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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 540-541

A drip in time worked just fine: Thrombolysis in stroke with recent myocardial infarction


Department of Neurology, Narayana Hrudayalaya, Bengaluru, Karnataka, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. Gopal K Dash
Department of Neurosciences, Narayana Hrudayalaya Hospital, Plot - 258/A Bommasandra Industrial Area, Hosur Road, Anekal Taluk, Bengaluru - 560 099, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.258026

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How to cite this article:
Adukia SA, Dash GK, Patanvadiya AH. A drip in time worked just fine: Thrombolysis in stroke with recent myocardial infarction. Neurol India 2019;67:540-1

How to cite this URL:
Adukia SA, Dash GK, Patanvadiya AH. A drip in time worked just fine: Thrombolysis in stroke with recent myocardial infarction. Neurol India [serial online] 2019 [cited 2019 May 24];67:540-1. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/540/258026




Sir,

Guidelines suggest that an acute myocardial infarction (AMI) within the last 3 months is a relative contraindication to thrombolysis in the presence of an acute ischemic stroke (AIS). This stems from the notion that thrombolysis may cause the poorly formed myocardial scar tissue to rupture. However, recent anecdotal literature challenges this notion and calls for a reconsideration of the fact that an AMI as a relative contraindication for thrombolysis in AIS.

A 75-year old diabetic, hypertensive, tobacco chewing male patient was admitted and conservatively managed as a patient of AMI. Echocardiography showed a large transmural acute inferior wall myocardial infarction (MI) with a left ventricular (LV) apical clot and a reduced LV ejection fraction (LVEF) of 30%. The patient was managed conservatively with heparin, antiplatelets agents, and statins. He was discharged on day 3 on cardiac medications, warfarin, and dual antiplatelet agents. However, he returned 48 hours later with an acute-onset global aphasia, right hemiparesis, and right-sided facial weakness of a 2-hour duration. The National Institutes of Health stroke scale (NIHSS) score at entry was 19. The computed tomography (CT) of the head with CT angiogram was normal [Figure 1]. The relative contraindications for thrombolysis included the presence of a fresh AMI, the administration of heparin during the last 48 hours, the presence of a periorbital hematoma due to a recent fall, and the presence of a large abdominal wall subcutaneous hematoma due to heparin usage. After discussing the potential risks with his family, a decision was taken to offer thrombolysis. With a body weight of 70 kg, the patient was given intravenous alteplase at 0.9 mg/kg, in a bolus dose of 6.3 mg followed by 56.7 mg as an infusion over 1 hour. Serial neurological assessment revealed a gradual improvement in his neurological status over 8 hours. By day 3 post-thrombolysis, he had complete reversal of all neurological deficits (modified Rankin scale: 1, NIHSS: 0) and remained stable at follow-up visits.
Figure 1: CT scan of the head with CT angiogram showing sequential images (a-d) of different segments of the left middle cerebral artery (white arrows) with no evidence of arterial occlusion

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In a large study involving patients receiving thrombolysis for AMI, <1% had subsequent cardiac rupture. The risk of cardiac rupture, as per the histopathological studies, exists for up to the first 7 weeks after AMI. Clinical experience states that a peak incidence of this phenomenon occurs within 48 hours. The risk factors for the cardiac rupture include an age >75 years, the female sex, a large anterior wall MI, a delayed coronary thrombolysis for the MI, a large infarct size, the transmural extent of the infarct, and the pericardial involvement.[1],[2] Pertaining to AIS, in a short case series on stroke thrombolysis in AMI, the outcomes varied from recovery to death. However, apart from an anecdotal evidence, a robust favourable data for this procedure is lacking. This is surprising considering that an 87% increase in the occurrence of AIS after AMI has been seen, and there is a 44-times increased likelihood of AIS in patients of AMI.[2] New updates notwithstanding, we suggest the use of thrombolytics in AIS at least for an inferior wall AMI; however, the management regimen may be tailored from patient to patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Maciel R, Palma R, Sousa P, Ferreira F, Nzwalo H. Acute stroke with concomitant acute myocardial infarction: Will you thrombolyse? J Stroke 2015;17:84.  Back to cited text no. 1
    
2.
Chang JJ, Khorchid Y, Gilbert RW, Woods T. Thrombolysis for acute ischemic stroke after recent myocardial infarction. J Cardiovasc Dis 2015;3:419-23.  Back to cited text no. 2
    


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