Intracerebral hemorrhage after fibrinolytic therapy for acute myocardial infarction

Spontaneous retroperitoneal and intracranial hemorrhage following streptokinase therapy in acute myocardial infarction: An autopsy case report

Bleeding complications following thrombolytic treatment for acute myocardial infarction (AMI) are not infrequent, among which intracranial hemorrhage is commonly reported. In contrast, retroperitoneal hematoma following the administration of thrombolytics is rarely reported in the literature. We are reporting a case of a middle-aged man, who presented with left-sided chest pain and was diagnosed with acute coronary syndrome with anterior wall ST elevation AMI. The patient was administered with thrombolytic drugs, including streptokinase and heparin. Percutaneous coronary intervention in the form of Coronary angioplasty with stent insertion was done to the left anterior descending artery, given coronary artery disease. The blood investigations showed elevated activated partial thromboplastin time and prothrombin time. The patient developed vomiting, altered sensorium, and left-sided weakness, and a non-contrast computerized tomography brain was done, which showed acute hemorrhage involving the right frontal lobe with intraventricular extension, so the ventricular drain was placed. The patient developed cardiac arrest and died on the third day. On autopsy examination, the brain showed subarachnoid hemorrhage, intraparenchymal hemorrhage over the right frontal lobe, and clotted blood in all the ventricles. A retroperitoneal hematoma of around 1500 cc was seen over the left side of the peritoneal cavity. This case highlights that although intracranial hemorrhage is a known complication after administrating thrombolytic therapy, clinicians should also be aware of the possibility of retroperitoneal hemorrhage. This case emphasizes the value of an autopsy in determining the cause of death in such situations.

Cerebral Amyloid Angiopathy in Stroke Medicine

BACKGROUND

Cerebral amyloid angiopathy (CAA) is a degenerative vasculopathy that is classically associated with lobar intracerebral or sulcal hemorrhage. Its prevalence is estimated at 30% in the seventh decade and 50% in the eighth and ninth decades. In this review, we summarize the risks linked to CAA with respect to the treatment and prevention of stroke.

METHODS

This review is based on pertinent publications retrieved by a selective search employing the terms "amyloid cerebral angiopathy," "stroke," "intra - cerebral bleeding," and "acute stroke therapy."

RESULTS

Among patients given systemic lytic treatment for stroke, those who have microhemorrhages tend to have a higher risk of treatment-associated brain hemorrhage. In a meta-analysis, 70% of patients who sustained a hemorrhage after thrombolytic therapy were found to have CAA, compared to only 22% in a control population. Patients with cerebral hemorrhages have microhemorrhages more commonly than patients with transient ischemic attacks (TIA) or infarcts. This was observed among persons under treatment with vitamin K antagonists (odds ratio, 2.7) or platelet aggregation inhibitors (odds ratio, 1.7). Moreover, the apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage (ICH) under oral anticoagulation. Strict treatment of arterial hypertension can lower the risk of ICH in persons with probable CAA by 77%. On the other hand, the use of statins after a lobar ICH increases the risk for a clinically manifest recurrent hemorrhage from 14% to 22%.

CONCLUSION

In patients with CAA, arterial hypertension should be tightly controlled. On the other hand, caution should be exercised in prescribing oral anticoagulants or platelet aggregation inhibitors for patients with CAA, or statins for patients who have already sustained a lobar ICH.

Cerebral amyloid angiopathy related hemorrhage after stroke thrombolysis: case report and literature review

Cerebral amyloid angiopathy (CAA) predisposes to symptomatic intracerebral hemorrhage (sICH) after combined thrombolytic and anticoagulant treatment of acute myocardial infarction. However, the role of CAA in stroke thrombolysis has not been established. Here, we describe a confirmed case of CAA-related hemorrhage in a patient receiving thrombolysis for acute ischemic stroke. On autopsy, immunohistochemistry revealed amyloid-β positive staining in thickened cortical and meningeal arteries at sites of hemorrhage. Further research is urgently needed to determine the hemorrhage risk related to CAA in stroke thrombolysis and develop better diagnostic tools to identify CAA in the emergency room.

