Intracranial Hemorrhage Following Thrombolytic Use for Stroke Caused by Infective Endocarditis
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PRACTICAL PEARL
Intracranial Hemorrhage Following Thrombolytic Use for Stroke Caused by Infective Endocarditis Parita Bhuva Æ Sheng-Han Kuo Æ J. Claude Hemphill Æ George A. Lopez
Published online: 18 August 2009 Ó Humana Press Inc. 2009
Abstract Background and Purpose Stroke is one of the most common neurological manifestations of infective endocarditis. The use of intravenous tissue plasminogen activator (t-PA) in the management of acute ischemic stroke is the accepted standard of practice. Current guidelines for intravenous (IV) t-PA therapy in acute ischemic stroke do not exclude patients with infective endocarditis. Summary of the Case We present three patients who received IV t-PA for acute ischemic stroke in the setting of infective endocarditis and developed multifocal intracranial hemorrhage as a complication. Conclusion Infective endocarditis related strokes are associated with a higher risk of hemorrhagic complications and our experience suggests that IV t-PA use may potentiate that risk. Keywords Stroke Intracranial hemorrhage Subarachnoid hemorrhage Endocarditis Thrombolysis t-PA
P. Bhuva S.-H. Kuo G. A. Lopez (&) Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030, USA e-mail: [email protected] J. Claude Hemphill Department of Neurology, University of California San Francisco, San Francisco, CA, USA
Case Reports Patient 1 A 46-year-old man with hypertension presented with acute onset left-sided weakness and a left facial droop. His initial National Institutes of Health stroke scale (NIHSS) was 15 and computed tomography (CT) of the head showed no acute abnormalities. He was afebrile with a normal white blood cell count; cardiac examination did not reveal any abnormal heart sounds and there was no evidence of distal emboli. Although the patient had a remote history of intravenous (IV) drug use, he adamantly denied any recent use. With no identifiable contraindications, he received 0.9 mg/kg of IV tissue plasminogen activator (t-PA) 110 min after onset of symptoms. An hour after t-PA infusion, he developed a temperature of 40.1°C along with vomiting, anisocoria, and downward eye deviation. Emergent head CT showed right middle cerebral artery (MCA) distribution infarction and interval development of cerebellar, occipital, and frontal lobe intracerebral hemorrhage (ICH) (Fig. 1a). He received cryoprecipitate, fresh frozen plasma and was started on broadspectrum antibiotics. Urine toxicology screen was positive for cocaine metabolites and blood cultures subsequently grew Corynebacterium. Transesophageal echocardiogram (TEE) did not show any signs of valvular vegetations. Cerebral angiogram revealed an area of focal narrowing with poststenotic dilatation at the proximal right MCA (Fig. 1b) but no evidence of mycotic aneurysm was seen. The patient’s mental status and left hemiparesis improved over the next several days. However, he became acutely obtunded with a dilated right pupil and extensor posturing on hospital day 7. Head CT revealed hemorrha
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