Myocardial Wall Rupture Following tPA Administration: A Case Report and Review of the Literature
Neurology(2017)
摘要
Objective: To describe the presentation of myocardial wall rupture following tPA administration. Background: Although acute myocardial infarction (MI) was an exclusion criterion in the NINDS Alteplase (tPA) studies, recent MI is not listed as a contraindication to IV tPA for acute ischemic stroke (AIS) on the FDA label. It is, however, listed as a relative exclusion criterion in the current AHA stroke guidelines. Of primary concern are the possibilities that tPA may dislodge a ventricular thrombus, lead to post-MI pericarditis with hemorrhage, or result in cardiac lysis. Design/Methods: Case report with review of literature. Results: We report on a 69-year-old woman with recent MI who presented to an emergency department after sudden onset of left hemiparesis and dysarthria. She had undergone percutaneous coronary intervention (PCI) with stenting two weeks prior. IV tPA was administered within 2.5 hours of symptom onset. Despite tPA, she had evidence of a significant right middle cerebral artery territory infarction on MRI. On hospital day 3, she developed dyspnea and pulmonary edema and was found to have pericardial effusion on a transthoracic echocardiogram (TTE). On hospital day 4, she developed bradycardia and hypotension; emergent TTE revealed pericardial tamponade with ventricular wall rupture. She died later that day from cardiogenic shock. Autopsy confirmed rupture of the myocardial wall. Currently, only 3 case reports describe myocardial wall rupture following tPA administration. Of these, only one report involved a patient with recent MI. Conclusions: Although the frequency of pericarditis, mural hemorrhage and subsequent myocardial rupture after MI is declining following PCI, clinicians should be mindful of this potential complication in tPA treated patients with recent MI. Further, cardiac wall rupture should be considered in patients who develop acute hypotension and bradycardia following tPA administration. The current literature is limited and insufficient to provide generalizable guidance on managing AIS patients with recent MI. Disclosure: Dr. Neu has nothing to disclose. Dr. Albright has nothing to disclose. Dr. Lyerly has nothing to disclose.
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