You're screwed along with your children and grandchildren until we get survivors in charge.
http://nnjournal.net/article/view/1879
+ See all authors and affiliations
Neuroimmunol Neuroinflammation 2017;4:216-8.
| https://doi.org/10.20517/2347-8659.2016.57 | © The author(s) 2017
Received: 29 Dec 2016 |
Accepted: 28 Mar 2017 |
Published: 19 Oct 2017
This is an open access article licensed under the terms of Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any
medium, as long as the original author is credited and the new creations
are licensed under the identical terms.
Abstract
Other Section
The authors report the first case of thrombolysis in a patient
already receiving both aspirin and prasugrel following a recent ischemic
coronary event. A 55-year-old gentleman was treated for inferior wall
myocardial infarction with aspirin, prasugrel and percutaneous
angioplasty of right coronary artery. Three days following the procedure
he developed acute ischemic stroke due to a left middle cerebral artery
infarction with a National Institute of Health Stroke Scale (NIHSS) of
24 and was treated with alteplase. Therapy was interrupted after
completion of 29 mg (for a body weight of 65 kg) dose due to oral
bleeding. Fifteen minutes post thrombolysis NIHSS was 5 and dropped to
zero after 12 h. This report highlights the benefits of alteplase in the
context of several relative contraindications like the setting of acute
myocardial infarction treated with percutaneous intervention and high
NIHSS.
Keywords:
Intravenous thrombolysis,
ischemic stroke,
percutaneous coronary angioplasty,
prasugrel
Introduction
Other Section
Intravenous
thrombolysis is the standard of care in acute ischemic stroke, and is
associated with significant improvement in outcome measures[1].
Intracerebral hemorrhage is an absolute contraindication for
thrombolysis. While due diligence must be exercised, strict
interpretations of relative contraindications might prove a barrier to
potentially life changing thrombolysis in stroke[2,3]. Hence decisions regarding thrombolysis are made on a case-by-case basis[4].
We report a patient who, whilst on prasugrel and aspirin for
post-myocardial infarction (MI), made a dramatic recovery from acute
ischemic stroke after thrombolysis.
Case report
Other Section
A
55-year-old gentleman was referred to our hospital two days following
the development of inferior wall myocardial infarction (IWMI) diagnosed
as ST-elevation myocardial infarction (STEMI) that had been treated with
antiplatelets and statin. The last ECG at the time of discharge after
the IWMI revealed evolved infarction. Three days after the onset of IWMI
he underwent percutaneous angioplasty of the right coronary artery.
Three days following this procedure, he was discharged on the following
medications: aspirin 150 mg/day, prasugrel 10 mg/day, and atorvastatin
40 mg/day. While being discharged he developed weakness of right sided
limbs, inability to comprehend or talk, and became drowsy. There was no
history of headache, vomiting, or convulsions. At the emergency room,
his vital parameters were: BP 110/60 mmHg, pulse 64/min. He had global
aphasia, right gaze palsy, right hemiplegia, hemianopia,
hemihypoaesthesia, and sensory inattention. National Institute of Health
Stroke Scale (NIHSS) was 28. Blood sugar was 160 mg%. CT scan of the
brain was unremarkable. MRI of the brain, done 30 min after the onset of
stroke, revealed a moderate sized infarct involving the left middle
cerebral artery territory [Figure 1A and B]. MR angiogram revealed diffuse pruning of M1 and significant reduction of signals in M2 and M3 segments [Figure 1C]. Echocardiogram revealed no intracardiac clot.
Figure 1: (A) is a
diffusion weighted image showing diffusion restriction involving left
gangliocapsular and perisylvian regions (shown by arrows) corresponding
to left middle cerebral artery territory; (B) is the corresponding
apparent diffusion coefficient map showing low signals in the left
gangliocapsular region; (C) shows diffuse pruning of M1 and significant
reduction of signals in M2 and M3 segments of the left middle cerebral
artery (shown by arrows)
Click here to view
Click here to view
The
risks and benefits of intravenous thrombolysis were discussed with the
family. After obtaining informed consent alteplase was administered.
Stroke-onset to needle-time was 55 min. Following the bolus of 5.5 mg, a
mild improvement in motor power was noted when he could minimally move
the right lower limb. There was a gradual improvement of limb power
during the infusion of alteplase. He developed an oral bleed after 29 mg
of the drug had been infused. Further infusion was discontinued. Limb
power improved to grade 3/5 over the upper and lower limbs, and verbal
comprehension was normal. However, he continued to have Broca’s aphasia.
CT scan of the brain, done immediately, did not reveal intracerebral
hemorrhage. No further administration of alteplase was done. Fifteen
minutes post thrombolysis Broca’s aphasia also significantly improved
and he could speak several words fluently. NIHSS was 5. Twelve hours
post thrombolysis, NIHSS was zero. Repeat CT scan did not reveal any
hemorrhagic complications. Aspirin, 150 mg/day, was started after 24 h
and clopidogrel, 75 mg/day, after 48 h. He maintained improvement and
was discharged 4 days after the onset of stroke.
Discussion
Other Section
Alteplase
is the only approved intravenous thrombolytic therapy for stroke and is
recommended in the first 4.5 h following the onset of acute ischemic
stroke[1].
Contraindications to its use were derived from the exclusion criteria
utilized in major stroke trials, and violation of protocols have been
shown to be associated with complications, importantly intracerebral
hemorrhage[5].
However, many of the contraindications have proven to be unnecessarily
restrictive in real-world clinical practice, and patients have been
thrombolysed off-label with consistent benefits[4,6].
Our patient had a recent myocardial infarction, traditionally
considered as a contraindication for intravenous thrombolysis. Since the
preferred option of mechanical thrombectomy is available only in a few
select centers with such expertise, we opted for intravenous
thrombolysis which has the inherent risks of myocardial rupture,
pericardial hemorrhage and cardiac tamponade. Fortunately, these
complications are less likely to occur with inferior wall myocardial
infarction in contrast to anterior, and patients have undergone
thrombolysis in this situation with benefits[7].
Also, we did not consider the percutaneous intervention, done 3 days
prior, as a specific contraindication for therapy. Traditionally, an
NIHSS of more than 20 or 25 has been considered as an exclusionary
criterion for administration of alteplase. However mounting evidence has
shown the benefits of intravenous thrombolysis, despite high NIHSS[1,8].
The occurrence of stroke while in the hospital allowed us to institute
treatment within one hour, a factor that could have contributed to the
dramatic recovery in our patient[9,10].
Prior antiplatelet therapy is not considered a contraindication for
stroke thrombolysis. While thrombolysis has been reported in patients on
aspirin or clopidogrel or both, this is the first report of
thrombolysis in a patient on prasugrel.
In
conclusion, stroke thrombolysis has to be considered on a case-to-case
basis after careful consideration of the risks-to-benefits ratio and
must be pursued where benefits outweigh the risks.
No comments:
Post a Comment