Simultaneous Acute Anterior ST-Elevation Myocardial Infarction and Acute Ischemic Stroke of Left Middle Cerebral Artery: A Case Report

Abstract OBJECTIVE AND IMPORTANCE Intra-arterial thrombolysis has been demonstrated to improve recanalization and outcomes among patients with acute ischemic stroke. However, thrombolytic agents have limited effectiveness and are associated with a significant risk of bleeding. Bivalirudin is a direct thrombin inhibitor that has been demonstrated in the cardiology literature to have a more favorable efficacy and bleeding profile than other antithrombotic medications. We report the use of bivalirudin during endovascular treatment of acute stroke, when hemorrhagic complications are not uncommon. CLINICAL PRESENTATION A 71-year-old woman with atrial fibrillation presented with right hemiparesis and aphasia and was found to have a National Institutes of Health Stroke Scale score of 10. Computed tomographic scans revealed no evidence of intracranial hemorrhage, aneurysm, or ischemic stroke. Cerebral angiography revealed thromboembolic occlusion of the superior division of the left middle cerebral artery. INTERVENTION For anticoagulation, a loading dose of bivalirudin was intravenously administered before the interventional procedure, followed by continuous infusion. Attempts to remove the clot with an endovascular snare failed to induce recanalization of the vessel. Bivalirudin was then administered intra-arterially. Immediate postprocedural angiography demonstrated restoration of flow in the left middle cerebral artery. Repeat computed tomographic scans demonstrated no intracranial hemorrhage. The patient's hemiparesis and aphasia were nearly resolved and her National Institutes of Health Stroke Scale score was 2 at the time of her discharge 5 days later. CONCLUSION To our knowledge, this is the first report of the use of bivalirudin for treatment of acute ischemic stroke. Bivalirudin may be a useful agent for intravenous anticoagulation and intra-arterial thrombolysis in this setting.

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Coexistence of ST-elevation myocardial infarction and acute ischemic stroke

International Journal of Cardiology ◽

10.1016/j.ijcard.2010.09.043 ◽

2011 ◽

Vol 146 (2) ◽

pp. 233 ◽

Cited By ~ 2

Author(s):

Salvatore Patanè ◽

Filippo Marte ◽

Concetta Lentini ◽

Sergio Buonamonte

Keyword(s):

Myocardial Infarction ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

St Elevation Myocardial Infarction ◽

St Elevation

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Adverse Outcome of Early Recurrent Ischemic Stroke Secondary to Atrial Fibrillation after Repeated Systemic Thrombolysis

Case Reports in Vascular Medicine ◽

10.1155/2013/371642 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 4

Author(s):

Luciano A. Sposato ◽

Valeria Salutto ◽

Diego E. Beratti ◽

Paula Monti ◽

Patricia M. Riccio ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Neurological Outcome ◽

Left Middle Cerebral Artery ◽

Cerebrovascular Event ◽

Middle Cerebral Artery Infarction ◽

Systemic Thrombolysis ◽

Left Middle

Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke.Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tomographic scans. The patient did not recover from the second cerebrovascular event and died 25 days after admission.Conclusion. To the best of our knowledge, this is the second case reporting the adverse neurological outcome of a patient with diagnosis of atrial fibrillation undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Our report represents a contribution to the scarce available evidence suggesting that repeated systemic thrombolysis for recurrent ischemic stroke should be avoided.

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