Cerebral amyloid angiopathy-associated intracerebral hemorrhage: pathology and management

Amyloid angiopathy-associated intracerebral hemorrhage (ICH) comprises 12%-15% of lobar ICH in the elderly. This growing population has an increasing incidence of thrombolysis-related hemorrhages, causing the management of hemorrhages associated with cerebral amyloid angiopathy (CAA) to take center stage. A concise reference assimilating the pathology and management of this clinical entity does not exist. Amyloid angiopathy-associated hemorrhages are most often solitary, but the natural history often progresses to include multifocal and recurrent hemorrhages. Compared with other causes of ICH, patients with CAA-associated hemorrhages have a lower mortality rate but an increased risk of recurrence. Unlike hypertensive arteriolar hemorrhages that occur in penetrating subcortical vessels, CAA-associated hemorrhages are superficial in location due to preferential involvement of vessels in the cerebral cortex and meninges. This feature makes CAA-associated hemorrhages easier to access surgically. In this paper, the authors discuss 3 postulates regarding the pathogenesis of amyloid hemorrhages, as well as the established clinicopathological classification of amyloid angiopathy and CAA-associated ICH. Common inheritance patterns of familial CAA with hemorrhagic strokes are discussed along with the role of genetic screening in relatives of patients with CAA. The radiological characteristics of CAA are described with specific attention to CAA-associated microhemorrhages. The detection of these microhemorrhages may have important clinical implications on the administration of anticoagulation and antiplatelet therapy in patients with probable CAA. Poor patient outcome in CAA-associated ICH is associated with dementia, increasing age, hematoma volume and location, initial Glasgow Coma Scale score, and intraventricular extension. The surgical management strategies for amyloid hemorrhages are discussed with a review of published surgical case series and their outcomes with a special attention to postoperative hemorrhage.

Blood-fluid level on computed tomography head: a sign of warfarin-associated intraparenchymal hemorrhage

“Blood/fluid level” represents interface between the plasma and sedimented blood and is defined radiologically as presence of area of low computed tomography (CT) attenuation above and high CT attenuation below a discrete line of separation in an area of intraparenchymal hemorrhage. It is a rare finding seen in association with large clot volume of intraparenchymal hemorrhage. We present a case of warfarin-related intraparenchymal hemorrhage presenting with a classic sign of “blood/fluid level” on CT head with small clot volume.

Differential diagnosis of nontraumatic intracerebral hemorrhage

A wide variety of nontraumatic pathologies can result in intracerebral hemorrhage (ICH). Primary causes such as arterial hypertension or cerebral amyloid angiopathy can be differentiated from secondary pathologies, such as neoplasms, arterio-venous malformations, coagulopathies, hemorrhagic ischemic strokes, and cerebral venous and sinus thrombosis.Here, the authors first provide some general information on epidemiology, clinical presentation, and imaging appearance of ICHs followed by a detailed discussion of the different underlying pathologic entities and their imaging presentation.

Neurosurgical aspects of sedimentation levels in acute intracerebral haematoma

We describe the neurosurgical aspects of sedimentation levels that are rarely found in acute intracerebral haematomas (ICH). We had four patients with acute ICH whose cerebral computed tomography revealed sedimentation levels. Two patients had received thrombolytic therapy for ischaemic heart disease and one for ischaemic stroke. Another patient, who was diagnosed later as having a coagulation disorder, did not have any medical history on admission. All patients had emergency ICH drainage under local anaesthesia. In the immediate postoperative period, we observed dramatic improvement in all the patients, without surgical complications. The sedimentation level in an ICH should be identified as a specific indicator of a coagulation defect and a thorough search for possible underlying coagulopathy is warranted. We believe that simple ICH drainage should be performed as the haematoma is in a liquid form.

