Cerebral aneurysm rupture after r-TPA thrombolysis for acute myocardial infarction

Tenecteplase-induced Nonaneurysmal Subarachnoid Hemorrhage in a Patient with Acute Ischemic Stroke: A Case Report and Literature Review

Recently, tenecteplase (TNK) has been used for intravenous thrombolysis in acute ischemic stroke (AIS). Although spontaneous subarachnoid hemorrhage (SAH) following thrombolysis with tissue plasminogen activator has been reported, there is a lack of literature regarding TNK-induced nonaneurysmal spontaneous SAH. Our index case received intravenous TNK within an hour of symptom onset of AIS. Following deterioration of sensorium, repeat noncontrast computed tomography was performed, which showed diffuse SAH. Cerebral angiography did not reveal any aneurysm. Nonaneurysmal SAH can be a complication of TNK thrombolysis, which is not reported in literature. Knowledge of this possible adverse reaction is critical for appropriate counseling and management.

Rupture of Anterior Communicating Artery Aneurysm after Intravenous Thrombolysis for Acute Ischemic Stroke: A Case Report

Objective

Rupture of intracranial aneurysms after tissue plasminogen activator (t-PA) administration for acute ischemic stroke with an unruptured cerebral aneurysm is rare. We report a case of ruptured cerebral aneurysm after t-PA administration.

Case Presentation

A 74-year-old woman with dysarthria and left hemiparesis was admitted to our hospital, and acute lacunar infarction was found in the right corona radiata. One hour after t-PA administration, she complained of sudden headache and nausea, and her consciousness level deteriorated. Subarachnoid hemorrhage due to rupture of the anterior communicating aneurysm was confirmed and coil embolization was performed.

Conclusion

T-PA administration for acute ischemic stroke with an unruptured cerebral aneurysm risks rupture of the cerebral aneurysm, and careful judgment is needed in each case.

Fatal intracranial aneurysm rupture after thrombolytic treatment for ischemic stroke: a case report and literature review

Intravenous thrombolysis is a proven treatment of acute ischemic stroke. Its complications include intracranial hemorrhage; the risk may be increased in the presence of an unruptured aneurysm. We present a case report of a patient who suffered fatal subarachnoid hemorrhage after thrombolysis from a known aneurysm. A history of recent previously inexperienced headaches was revealed retrospectively, suggestive of sentinel bleedings. A similar patient was identified in the literature; we thus propose that this history should be excluded in patients harboring an aneurysm considered for thrombolytic treatment.

Is acute reperfusion therapy safe in acute ischemic stroke patients who harbor unruptured intracranial aneurysm?

Background

Intracranial aneurysms are currently considered as contraindication for intravenous thrombolysis in acute ischemic stroke, very likely due to a possible increase in the risk of bleeding from aneurysm rupture; however, there is limited data available on whether intravenous thrombolysis is safe for acute ischemic stroke patients with pre-existing intracranial aneurysms.

Aims and/or hypothesis

To find out the safety of intravenous thrombolysis in acute ischemic stroke patients who harbor unruptured intracranial aneurysms.

Methods

We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with intravenous thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with unruptured intracranial aneurysm present on cerebrovascular images prior to acute reperfusion therapy were identified. Post-thrombolysis brain imaging was reviewed to evaluate for any intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysm.

Results

A total of 637 patients received intravenous thrombolysis for acute ischemic stroke in our center during an 8.3-year period. Thirty-three (5.2%) were found to have at least one intracranial aneurysms. Twenty-three (70%) of those received only intravenous thrombolysis, and 10 patients received combination of intravenous and intra-arterial throm-bolysis. The size of the largest aneurysm was 10 mm in maximum diameter (range: 2-10 mm). The mean size of aneurysms was 4.8 mm. No symptomatic intracranial hemorrhage occurred among the 23 patients receiving only intravenous thrombolysis. Out of those who received a combination of intravenous and intra-arterial thrombolysis, one developed symptomatic intracranial hemorrhage in the location of acute infarct, distant to the aneurysm location.

Conclusion

Our findings suggest that neither intravenous thrombolysis nor combination of intravenous and intra-arterial thrombolysis increases the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for intravenous throm-bolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.

Intracranial aneurysm formation in type-one diabetes rats

BACKGROUND & OBJECTIVE

Diabetes mellitus (DM) plays an important role in the pathogenesis of vascular complications including arteriosclerosis and ischemic stroke. Whether DM impacts intracranial aneurysm (IA) formation has not been extensively investigated. In this study, we tested the underlying mechanism of type one DM (T1DM) induced IA formation in rats.

