Subarachnoid hemorrhage—a rare complication after intravenous thrombolysis in an ischemic stroke patient

Massive Brainstem and Cerebellum Infarction Due to Traumatic Extracranial Vertebral Artery Dissection in a Motor Traffic Accident: An Autopsy Case Report

ABSTRACT

Traumatic unilateral vertebral artery (VA) injury can cause focal thrombosis and may block the basilar artery which can further lead to ischemic stroke and massive cerebral infarction and subarachnoid hemorrhage and even rapid death. Here, we present an autopsy case with a traumatic extracranial VA dissection in a motor traffic accident, and the identification of cause of death underwent 2 autopsies. A 62-year-old male pedestrian collided with the right rearview mirror of a car and fell down to the ground. He complained pains in the head and neck. Head computed tomography (CT) showed a right linear temporal bone fracture and a small left temporal subdural hematoma. Neck CT and magnetic resonance imaging (MRI) examination showed left transverse process fracture of the sixth cervical vertebra (C6) and left extracranial VA injury. After 6 days of hospitalization, the left temporal subdural hematoma had been nearly absorbed, and the man was discharged home. On day 15 after the traffic accident, the man suffered sudden unconsciousness accompanied by frequent vomiting at home. The man was taken to hospital, and there were no obvious abnormal findings by head CT examination. However, the man soon fell into a coma state and died 2 days later. The first autopsy was performed 7 days after death and confirmed a left transverse process fracture of C6 and that the deceased died of cerebral infarction and secondary subarachnoid hemorrhage caused by blunt force in the motor traffic accident. In the civil lawsuit, the traffic accident wrecker put forward the objection whether the deceased had fatal diseases. The second autopsy (84 days after the death) findings verified the left extracranial VA injury. Histopathological examination further showed intimal dissection and thrombus formation of the left extracranial VA and secondary basal arterial thromboembolism. Massive infarction of the brainstem and cerebellum was disclosed. Therefore, the deceased died of delayed massive brainstem and cerebellum infarction because of left extracranial VA dissection in the motor traffic accident.

Tenecteplase-induced Nonaneurysmal Subarachnoid Hemorrhage in a Patient with Acute Ischemic Stroke: A Case Report and Literature Review

Recently, tenecteplase (TNK) has been used for intravenous thrombolysis in acute ischemic stroke (AIS). Although spontaneous subarachnoid hemorrhage (SAH) following thrombolysis with tissue plasminogen activator has been reported, there is a lack of literature regarding TNK-induced nonaneurysmal spontaneous SAH. Our index case received intravenous TNK within an hour of symptom onset of AIS. Following deterioration of sensorium, repeat noncontrast computed tomography was performed, which showed diffuse SAH. Cerebral angiography did not reveal any aneurysm. Nonaneurysmal SAH can be a complication of TNK thrombolysis, which is not reported in literature. Knowledge of this possible adverse reaction is critical for appropriate counseling and management.

Biochemical markers as diagnostic/prognostic indicators for ischemic disease

Objective

The use of a biomarker was extremely useful in clinical emergencies such as stroke to aid in triage and early management of cases. The diagnostic accuracy of laboratory biomarkers is run to approve the identification of easy, cheap and fast tests associated with cerebral ischemia and intracranial hemorrhage. The present study was designed to screen serum enolase activity, activities of CK-BB, LDH and lipid profile in patients with ischemic or related diseases as good diagnostic/ prognostic indicator for ischemic diseases.

Methods

Sixty male subjects in the age range of (45 ±2years) were divided into four groups each with 15 participants: Group (I) normal . Group (II) patients recently diagnosed as ischemic disease; Group (III) hypertensive patients and Group (IV); diabetic patients enolase activity (p<0.001) and CK-BB (p<0.01) in ischemic and hypertensive patients compared with control and diabetic groups. LDH level was significantly elevated in ischemic, hypertensive and diabetic patients compared with controls (p<0.001). The cut -off value for serum enolase was 62.5 nmol/l showing 90% sensitivity and 93% specificity for differentiation of ischemic disease. Positive correlations were observed between serum enolase (r = 0.56), and CK-BB (r = 0.53).

Conclusion

Serum enolase can be considered as a more sensitive and specific marker and used as a sensitive diagnostic or prognostic marker for ischemic related diseases.

Republished: Delayed subarachnoid hemorrhage 7 years after cerebellar infarction from traumatic vertebral artery dissection

Vertebral artery dissection (VAD) is an important cause of ischemic stroke and subarachnoid hemorrhage (SAH). Dissections presenting with ischemia rarely cause SAH after more than a few hours, especially without radiographic evidence of pseudoaneurysm. We successfully treated a patient for persistent vessel injury presenting with SAH 7 years after presenting with extracranial subocclusive dissection of the right vertebral artery and an associated right posterior inferior cerebellar artery stroke. This is one of only three reported cases of delayed SAH occurring more than 2 weeks after an initial ischemic presentation of a VAD, and the only one without radiographic evidence of pseudoaneurysm at standard follow-up duration.

Delayed subarachnoid hemorrhage 7 years after cerebellar infarction from traumatic vertebral artery dissection

Vertebral artery dissection (VAD) is an important cause of ischemic stroke and subarachnoid hemorrhage (SAH). Dissections presenting with ischemia rarely cause SAH after more than a few hours, especially without radiographic evidence of pseudoaneurysm. We successfully treated a patient for persistent vessel injury presenting with SAH 7 years after presenting with extracranial subocclusive dissection of the right vertebral artery and an associated right posterior inferior cerebellar artery stroke. This is one of only three reported cases of delayed SAH occurring more than 2 weeks after an initial ischemic presentation of a VAD, and the only one without radiographic evidence of pseudoaneurysm at standard follow-up duration.