Amyloid beta degradation: a challenging task for brain peptidases

Amyloid beta (Abeta) accumulates in the neuropil and within the walls of cerebral vessels in association with normal aging, dementia or stroke. Abeta is released from its precursor protein as soluble monomeric species yet, under pathological conditions, it self-aggregates to form soluble oligomers or insoluble fibrils that may be toxic to neurons and vascular cells. Abeta levels could be lowered by inhibiting its generation or by promoting its clearance by transport or degradation. Here we will summarize recent findings on brain proteases capable of degrading Abeta, with a special focus on those enzymes for which there is genetic, transgenic or biochemical evidence supporting a role in the proteolysis of Abeta in vivo.

Cerebral amyloid angiopathy and thrombolysis-related intracerebral haemorrhage

Intracerebral haemorrhage is a complication of thrombolytic therapy for acute myocardial infarction, pulmonary embolism, and ischaemic stroke. There is increasing evidence that cerebral amyloid angiopathy (CAA), which itself can cause haemorrhage (CAAH), may be a risk factor for thrombolysis-related intracerebral haemorrhage. CAAH and thrombolysis-related intracerebral haemorrhage share some clinical features, such as predisposition to lobar or superficial regions of the brain, multiple haemorrhages, increasing frequency with age, and an association with dementia. In vitro work showed that accumulation of amyloid-beta peptide causes degeneration of cells in the walls of blood vessels, affects vasoactivity, and improves proteolytic mechanisms, such as fibrinolysis, anticoagulation, and degradation of the extracellular matrix. In a mouse model of CAA there is a low haemorrhagic threshold after thrombolytic therapy compared with that in wild-type mice. To date only a small number of anecdotal clinicopathological relations have been reported; neuroimaging advances and further study of the frequency and role of CAA in patients with thrombolysis-related intracerebral haemorrhage are required.

Spontaneous intracerebral hemorrhage due to coagulation disorders

Although intracranial hemorrhage accounts for approximately 10 to 15% of all cases of stroke, it is associated with a high mortality rate. Bleeding disorders account for a small but significant risk factor associated with intracranial hemorrhage. In conditions such as hemophilia and acute leukemia associated with thrombocytopenia, massive intracranial hemorrhage is often the cause of death. The authors present a comprehensive review of both the physiology of hemostasis and the pathophysiology underlying spontaneous ICH due to coagulation disorders. These disorders are divided into acquired conditions, including iatrogenic and neoplastic coagulopathies, and congenital problems, including hemophilia and rarer diseases. The authors also discuss clinical features, diagnosis, and management of intracranial hemorrhage resulting from these bleeding disorders.

The degradation of amyloid beta as a therapeutic strategy in Alzheimer's disease and cerebrovascular amyloidoses

The deposition of 4-kDa amyloid beta peptide in the brain is a prominent feature of several human diseases. Such process is heterogeneous in terms of causative factors, biochemical phenotype, localization and clinical manifestations. Amyloid beta accumulates in the neuropil or within the walls of cerebral vessels, and associates with dementia or stroke, both hereditary and sporadic. Amyloid beta is normally released by cells as soluble monomeric-dimeric species yet, under pathological conditions, it self-aggregates as soluble oligomers or insoluble fibrils that may be toxic to neurons and vascular cells. Lowering amyloid beta levels may be achieved by inhibiting its generation from the amyloid beta-precursor protein or by promoting its clearance by transport or degradation. We will summarize recent findings on brain proteases capable of degrading amyloid beta with a special focus on those enzymes for which there is genetic, transgenic or biochemical evidence suggesting that they may participate in the proteolysis of amyloid beta in vivo. We will also put in perspective their possible utilization as therapeutic agents in amyloid beta diseases.

Cerebral amyloid angiopathy: an overview

Cerebral amyloid angiopathy (CAA) is characterized by amyloid deposition in cortical and leptomeningeal vessels. Several cerebrovascular amyloid proteins (amyloid beta-protein (Abeta), cystatin C (ACys), prion protein (AScr), transthyretin (ATTR), gelsolin (AGel), and ABri (or A-WD)) have been identified, leading to the classification of several types of CAA. Sporadic CAA of Abeta type is commonly found in elderly individuals and patients with Alzheimer's disease. Cerebral amyloid angiopathy is an important cause of cerebrovascular disorders including lobar cerebral hemorrhage, leukoencephalopathy, and small cortical hemorrhage and infarction. We review the clinicopathological and molecular aspects of CAA and discuss the pathogenesis of CAA with future perspectives.

