination in cases of pregnant women otherwise ineligible for EVT.
Perfusion Imaging and Late Presenting or Unknown Onset AIS Patients
A subset of late presenting stroke patients benefits from reperfusion treatment when appropriately selected [
7]. Several selection methods have been evaluated and are now widely employed. AIS patients with LVO presenting between 6 and 24 h from symptom onset are good candidates for EVT as long as they have favorable clinical radiological mismatch profile, where diffusion-weighted imaging (DWI) MRI sequences serve as a radiological and NIHSS score as a clinical component according to DAWN trial criteria [
37]. In the 6–18 h window CTP and MRP may serve the same purpose as shown in DEFUSE‑3 trial [
38]. Recently, CLEAR study showed no significant differences in outcomes with non-contrast CT only compared with CTP or MRI-based patient selection, which may bring new insights into the previous EVT qualification paradigm [
39]. Similarly, IVT may be offered to a subset of late presenting patients or those with unknown stroke onset. According to European Stroke Organization (ESO) guidelines, patients with AIS of 4.5–9 h duration and CTP/MRP mismatch or those with symptoms on awakening and MRI DWI fluid inversion recovery (FLAIR) mismatch are good candidates for IVT [
40]. It shows several clinical scenarios in which childbearing women with AIS may be found. None of them have been assessed in clinical trials, as pregnancy was an exclusion criterion in all of them. Considering that perfusion studies play a pivotal role in most of those scenarios, their safety for an unborn child should be taken into consideration.
Depending on the study, additional effective radiation dose for CTP varies between 0.2 and 9 mSv [
41‐
43]. The cumulative dose of non-contrast CT, CTA and CTP was estimated to be 11.48 mSv, but can be reduced by nearly 50% using some low-dose protocols [
43,
44]. There are no studies evaluating CTP radiation dose absorbed by fetus, but it is probably low, as local organ dose for gonads was shown to equal 0.2 mSv [
42]. The threshold for radiation exposure adverse events is thought to be much higher than the amount absorbed during entire AIS CT evaluation (non-contrast CT, CTA, CTP). The risk of additional contrast injection has not been evaluated but is probably negligible as described in the “Noninvasive cerebral vessel imaging” section. In late presenting or unknown onset pregnant patients with disabling stroke, CTP may bring some vital information that would potentially lead to reperfusion treatment. Therefore, its utilization in selected patients appears to be highly reasonable.
The most commonly used MRP technique is the dynamic susceptibility contrast (DSC) imaging that requires gadolinium administration, which may lead to some serious fetal adverse effects. As other methods of reperfusion treatment patient selection are easily accessible, DSC-MRP should probably not be used during pregnancy. Clinical DWI, DWI/FLAIR or CTP mismatch could serve this purpose in cases of EVT, IVT or both treatment modalities, respectively. It is also reasonable to utilize arterial spin labeling (ASL) MRI as a noninvasive, non-contrast technique that enables not only cerebral blood flow (CBF), but also occlusion site and collateral flow evaluation [
45]. In a systematic review by Liu et al. the agreement on several metrics (hypoperfusion, hyperperfusion, mismatch, and reperfusion) for ASL and DSC was concluded to be moderate to very high, with some heterogeneity of perfusion parameters in analyzed studies [
46]. ASL-MRP is a valuable imaging method in certain populations with contraindications for contrast administration, including childbearing women in cases of AIS.
It seems reasonable to forfeit perfusion imaging in AIS pregnant patients presenting within the reperfusion treatment window and proceed to appropriate management immediately after non-contrast and cerebral vessel imaging. Patients presenting after 6 h of symptom duration and otherwise eligible for EVT should probably have CTP performed when non-contrast CT and CTA were initially selected. If MRI and MRA were chosen, the clinical DWI mismatch or ASL-MRP should be used to determine EVT eligibility, rather than proceeding to DSC-MRP. In view of new data from the CLEAR trial, non-contrast CT evaluation may be sufficient for EVT qualification in the extended window in LVO patients. For this purpose the Alberta Stroke Program Early CT Score (ASPECTS) threshold of ≥ 6 might be used, as applied in most centers participating in this study [
39].
Pregnant AIS patients presenting after 4.5 h and before 9 h of last seen well and otherwise eligible for IVT should probably have CTP performed to determine tissue status and potentially initiate treatment. When symptoms are noticed on awakening, DWI-FLAIR mismatch on non-contrast MRI or CTP may be used to determine IVT eligibility. Although not being confirmed by solid evidence, this approach appears to be reasonable, given the very low probability of serious fetal adverse effects and potentially devastating consequences of untreated disabling stroke.