Successful intravenous thrombolysis for acute ischemic stroke caused by aortic dissection with severe hypofibrinogenemia: a case report and literature review

Figures & data

Figure 1. (a) Computed tomography (CT) performed before intravenous thrombolysis (IVT) shows old lacunar infarctions bilaterally in the area under the cortex of the head. (b) Head CT shows low-density foci in the right frontal and temporal lobes with minor hemorrhaging (no space-occupying effect) on the second day after IVT. (c) Chest CT shows inward displacement of the calcified plaques in the thoracic aortic arch (arrow) and suspicious double lumens from the aortic arch to the descending aorta, suggesting aortic dissection (AD). (d) CT angiography of the thoracoabdominal aorta shows a thoracoabdominal AD (DeBakey type I), with the AD extending from the aortic root to the brachiocephalic trunk (e) and then to the right common carotid artery. (f) Intimal slices split the lumen into two cavities in the aortic arch.

Table 1. Coagulation function before and after intravenous thrombolysis.

Coagulation function marker	Date and time				Reference range
	August 11, 2018, 20:41	August 11, 2018, 22:39	August 13, 2018, 09:07	August 14, 2018, 07:47
Thrombin time (s)	28.2	73.6	17.5	18.4	14–20
Prothrombin time (s)	15.8	23.4	13.9	12.5	10.5–14
INR	1.49	2.25	1.24	1.17	0.8–1.2
Fibrinogen (g/L)	1.10	<0.25*	1.72	3.53	2–4
APTT (s)	58.2	105.4	41.7	33.5	21–34
Prothrombin activity (%)	48	27	73	74	88–120

* The fibrinogen level was too low to be measured.

INR, international normalized ratio; APTT, activated partial thromboplastin time.

Table 2. Details of cases that underwent IVT with rt-PA for AD-related acute ischemic stroke.

	Choi et al. [8]	Jo et al. [4]	Do et al. [12]	Rodríguez-Luna et al. [9]	Hong et al. [14]	Kazmi et al. [13]
Age (years)/sex	59/male	75/female	80/female	80/female	64/female	72/female
Hypertension	–	Yes	Yes	No	–	Yes
Initial symptom	Dizziness and seizure	Loss of consciousness and left hemiplegia	Consciousness degradation and left hemiplegia	Consciousness disorder, aphasia, hemianopsia, and monoparesis	Unconsciousness and left hemiparesis	Left hemiparesis and dysarthria
BP (mmHg)	77/66	–	110/70	135/85, decreased to 100/60 during IVT	140/90	109/50
HR/PR (bpm)	HR, 40	–	PR, 62	80, PR decreased during IVT	Bilaterally diminished pulses	PR, 100
NIHSS score	–	4	–	16	Decreased from 8 to 4	Decreased from 6 to 3 after IVT
Chest/back/abdomen pain	–	–	No	No	Transient chest discomfort and the pain developed during IVT	–
Main examination	MRI showed multiple cerebral infarctions.	Troponin I and CK-MB results were not meaningful.	ECG and cardiac enzyme were normal.	ECG and cardiac enzymes were normal.	ECG and cardiac enzymes were normal.	ECG showed sinus bradycardia.
	Chest CT revealed an AD.	Chest X-ray did not suggest AD.	TEE showed heart failure; chest X-ray showed widening of the mediastinum.	Carotid ultrasound demonstrated left common carotid artery dissection.	Chest CT revealed AD.	Chest X-ray demonstrated mild prominence of the mediastinum.
		Chest CT showed AD and hemopericardium.	CTA showed AD.	CTA showed AD.		CTA showed AD.
Main treatment	The emergency operation was delayed for 13 hours due to IVT.	rt-PA was administered intravenously.	Sufficient rt-PA was administered.	rt-PA infusion was stopped after 15 mg was perfused.	Intravenous rt-PA infusion was stopped after 60% of the amount was administered.	Sufficient rt-PA was administered and emergency cardiothoracic surgery was performed.
			Underwent surgery for AD 12 hours after IVT.	Surgical repair was refused	Emergent aortic surgery was performed.
Outcomes and follow-up	The patient died of massive bleeding.	The patient had sudden cardiac arrest and soon died.	Symptoms improved after IVT. The patient had left-sided paralysis after 3 months.	The patient died 2 days later.	He completely recovered	NIHSS score of 16 and modified Rankin scale score of 4 at 30 days post-operation
					MRI revealed postoperative recovery of the arteries.

AD, aortic dissection; BP, blood pressure; bpm, beats per minute; CK-MB, creatine kinase-MB; CT, computed tomography; CTA, computed tomography angiography; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IVT, intravenous thrombolysis; NIHSS, National Institutes of Stroke Scale; PR, pulse rate; rt-PA, recombinant tissue plasminogen activator; TEE, transesophageal echocardiography; –, not mentioned. All patients had Stanford type A aortic dissection.

Choi N, Yoon J-E, Park B-W, et al. Delayed surgery for aortic dissection after intravenous thrombolysis in acute ischemic stroke. Korean J Thorac Cardiovasc Surg. 2016;49(5):392–396.

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Jo KW, Park IS, Kim YD, et al. Unexpected complication of intravenous recombinant tissue plasminogen activator thrombolysis in a patient with acute ischemic stroke: aortic dissection. Korean J Cerebrovasc Surg. 2009;11:204–206.

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Do YR. Aortic dissection after intravenous thrombolysis in acute cerebral infarction. Kosin Med J. 2017;32(1):127–132.

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Rodrıíguez-Luna D, Vilar RM, Peinazo M, et al. Intravenous thrombolysis in an elderly patient with acute ischemic stroke masking aortic dissection. J Stroke Cerebrovasc Dis. 2011;20(6):559–561.

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Hong KS, Park SY, Whang S, et al. Intravenous recombinant tissue plasminogen activator thrombolysis in a patient with acute ischemic stroke secondary to aortic dissection. J Clin Neurol. 2009;5(1):49–52.

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Kazmi SO, Achi O, Damani R. Full-dose thrombolysis for a right middle cerebral artery stroke after an acute aortic dissection. Ann Indian Acad Neurol. 2018;21(3):223–224.

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