Cerebral hemorrhagic complications of thrombolytic therapy

Thrombolytic therapy is well established in the management of a select group of atherothrombotic and thromboembolic diseases at the expense of definite but increased risk of intracranial hemorrhage. The incidence of intracranial hemorrhage is higher (6.4% to 20%) in the thrombolytic treatment of acute ischemic stroke, whereas the cerebral hemorrhagic complications of thrombolytic treatment in acute myocardial infarction, acute pulmonary embolism, deep venous thrombosis, and arterial and graft occlusion is less than 2%. Although systemic fibrinolysis after thrombolysis is responsible for hemorrhagic complications, many factors are implicated in predisposition to cerebral hemorrhagic complications such as old age, untreated or chronic hypertension, history of cardiac disease, hyperglycemia, patients with small body mass, previous stroke, longer therapeutic treatment window, increasing neurological deficit or severity of neurological deficit, higher thrombolytic dose and computed tomography findings of mass effect, edema, or extended infarct sign involving more than one third of the territory of the middle cerebral artery. Although the knowledge of different factors associated with intracranial hemorrhage is important, it is the judicious use and strict adherence of appropriate clinical protocols in different clinical settings of thrombolytic treatment and avoidance of the contra-indications that will minimize the rate of hemorrhagic complication to achieve good clinical outcome and desired benefit.

Intracranial hemorrhage: diagnosis and emergency management

Intracranial hemorrhages are an important cause of acute neurologic disease presenting in the emergency setting. To optimize outcome, it is important that the physician quickly recognize intracranial hemorrhages. To minimize mortality and neurologic morbidity, it is often necessary to initiate urgent therapy in the emergency rooms and to obtain neurosurgical consultation in order to pursue early surgical therapy. This article discusses the recognition and early treatment of the various types of intracranial hemorrhages.

A randomized trial of anticoagulants versus aspirin after cerebral ischemia of presumed arterial origin. The Stroke Prevention in Reversible Ischemia Trial (SPIRIT) Study Group

Aspirin is only modestly effective in the secondary prevention after cerebral ischemia. Studies in other vascular disorders suggest that anticoagulant drugs in patients with cerebral ischemia of presumed arterial (noncardiac) origin might be more effective. The aim of the Stroke Prevention in Reversible Ischemia Trial (SPIRIT) therefore was to compare the efficacy and safety of 30 mg aspirin daily and oral anticoagulation (international normalized ratio [INR] 3.0-4.5). Patients referred to a neurologist in one of 58 collaborating centers because of a transient ischemic attack or minor ischemic stroke (Rankin grade < or =3) were eligible. Randomization was concealed, treatment assignment was open, and assessment of outcome events was masked. The primary measure of outcome was the composite event "death from all vascular causes, nonfatal stroke, nonfatal myocardial infarction, or nonfatal major bleeding complication." The trial was stopped at the first interim analysis. A total of 1,316 patients participated; their mean follow-up was 14 months. There was an excess of the primary outcome event in the anticoagulated group (81 of 651) versus 36 of 665 in the aspirin group (hazard ratio, 2.3; 95% confidence interval [CI], 1.6-3.5). This excess could be attributed to 53 major bleeding complications (27 intracranial; 17 fatal) during anticoagulant therapy versus 6 on aspirin (3 intracranial; 1 fatal). The bleeding incidence increased by a factor of 1.43 (95% CI, 0.96-2.13) for each 0.5 unit increase of the achieved INR. Anticoagulant therapy with an INR range of 3.0 to 4.5 in patients after cerebral ischemia of presumed arterial origin is not safe. The efficacy of a lower intensity anticoagulation regimen remains to be determined.

