Fatal Contralateral Cardioembolic Stroke Promoted by Systemic Thrombolysis with rtPA in Ischemic Stroke

Case Report

Austin J Cerebrovasc Dis & Stroke. 2014;1(3): 1015.

Fatal Contralateral Cardioembolic Stroke Promoted by Systemic Thrombolysis with rtPA in Ischemic Stroke

von Sarnowski B1*, Zyber H1, Brückmann S2, Vogelgesang S2,Behrndt PO3, Kirsch M3 and Schminke U1

1Department of Neurology, University Medicine Greifswald, Germany

2Department of Pathology and Neuropathology, University Medicine Greifswald, Germany

3Department of Radiology, University Medicine Greifswald, Germany

*Corresponding author: von Sarnowski B, Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str, D-17475 Greifswald, Germany

Received: July 15, 2014; Accepted: August 15, 2014; Published: August 19, 2014

Abstract

Background and Purpose: Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is the most effective and the only approved causal treatment in acute ischemic stroke.

Summary of Case: We treated an 88-year-old hale woman with atrial fibrillation and acute left middle cerebral artery (MCA) infarction with intravenous thrombolysis. Directly thereafter, she developed an epileptic status. Immediate CT scan was normal. Fourteen hours later, it showed a normal left hemisphere but a fatal space-occupying contralateral MCA and anterior cerebral artery (ACA) infarction. Autopsy revealed thrombi in atria, large right MCA and ACA ischemia, and occlusion of two major visceral arteries.

Conclusion: RtPA, though effective for the initial infarction, caused a rarely observed fatal adverse event, i.e. cardioembolism by detachment of atrial thrombi fragments, with an uncommon presentation as epileptic status. Stroke physicians’ awareness of this potential course will allow treatment in time.

Keywords: Thrombolysis therapy; Cardioembolic stroke; serious adverse event

Abbreviations

rtPA: Recombinant Tissue Plasminogen Activator; AF: Atrial Fibrillation; NIHSS: National Institute of Stroke Scale score; MCA: Middle Cerebral Artery; CT: Computed Tomography; ACA: Anterior Cerebral Artery; IV: Intravenous

Abstract

Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is the most effective and the only approved causal treatment within the first 4.5 hours of acute ischemic stroke [1]. Its most dreaded adverse event is symptomatic intracranial hemorrhage, which occurs in 2.4% [1] to 5.2% [2] of patients. Hence, most exclusion criteria are aimed to reduce bleeding risks. In contrast, cardioembolism to other vascular territories during or in direct course of thrombolysis for stroke is rarely observed in atrial fibrillation (AF) [3-5] and presence of intracardiac thrombus [6]. Although not systematically reported in large randomized controlled trials, up to 6.8% of thrombolysis patients with AF may have clinically significant cardioembolic strokes in other cerebrovascular territories possibly linked to rtPA [3]. Still, it is not the focus of stroke physicians which may oftentimes delay diagnosis and therapy [5].

Case Presentation

We report an 88-year-old woman who still attended to most of her daily needs until she developed acute right-sided brachiofacial hemi paresis, slight dysarthria, and a hypaesthetic right leg (National Institute of Stroke Scale score (NIHSS) 8) due to acute left middle cerebral artery (MCA) infarction. Cerebral CT scan confirmed our clinical diagnosis by time-to-peak prolongation in a small part of the MCA territory (Figure 1A-D). There were no early ischemic signs or evidence of carotid artery or MCA occlusion on CT angiography. Formerly unknown tachyarrhythmia AF indicated cardioembolic etiology.

Citation: Lopez JI, Rothrock JF and Cortez JV. Therapeutic Approaches for Patients with Acute Ischemic Stroke: IV t-PA, Endovascular/Catheter-based Intervention, or Both?. Austin J Cerebrovasc Dis & Stroke. 2014;1(3): 1015. ISSN: 2381-9103.