Korean Journal of Cerebrovascular Surgery 2009;11(4):204-206.
Published online December 1, 2009.
Unexpected Complication of Intravenous Recombinant Tissue Plasminogen Activator Thrombolysis in a Patient with Acute Ischemic Stroke: Aortic Dissection.
Jo, Kwang Wook , Park, Ik Seong , Kim, Young Doo , Kim, Seong Rim
1Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea. twinpapa@catholic.ac.kr
2Department of Cardiovascular Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea.
Abstract
We report here on a case of acute aortic dissection after intravenous tissue plasminogen activator (t-PA) administration in a patient with acute ischemic stroke. A 75-year-old woman with a history of hypertension and diabetes mellitus presented with left hemiplegia and a decreased mentality. The admission studies revealed severe stenosis of the right middle cerebral artery and decreased cerebral perfusion. Initial chest radiography showed hypertensive cardiovascular changes and increased interstial markings on both lung fields. Cyanosis and cardiac arrest occurred 80 minutes after intravenous t-PA administration. Emergency cardiopulmonary resuscitation was done and chest CT showed a dissection involving the whole aorta and pericardial effusion due to bleeding. In spite of our earnest efforts, the patient died. It should be kept in mind that aortic dissection can occur after intravenous t-PA administration and an early clinical suspicion and diagnosis is needed to avoid this devastating complication.
Key Words: Aortic dissection, Stroke, Thrombolysis, Tissue plasminogen activator

Introduction

Acute aortic dissection usually induces chest, back, and abdominal pain and can cause ischemic stroke with or without pain.7) It is devastating unless emergency treatment is performed. The authors report a case of acute aortic dissection after intravenous t-PA administration in a patient with acute ischemic stroke.

Case Report

A 75-year-old woman with a history of hypertension and diabetes mellitus presented with loss of consciousness and left hemiplegia (grade II). She admitted the emergency room 80 minutes after ictus. On admission, she was nearly alert (GCS 14, E3/V5/M6) but left hemiplegia was still sustained (NIHSS score 4). Initially, her vital signs were stable and laboratory results including cardiac enzymes (Troponon I, CK-MB) were not meaningful. Chest radiography showed hypertensive cardiovascular changes and increased interstial markings on both lung fields and these findings were thought to be due to aging process (Fig. 1). Brain computed tomography (CT) angiography and perfusion CT revealed severe stenosis of the right middle cerebral artery and decreased cerebral perfusion (Fig. 2). Tissue plasminogen activator was given intravenously 150 minutes after ictus.

Eighty minutes thereafter, the patients suddenly presented with cyanosis followed by cardiac arrest. Cardioplumonary resuscitation was performed immediately and vital signs were stabilized. Emergent chest CT revealed a dissection invading the whole aorta and pericardial effusion suggesting hemorrhage (Fig. 3). Echocardiography showed cardiac tamponade and emergency operation was planned by cardiovascular surgeon. However, cardiac arrest occurred again and she expired 30minute after cardiopulmonary resuscitation.

 

Discussion

Aortic dissection is life-threatening, so it should be diagnosed promptly and accurately. Acute aortic dissection is a cardiovascular emergency, but outcomes are poor.3) Pain develops suddenly and reaches its maximal level unexpectedly.9) Spreading of the pain to abdomen, hips, and legs suggests distal progression of the aortic dissection.10) A pain-free interval may follow the initial pain of aortic dissection, lasting from hours to days, and the subsequent recurrence of pain usually indicates impending rupture.7) The most commonly involved organ system is the cardiovascular system with manifestations of aortic regurgitation (18 to 50%), hypotension (25%), and left ventricular regional wall abnormalities (10 to 15%) respectively; acute pericardial effusion, cardiac tamponade, and symptomatic ischemia of an extremity may also ensue.10)

Ischemic strokes are caused by the compromised blood flow to or obstruction of supraaortic arteries.10) In 17 to 40% of the patents, transient or permanent neurologic deficits are found at the onset of aortic dissection and may mask the underlying condition. Especially in pain-free patients with predominant neurological symptoms, diagnosis of aortic dissection can be difficult and delayed.2) Thrombolytic treatment with t-PA is an established therapy for selected patients with ischemic stroke within a narrow time window of 3 hours from the onset of symptoms.10)11) However, severe complications and poor outcomes are likely to ensue if a patient with acute aortic dissection is improperly treated with thrombolytic agents.6)10) Five cases of aortic dissection after intravenous t-PA administration have been documented in the literature.4)5) It is uncertain whether t-PA is indicated for acute ischemic stroke secondary to aortic dissection, especially for patients expected to have severe disability without treatment. Current guidelines do not state specifically whether this situation is contraindicated for intravenous t-PA administration in patients acute ischemic stroke. Surgeons are reluctant to perform surgery on aortic dissection patients complicated by acute ischemic stroke. However, the outcome of aortic dissection is dismal without surgery.5) Thrombolysis might contribute to dissection extension or rupture by interfering with thrombus formation at the intimal tear, increasing the risk of early death due to worsening hemothorax, or hemopericardium as our patient. Thrombolysis can also delay surgery and interfere with hemostasis. The outcome of these patients after t-PA treatment was poor, with a reported mortality of up to 71%.6)

In recent guidelines, a routine heart examination including chest radiography is not recommended as an initial evaluation method for intravenous t-PA in order to avoid delay of the treatment.4) Learned from our case, chest radiography should be checked in patients with old age or clinical evidence of acute cardiopulmonary disease.1) If the radiographic findings are abnormal, portable echocardiography may be desirable and it is also required to monitor the patient carefully while t-PA is administered.

 

Conclusion

It should be kept in mind that aortic dissection can occur after intravenous t-PA administration and early clinical suspicion and diagnosis is essential to avoid this devastating complication.

 

REFERENCEs

1)              Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 38:1655-711, 2007

2)              Gaul C, Dietrich W, Erbguth FJ. Neurological symptoms in aortic dissection: A challenge for neurologists. Cerebrovasc Dis 26:1-8, 2008

3)              De Sanctis RW, Doroghazi RM, Austen WG, Buckley MJ. Aortic dissection. N Engl J Med 317:1060-7, 1987

4)              Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological symptoms in type A aortic dissections. Stroke 38:292-7, 2007

5)              Hong KS, Park SY, Whang SI, Seo SY, Lee DH, Kim HJ, et al. Intravenous Recombinant Tissue Plasminogen Activator Thrombolysis in a Patient with Acute Ischemic Stroke Secondary to Aortic Dissection. J Clin Neurol 5:49-52, 2009

6)              Kamp TJ, Goldschmidt-Clermont PJ, Brinker JA, Resar JR. Myocardial infarction, aortic dissection, and thrombolytic therapy. Am Heart J 128:1234-7, 1994

7)              Kawarabuki K, Sakakibara T, Hirai M, Shirasu M, Kohara I, Tanaka H, et al. Acute aortic dissection presenting as a neurologic disorder. J Stroke Cerebrovasc Dis 15: 26-9, 2006

8)              Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 122:311-28, 2002

9)              Mo HH, Chen SC, Lee CC. Seizure: an unusual primary presentation of type A aortic dissection. Am J Emerg Med 26: 245, 2008

10)            Moti Grupper, Ayelet Eran, Alla Shifrin. Ischemic stroke, aortic dissection, and thrombolytic therapy: the importance of basic clinical skills. J Gen Intern Med 22: 1370-2, 2007

11)            Yeh JF, Po H, Chien CY. Ischaemic infarction masking aortic dissection: a pitfall to be avoided before thrombolysis. Emerg Med J 24: 594-5, 2007



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