Mental Dullness after thrombolytic therapy

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Simultaneous bilateral thalamic hemorrhages following the administration of intravenous tissue plasminogen activator

A patient suffered the onset of simultaneous bilateral thalamic hemorrhage several hours after the administration of intravenous tissue plasminogen activator. The patient exhibited features of the paramedian diencephalic syndrome, including executive dysfunction, anterograde amnesia, inattention, and disturbances of visual perception. During rehabilitation, she made significant gains in overlearned activities of daily living tasks, but her inability to retain new information left her severely disabled. The use of intravenous thrombolytic therapy is believed to account for this patient's unusual stroke syndrome. With recent evidence supporting the efficacy of intravenous thrombolysis in acute stroke, patients with multiple hemorrhagic strokes as a result of thrombolysis may become more common on rehabilitation services.

Non-traumatic cerebral hemorrhage in Saudi Arabs: a hospital-based study of 243 cases

This is a retrospective study involving 243 Saudi Arabs with non-traumatic cerebral hemorrhages confirmed by CT scan. Intracerebral hemorrhages accounted for about 20% of all strokes in this population. THe male to female ratio was 2.74 which is slightly higher than those reported from elsewhere. Peak frequency was around 60 years. Hypertension was the most common cause accounting for 64% of the cases, hemopathies/coagulopathies for 10% and arteriovenous malformations (AVMs) for 6%. THe cause was undetermined in 21% of patients. Amyloid angiopathy was probably underrepresented due to lack of autopsy correlation. The etiologies were, however, age-related with a clear predominance of AVMs and coagulation disorders before the age of 40 years. Hypertensive hemorrhages were located in the putamen in 46% of cases compared to 20% in non-hypertensive patients while 52% of non-hypertensive hemorrhages were lobar in location compared to 20.5% in hypertensives. Early mortality (19%) in our series was relatively low compared to reports from the industrialized world.

Vertebrobasilar thrombosis: diagnosis, management, and the use of intra-arterial thrombolytics

OBJECTIVES

To review the diagnosis and management of vertebrobasilar thrombosis and to discuss the use of thrombolytics in the treatment of this disease.

DATA SOURCES

Selected references discussing epidemiology, anatomy, pathophysiology, diagnosis, therapy, and rehabilitation of vertebrobasilar occlusive disease.

STUDY SELECTION

Studies addressing acute intervention and outcome in the therapy of vertebrobasilar thrombosis were reviewed.

DATA EXTRACTION

Only those studies with angiographic documentation of arterial thrombosis and, in the case of thrombolysis, recanalization, were considered valid.

DATA SYNTHESIS

Thrombosis of the vertebrobasilar system is a highly fatal disease and should be treated as a neurologic emergency. The key to effective management depends on early recognition of the symptom complex and a thorough understanding of the anatomy and pathophysiology of the disease process.

CONCLUSIONS

A timely, integrated, multidisciplinary approach to the patient with vertebrobasilar thrombosis can improve outcome. The use of thrombolytics in the treatment of vertebrobasilar occlusion holds promise but the benefits have not yet been proven in a controlled, randomized study.

In vitro stimulation of tissue-type plasminogen activator by Alzheimer amyloid beta-peptide analogues

We have studied the effects of amyloid beta-peptide analogues on the activity of tissue-type plasminogen activator (t-PA) in vitro. We have found that these peptides have a marked stimulatory effect upon plasminogen activation by t-PA, comparable to that of known stimulators of t-PA. This stimulatory activity appears to increase when beta-peptides form aggregated fibrillar structures similar to those found in amyloid deposits. This finding is significant in that it may provide insights into the pathogenesis of hereditary cerebral haemorrhage with amyloidosis-Dutch type (HCHWA-D) and cerebral amyloid angiopathy-related cerebral haemorrhage. It may also provide an explanation for the deaths resulting from intracerebral haemorrhage that have occurred in patients undergoing t-PA treatment for acute myocardial infarction.