Thrombolysis in a Patient with Capsular Warning Syndrome and Incidental Pineal Tumor

Case Report

Austin J Cerebrovasc Dis & Stroke. 2015;2(1): 1032.

Thrombolysis in a Patient with Capsular Warning Syndrome and Incidental Pineal Tumor

Bain L1, Rana A³, Bhatt P², Clarke R¹ and Reid JM¹*

1Acute Stroke Unit, Aberdeen Royal Infirmary, UK

2Department of Neurosurgery, Aberdeen Royal Infirmary, UK

3Department of Neuroradiology, Aberdeen Royal Infirmary, UK

*Corresponding author: John Reid, Acute Stroke Unit, Department of Neuroradiology, Aberdeen Royal Infirmary, UK.

Received: March 09, 2015; Accepted: March 30, 2015; Published: April 01, 2015

Abstract

There are many relative contraindications to administering intravenous thrombolysis (IVT) for acute ischemic stroke (AIS), such as rapidly improving symptoms. In addition there has been debate about whether certain stroke subtypes are less likely to respond to IVT (e.g. lacunar stroke). We describe a case with consent of a 63 year old man with Capsular Warning Syndrome (CWS), who was later identified to also have a pineal tumor. The patient was treated with IVT, but this was stopped part way through the infusion when the tumor diagnosis was realized and the patient had clinically improved. The patient’s stroke symptoms later recurred, and following discussion with neuroradiology and neurosurgical colleagues IVT was then restarted. This case emphasizes the debate about the best treatment for CWS and supports use of thrombolysis for this condition. Secondly we believe this to be the first case report of a patient with a pineal tumor receiving IVT for AIS. It highlights that for some types of brain tumors, particularly if benign or extra-axial location, IVT may be relatively safe.

Keywords: Intravenous thrombolysis; Lacunar stroke; Acute ischemic stroke; Intracranial tumors

Introduction

There are many contraindications to the use of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) including rapidly recovering symptoms and the presence of an intracranial mass lesion [1]. We describe a patient with capsular warning syndrome (CWS) who appeared to benefit from IVT without negative consequence, despite the presence of a previously unknown intracranial mass. This case highlights areas of uncertainty that can be encountered when considering use of IVT in AIS patients.

Case Presentation

A 63 year old man developed right sided weakness and dysarthria at 0545, 20 minutes after waking. His medical history was significant for untreated hypertension and current smoking (20 cigarettes/day). Upon arrival in the emergency department (ED) at 0803, there had been some partial recovery in his weakness, and National Institutes of Health Stroke Scale (NIHSS) score was 6. Blood pressure was 158/82 mmHg and he was in sinus rhythm. A non-contrast CT head scan was reviewed by a junior radiologist and the consultant stroke physician. This was thought to show ventriculomegaly but no cause for this noted. There was no hemorrhage, early ischemic change or other abnormality. The patient had no symptoms of headache or papilledema. Following discussion of the risks and benefits of IVT, alteplase (initial 10% bolus dose and total dose 0.9 mg/kg over 60 minutes) was initiated with consent at 0846. Approximately 25 minutes through the alteplase infusion (0910), further radiological review of the CT scan by a consultant neuroradiologist suggested the scan demonstrated a pineal tumor (Figure 1A). At this point, the patient’s symptoms had fully resolved (NIHSS = 0) and therefore, in view of the possible risks associated with IVT and the new radiological interpretation, the alteplase infusion was stopped. At 1025 the patient developed recurrent flaccid right sided weakness, with mild dysarthria and facial droop (NIHSS = 8). A repeat CT scan was unchanged. His case was further discussed with the on-call neurosurgical consultant who was of the opinion that the pineal tumor was likely benign and longstanding, and felt the risks of intracerebral hemorrhage from IVT were probably negligible. Following further discussion with the patient, and in view of recurrent disabling weakness it was decided to continue and complete the alteplase infusion. His symptoms had fully resolved on completion of the alteplase infusion and he was transferred to the acute stroke unit at 1200. At 1230 he developed a further flaccid right hemi paresis resolving after one hour. There was one final episode of severe right arm weakness at 0030 which resolved after one hour. 24 hours after presentation, only a mild right arm and leg drift was present (NIHSS = 2) and he was started on Aspirin 300mg daily. T2-weighted cranial MRI showed a wedged-shaped hyperintensity in the posterior limb of the left internal capsule, with restriction on diffusion weighted images typical of recent infarct, and no intracranial hemorrhage (Figure 1B). ECG, 24-hour cardiac monitor and carotid duplex ultrasound were within normal limits. He was discharged home after a further 24 hours and initiated on Aspirin 300 mg/day and Simvastatin 40 mg at night. NIHSS was 0 at one week following presentation and modified Rankin score (mRS) 0 at 3 months. Further neurosurgical review is planned with follow-up imaging to determine if the pineal tumor is changing.

Citation: Bain L, Rana A, Bhatt P, Clarke R and Reid JM. Thrombolysis in a Patient with Capsular Warning Syndrome and Incidental Pineal Tumor. Austin J Cerebrovasc Dis & Stroke. 2015;2(1): 1032. ISSN: 2381-9103.