EXPERIMENTAL APPROACHES

T1DM was induced by streptozotocin injection. Rats were euthanized at 0, 4 and 10 weeks after T1DM induction. To evaluate cerebral vascular perfusion, Fluorescein isothiocyanate - dye was injected at 5 min prior to euthanasia. Vascular perfusion was measured by laser scanning confocal microscopy. Trichrome, Elastica van Gieson, alpha-smooth muscle actin (a-SMA) and receptor of advanced glycation end-products (RAGE), toll-like receptor 4 (TLR4) and matrix metalloproteinase 9 (MMP9) immunostaining were performed. The IA formation was classified by 0-3 stages: 0: Normal; 1: Endothelial damage; 2: Moderate protrusion; and 3: Saccular aneurysm formation.

RESULTS

T1DM significantly increased IA formation identified by the classification of aneurysmal changes compared with non-DM rats (p<0.05). However, T1DM induced IA formations were classified as stage 1 and stage 2, but not stage 3. Cerebral vascular perfusion was significantly decreased in T1DM rats compared to non-DM rats (p<0.01). DM10W rats exhibited a significant decrease of cerebral vascular perfusion compared to DM4W rats (p<0.05). T1DM rats also significantly increased the internal carotid artery (ICA) intimae and media thickness, and decreased the internal carotid artery diameter compared to non-DM rats. RAGE, MMP9 and TLR4 expression were significantly increased in T1DM rats compared to non-DM rats. The increased RAGE, TLR4 and MMP9 significantly correlated with IA formation (p<0.05).

CONCLUSION

T1DM increases IA formation. The increased RAGE, MMP9 and TLR4 expressions might contribute to IA formation in T1DM rats.

Thrombolysis of an acute stroke presentation with an incidental unruptured aneurysm

Many patients with acute ischaemic stroke have contraindications to thrombolytic therapy. We describe a 45 yr old Afro-Caribbean female with HbSC disease whom was electively admitted for a cerebral angiogram to evaluate an intracavernous aneurysm measuring 20 mm in diameter. During the procedure, she suffered a right MCA territory ischaemic event with a NIHSS of 10. A CT angiogram demonstrated no dissection and no evidence of a major vessel occlusion. Tissue plasminogen activator (tPA) was administered intravenously within 60 minutes of symptom onset. She had clinical and haematological evidence of a painful sickle cell crisis and required manual exchange transfusion within a few hours of thrombolysis. This is the first reported case of the use of thrombolysis for acute stroke in a sickle cell crisis; and in the presence of such a large unruptured aneurysm. A registry of unusual thrombolysis cases might help clinicians in cases when there is little evidence to support decision-making.

Anterior Communicating Artery Aneurysm Rupture After Intravenous Thrombolysis for Acute Middle Cerebral Artery Thromboembolism

BACKGROUND AND IMPORTANCE:

The use of intravenous recombinant tissue plasminogen activator (IV rtPA) has become an integral part of modern acute ischemic stroke management; however, its use has been associated with the development of intracranial hemorrhage in 6.4% of patients. It is possible that underlying and unsuspected vascular lesions, such as cerebral aneurysms, may lead to intracranial hemorrhage after IV rtPA thrombolysis.

CLINICAL PRESENTATION:

We present a previously unreported case of a 51-year-old woman who presented with subarachnoid hemorrhage from an acutely ruptured a nterior communicating artery aneurysm after IV rtPA treatment for acute left middle cerebral artery thromboembolism. The patient underwent mechanical thromboembolectomy of the left middle cerebral artery occlusion with resultant TIMI (Thrombolysis In Myocardial Infarction) grade I recanalization, followed by coil embolization of the anterior communicating artery aneurysm. The patient never improved neurologically, and she ultimately died.

CONCLUSION:

Screening to identify patients at risk for development of hemorrhagic complications from underlying structural vascular lesions before the use of IV rtPA with computed tomography angiography should be considered.

Detection and significance of incidental unruptured cerebral aneurysms in patients undergoing intravenous thrombolysis for acute ischemic stroke

BACKGROUND

It is still controversial whether intravenous (IV) thrombolysis for acute ischemic stroke increases the risk of aneurysmal bleeding. We sought to find the risk for aneurysmal bleeding after IV thrombolysis in ischemic stroke patients with unruptured cerebral aneurysms.

METHODS

We retrospectively analyzed consecutive patients with acute ischemic stroke who had received IVT between August 2006 and November 2009. Immediately after IV-tissue plasminogen activator (tPA) therapy (.9 mg/kg), patients underwent CT angiography, MR angiography. After that, all patients underwent follow-up angiography within 36 hours of the initiation of IV thrombolysis. Aneurysm-related hemorrhage was defined as a hemorrhage that was related to the aneurysm site.

