Rupture of a thrombosed intracranial aneurysm during arterial thrombolysis

Abstract

Sirs: Presence of an aneurysm known in advance or incidentally identified is not labelled as an exclusion criterion in the accepted protocols for stroke patients considered for thrombolysis [3,4,9]. Taking the presence of asymptomatic aneurysms in 2-5 % of the population into account [11], every twentieth to fiftieth stroke patient scheduled for thrombolysis has an undetected intracranial aneurysm. The appropriate treatment for a patient, who suffers an occlusion of a large brain artery and has an incidental intracranial aneurysm is an unsolved issue.A 72-year-old man presented to our department with sudden rightsided weakness and speech arrest starting 45 minutes prior to admission. Past medical history revealed arterial hypertension, hypercholesterolemia, and a two-vessel coronary artery bypass grafting performed 10 years previously, leaving the patient free of cardiac symptoms.On admission, the patient was alert and followed commands, but there was no active speech production. He had a severe central rightsided sensorimotor paresis.Emergency computed tomography [CT] of the head was diagnostic for a hyperdense-MCA-sign on the left. No hemorrhage and no early signs of infarction were noted. A small hyperdense nodular structure in the posterior part of the left M1-segment hinted to the presence of an intracranial aneurysm. The full extent of the aneurysm however, was not visible [cf. Fig. 1].CT-angiography [CTA] and digital subtraction angiography [DSA], the latter performed for intra-arterial lysis, demonstrated a proximal MCA-mainstem occlusion but no aneurysms. After selective probing of the left MCA via a coaxial tracker catheter, lysis was started with two boluses of 5 mg rt-PA each intra-arterially at 2 hours and 40 minutes after the onset of symptoms. Approximately one minute after giving the second dose, the patient suffered a generalized tonic seizure. Angiography was repeated at once and showed re-opening of the artery, but, simultaneously, a 15 mm in diameter, ruptured saccular M1-aneurysm [cf. Fig. 2] not visible in this extent on the plain CT or the radiographs.Another emergency CT was performed and showed extensive subarachnoid hemorrhage, as well as the re-perfused aneurysm in its full size [cf. Fig. 3]. The patient died 6 hours later on the ICU.The coincidence of an acute stroke due to MCA-occlusion and LETTER TO THE EDITORS JON 1177 Fig. 1 Pre-lysis plain CT-scan at the level of circle of Willis shows increased density of the middle cerebral artery on the left . Other early signs of infarction are absent. A small hyperdense nodular structure hints at the presence of a middle cerebral artery aneurysm. No further hyperdensities were seen in adjacent slices and thus the size of the aneurysm was significantly underestimated ➜ Fig. 2 Angiographic image of the left middle cerebral artery after re-opening of the artery. Note the extravasation of contrast media (white v) through the sac of the aneurysm (✖) into the subarachnoid space and the left temporal ventricle. (୴୴) microcatheter within the internal...

Cerebral Ischemia Complicating Intracranial Aneurysm: A Warning Sign of Imminent Rupture?

“…8,9,13,14,19 Our study has several practical consequences. First, antithrombotics and fibrinolytics and also intra-arterial therapies should be used with caution for acute ischemic stroke that occurs distal to an intracranial aneurysm because of the risk of bleeding.…”

“…In such cases, arterial reopening may recanalize the aneurysm, sometimes leading to rupture. 14,19 Ideally, when CT or MR imaging depicts an intracranial aneurysm without bleeding, an SAH should be ruled out by CSF spectrophotometric analysis in accordance with published guidelines before a treatment decision. [15][16][17] However, in the context of Thrombosis of an intracranial aneurysm and parent artery with early recanalization (case 9).…”

Hemorrhagic Complications After Off-Label Thrombolysis for Ischemic Stroke

“…IVT was performed in 2 patients 11,12 and IAT in 29 (24 with urokinase [UK], 13-17 4 with tPA, 15,18,19 and one with both UK and tPA 20 ). SICH occurred in 3 patients treated with IAT (2 with UK, one with tPA), with 2 being subarachnoid hemorrhages.…”

Post-Thrombolysis Hemorrhage Risk of Unruptured Intracranial Aneurysms

“…Recently, Haji et al firstly reported a patient with multiple unruptured IAs suffered massive (and ultimately fatal) SAH following intravenous tPA [4]. Furthermore, one case also showed that intra-arterial thrombolysis may have additional risk of hemorrhages especially when aneurysm was hidden by the occluding clot [7]. …”

“…Although anecdotal case reports have indicated IAs might rupture following intravenous or arterial thrombolysis for acute ischemic stroke, a small number of nonrandomized observational researches are yet to produce a statistically significant association [4,5,6,7]. As all of these studies were confounded by small sample sizes, the safety of thrombolysis in acute ischemic stroke patients with unruptured IAs remains presently unknown.…”