Alteplase

Abstract

Lack of efficacy: case reportA 32-year-old man exhibited lack of efficacy while receiving anticoagulant therapy with alteplase. The man, who had a history of excessive drinking, heavy smoking (more than 30 cigarettes a day and 30 drinks per week for nearly 14 years) and 2-year history of poorly controlled hypertension, presented to the emergency room with dizziness and fatigue for 4 hours. Physical examination showed high BP. Nicardipine was started for BP stabilisation. After 9 hours, he developed severe vertigo, vomiting and left sided weakness [aetiology not stated]. Neurological examination showed horizontal nystagmus in the both eyes, ataxia and mild dysarthria. National Institute of Health Stroke Scale score was noted to be 7. CT angiography showed acute proximal basilar artery thrombosis. He was diagnosed with acute basilar artery occlusion. He received thrombolysis with IV alteplase [dosage not stated] and transferred for mechanical thrombectomy. However, the first intervention failed to restore the flow. Over the next 8-hours, he deteriorated with quadriparesis and drowsiness. The National Institute of Health Stroke Scale score increased to 12. MRI showed small pontine infarct. The second angiography intervention reconstituted arterial flow. After 24-hours of the post-thrombolysis, he received loading dose of clopidogrel and aspirin combined with a high dose of HMG-CoA-reductaseinhibitors [statins]. On the subsequent morning, he progressively debilitated with bilateral Babinski sign and quadriplegia. Glasgow Coma Scale score was noted to be 6. Brain CT scan and transcranial doppler confirmed re-occlusion of the proximal basilar artery. He underwent angioplasty. Excellent angiographic recanalisation and fully patent vessel was noted. He was transferred to the ICU. On the following day, he was conscious with only mild weakness in the limbs and spoke clearly. National Institute of Health Stroke Scale score was noted to be 5. On day 7 of the hospitalisation, he was discharged with dual antiplatelet therapy and HMG-CoAreductase-inhibitors.