RESULTS

A total of 201 patients were analyzed, and 8 (4.1%) had unruptured cerebral aneurysms. Of the 8 patients, 4 had aneurysms over 5 mm of the longest diameter. Three patients had intracerebral hemorrhage that developed at the site of infarction, which was unrelated to the aneurysms.

CONCLUSION

The results of this study suggest that IV thrombolysis might not increase the risk of aneurysmal bleeding in acute stroke patients with unruptured aneurysm < 10 mm in diameter. Further studies with a larger sample size are needed to confirm our result.

Unruptured Cerebral Aneurysm Detected after Intravenous Tissue Plasminogen Activator for Stroke

Therapeutic guidelines of intravenous thrombolysis with tissue plasminogen activator (tPA) for hyperacute ischemic stroke are very strict. Because of potential higher risk of bleeding complications, the presence of unruptured cerebral aneurysm is a contraindication for systemic thrombolysis with tPA. According to the standard CT criteria, a 66-year-old woman who suddenly developed aphasia and hemiparesis received intravenous tPA within 3 h after ischemic stroke. Magnetic resonance angiography during tPA infusion was performed and the presence of a small unruptured cerebral aneurysm was suspected at the anterior communicating artery. Delayed cerebral angiography confirmed an aneurysm with a size of 7 mm. The patient did not experience any adverse complications associated with the aneurysm. Clinical experiences of this kind of accidental off-label thrombolysis may contribute to modify the current rigid tPA guidelines for stroke.

Ruptured cerebral aneurysm complicated with rebleeding following thrombolysis during endovascular embolization: two case reports

A 68-year-old woman and a 42-year-old woman presented with subarachnoid hemorrhage due to rupture of cerebral aneurysm. Both patients were treated with endovascular coil embolization. Thromboembolic complications occurred during the procedure and local thrombolysis was performed for recanalization. One patient developed massive rebleeding immediately after the procedure and the other suffered minor hemorrhage adjacent to the embolized aneurysm 2 days later. Local thrombolysis during treatment of ruptured aneurysm by coil embolization carries a significant risk of rebleeding. Prevention of thromboembolic complication by adequate heparinization is important.

Hemorrhagic Complications After Off-Label Thrombolysis for Ischemic Stroke

BACKGROUND AND PURPOSE

Only 2% to 4% of patients with acute ischemic stroke receive thrombolytic therapy resulting from the current strict inclusion criteria among other issues. Safety of intravenous and intraarterial thrombolysis in off-label situations is controversially discussed. We sought to review the reports on such patients regarding intra- and extracranial hemorrhage.

SUMMARY OF REVIEW

A MEDLINE search for off-label uses of thrombolysis revealed reports on 273 patients treated with intraarterial or intravenous thrombolysis for ischemic stroke. Symptomatic intracranial hemorrhage occurred in 19 of 273 patients (6.95%) and extracranial hemorrhage in 17 of 273 (6.22%).

CONCLUSIONS

These data suggest that the overall bleeding risk in off-label thrombolysis may not be as high as presumed. However, the small number of patients in each group and the likely underreporting of worse outcomes preclude drawing any conclusion as to specific treatment recommendations. Selected patients might benefit, however, from thrombolysis in situations not currently considered in the inclusion criteria. To obtain a meaningful database, a registry for off-label thrombolysis should be created.

Restoration of hearing loss with tissue plasminogen activator. Case report

A 59-year-old man with a 2-year history of sudden onset of hearing loss in the left ear was treated with tissue plasminogen activator (tPA) for myocardial infarction. The patient had 50 dB of hearing recovery after the full dose (100 mg of tPA followed by 3 mg/d of tPA for 2 weeks).

Intravenous infusion of recombinant tissue plasminogen activator for the treatment of patients with sudden and/or chronic hearing loss

Seventeen patients with sudden hearing loss and 10 patients with chronic hearing loss were treated with intravenous infusion of tissue plasminogen activator. For sudden hearing loss, the recombinant tissue plasminogen activator was used, and 3 mg (in 3 mL of diluent) was diluted into 250 mL of physiological saline solution and given intravenously every 12 hours. Sixteen patients of the sudden hearing loss group and all 10 patients of the chronic hearing loss group showed an improvement after this treatment. No patients had side effects from the treatment. The results indicate that this would be an excellent mode of therapy for patients with hearing loss.