Safety and Efficacy of Thrombolytic Therapy in Postoperative Cerebral Infarctions

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit

Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered.

Perioperative stroke

It is increasingly recognized that one can identify a higher risk patient for perioperative stroke. The risk of stroke around the time of operative procedures is fairly substantial and it is recognized that patients initially at risk for vascular events are those most likely to have this risk heightened by invasive procedures. Higher risk patients include those of advanced age and there is a cumulative risk, over time, of coexistent hypertension, atherosclerosis, diabetes mellitus, cardiac disease and clotting disorders. There are a number of possible mechanisms associated with the procedure (e.g., preoperative hypercoagulability, holding of antithrombic therapy at the time of the procedure and cardiac arrhythmia) that can promote a thrombo-embolic event. Examples of these include: direct mechanical trauma to extracranial vessels related to operations on the head and neck; and vascular injury as a consequence of vascular and innovative endovascular procedures affecting the cerebral circulation (e.g., carotid endarterectomy, extracranial or intracranial angioplasty with stenting, and use of the MERCI clot retrieval device), as well as various endovascular methods that have been developed to obliterate cerebral aneurysms and arteriovenous malformations as an alternative to surgical clipping and surgical resection, respectively.

Neurologic complications of cardiac surgery and interventional cardiology

A wide array of neurologic complications can occur in relation to cardiac surgical procedures, most of which are transient and do not result in permanent sequelae. Specific neurologic insults can occur depending on the type of cardiac procedure and are an important cause of morbidity and mortality. Neurologists practicing in the hospital setting as well as outpatient neurologists should be familiar with the cardiac surgical procedures currently available. Prompt identification of neurologic deficits is important in order to plan an appropriate systematic evaluation and initiate possible treatments in a timely manner. This chapter provides a comprehensive overview of all facets of neurologic complications after cardiac surgical procedures.

Successful recovery from carotid terminus occlusion after mechanical embolectomy in a fully anticoagulated patient

CASE DESCRIPTION

We describe a case of the patient with multiple contraindications for thrombolysis who underwent successful mechanical embolectomy for occlusion of the right carotid terminus. Her pre-procedural NIHSS was 16.

DISCUSSION

The patient demonstrated remarkable recovery within an hour of the procedure, and this clinical improvement was sustained at followup.

RESULTS

This case illustrates that mechanical embolectomy is a safe and potentially very effective intervention to treat major intracranial vessel occlusions in patients with multiple contraindications for thrombolysis.

Intravenous alteplase for stroke: beyond the guidelines and in particular clinical situations

BACKGROUND AND PURPOSE

Because of the risk of hemorrhage, especially in the brain, thrombolytic therapy with intravenous alteplase is restricted by guidelines, and only a small number of selected patients are being treated. Findings from metaanalyses, post hoc analyses of the randomized trials, and postlicensing experience suggest that more subjects, who otherwise have a poor predicted outcome without treatment, might benefit from intravenous alteplase. Summary of Review- There is a strong indication that treatment may still be beneficial beyond 3 hours up until 4.5 hours. The risk of symptomatic intracerebral hemorrhage is not increased in patients aged 80 years or older. Excluding patients with severe stroke or with early ischemic changes in more than one third of the middle cerebral artery territory on baseline CT scan is probably not necessary when treatment is started <3 hours of symptom onset. Patients with minor or improving symptoms can also benefit. Intravenous thrombolysis appears appropriate as first line therapy for posterior circulation stroke. Alteplase can be given to patients with cervical artery dissection, seizure at onset and evidence of acute ischemia on brain imaging, and after carefully weighing risk and benefit in pregnancy and during menstruation. There are anecdotal reports on its use in children, patients with recent myocardial infarction, cardiac embolus, intracranial aneurysm or arteriovenous malformation, prior stroke and recent surgery. There appears to be a substantially increased risk of symptomatic cerebral hemorrhage in hyperglycemic stroke patients. The combined intravenous and intraarterial approach to recanalization appears safe and is currently under investigation in a randomized trial.

CONCLUSIONS

This document does not intend to change the guidelines but reviews the literature on the use of intravenous alteplase for stroke beyond guidelines and in particular conditions.