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Thrombolytic Associated Pontine Hemorrhage in a Stroke Patient

Stella Onyi, Chukwuemeka A. Umeh , Frederick White
American Journal of Medical Case Reports. 2021, 9(12), 739-742. DOI: 10.12691/ajmcr-9-12-20
Received September 04, 2021; Revised October 09, 2021; Accepted October 18, 2021

Abstract

Stroke is a leading cause of disability and death, and the use of tissue plasminogen activator (tPA) has been shown to improve outcomes in ischemic stroke. However, despite the favorable outcome from the use of tPA, it has been associated with complications, including intracranial hemorrhage, major systemic hemorrhage, and angioedema. Though there are few reports of intracerebral hemorrhage complicating tPA use, pontine hemorrhage, a sub-set of intracerebral hemorrhage, is rarely reported. We report a case of pontine hemorrhage in an ischemic stroke patient after tPA and discussed the management of this rare complication of tPA.

1. Introduction

There are about 795,000 stroke cases in the United States yearly, and stroke is a leading cause of severe long-term disability and death 1. Intravenous recombinant tissue plasminogen activator (tPA) is currently the only pharmacotherapy approved by the US Food and Drug Administration for ischemic stroke. In addition, the use of tPA early in ischemic stroke has been shown to improve outcomes 2, 3. However, only a tiny percentage of those with acute ischemic stroke, about 2% to 5%, receive tPA 4. Despite the favorable outcome from the use of tPA, it has been associated with complications, including symptomatic intracranial hemorrhage, major systemic hemorrhage, and angioedema 4. The incidence of symptomatic intracranial hemorrhage in several major studies ranged from 1% to 11.2. Risk factors for symptomatic hemorrhage include age, black race, male gender, obesity, increased stroke severity, diabetes, hyperglycemia, uncontrolled hypertension, combined antiplatelet use, large areas of early ischemic change, atrial fibrillation, and congestive heart failure 3, 4, 5. Though there have been few reports of intracerebral hemorrhage complicating tPA use, pontine hemorrhage, a sub-set of intracerebral hemorrhage, is rarely reported. We report the case of pontine hemorrhage in an ischemic stroke patient after tPA.

2. Case

A 60-year-old female with underlying paranoid schizophrenia, hepatitis C, hypertension, and migraines presents to the emergency department for left-sided weakness, onset 40 minutes before presentation. Initial numbness started over her left hand and radiated up to her left arm and face, with the patient subsequently developing left lower extremity weakness. Examination showed an alert and oriented patient with decreased sensation on her left face, arm, and hand and decreased strength on her left lower extremity.

In the emergency department, code stroke was initiated, and the patient was placed on continuous oxygen and cardiac monitoring. Systolic blood pressure was 212/115 at presentation with a heart rate of 95, and the patient was given IV labetalol 20 mg push. She was then started on labetalol drip, with blood pressure going down to the 130s over the 70s. Laboratory tests were grossly unremarkable.

Initial computed tomography (CT) brain showed no acute pathology (Figure 1, Figure 2). Tele-neurology was consulted, who recommended starting tPA. The patient was administered tPA with an improvement of symptoms. After tPA administration patient was able to lift both the left arm and left leg with no facial asymmetry noted on smiling. The patient was also able to answer questions appropriately.

Two hours after tPA, the patient complained of a headache associated with one episode of vomiting. The patient was sent for a repeat CT brain and returned from CT agitated with recurrent vomiting. The patient became unresponsive with decerebrate posturing and intermittent seizure-like activity and was subsequently intubated in the emergency department. CT brain post-tPA demonstrated acute parenchymal hemorrhage in the inferior midline pons 1.4 x 1.3 x 1 cm size with minimal edema (Figure 3, Figure 4). A neurologist was consulted and recommended the patient be taken off sedation for a neurology exam. After being 45 mins off sedation, the patient was examined, and she had bilateral pinpoint pupils and a Glasgow Coma Scale score of 3. The patient received two units of platelets and one pooled unit of cryoprecipitates and was transferred to a tertiary hospital for neuro-intensive care unit monitoring.

3. Discussion

Symptomatic intracerebral hemorrhage (sICH) is the most dreaded complication of tPA 6. Acute onset of headache, vomiting or impaired consciousness level in a patient who received tPA could indicate an intracerebral bleed 7. However, a definite diagnosis of intracerebral bleed can only be made through imaging. Computed tomography (CT) and magnetic resonance imaging (MRI) have equal ability to identify acute intracerebral hemorrhage, its size and location, and hematoma enlargement 7. While MRI is superior at delineating the extent of perihematomal edema, herniation, and any underlying structural lesions, CT may be superior at demonstrating a ventricular extension of intracerebral bleeds 7.

Management of patients with thrombolytic associated symptomatic intracerebral hemorrhage is challenging. Currently, there are no evidence-based guidelines for managing thrombolytic associated symptomatic intracerebral hemorrhage. The American Heart Association/American Stroke Association has suggested empirically replacing clotting factors and platelets in patients with symptomatic intracerebral hemorrhage. However, it acknowledges the lack of strong evidence to support any specific therapy 7, 8. Analysis of procoagulant therapies used in a large single urban tertiary care hospital, including administering fresh frozen plasma, cryoprecipitate, vitamin K, platelets, and aminocaproic acid, did not show a statistically significant association with any patient outcome 8. However, the discovery of continued bleeding (>33% increase in intracerebral hemorrhage volume) in some patients with a thrombolytic associated symptomatic intracerebral hemorrhage who did not receive procoagulant therapy suggests that therapy may be beneficial 8. Our patient received platelet and cryoprecipitate and was transferred to a neuro-intensive care unit.

Pontine hemorrhage is associated with high morbidity and mortality. In a study reviewing predictive factors of poor outcome in pontine hemorrhage, 55% of the patients died shortly after hospital admission, 24% were severely or moderately disabled, and 21% had a good recovery 9. Another study found a 60% mortality in patients with thrombolysis-related intracranial hemorrhage 10. A history of hypertension, coma on admission, the need for mechanical ventilation, absent motor response, absent corneal reflex or oculocephalic responses, hyperthermia (core temperature >39 °C), tachycardia (>110 beats/min), the volume of intracerebral hemorrhage, extrapontine extension of bleed, intraventricular extension, and acute hydrocephalus on admission were associated with mortality in patients with pontine hemorrhage 9, 11, 12. Conversely, being alert on admission and having small unilateral pontine hemorrhage were associated with good recovery 9.

4. Conclusion

In conclusion, we present a case of thrombolysis-related pontine hemorrhage, a very rare and severe complication of tPA. Despite the favorable outcome from the use of tPA, this case highlights a severe complication associated with tPA and the need to carefully screen stroke patients to ensure that only patients without contraindications to tPA receive it.

References

[1]  CDC. Stroke facts. Accessed on June 18, 2021 from https://www.cdc.gov/stroke/facts.htm.
In article      
 
[2]  Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial. Jama. 1999 Dec 1; 282(21): 2003-11.
In article      View Article  PubMed
 
[3]  Meyers PM, Schumacher HC, Connolly Jr ES, Heyer EJ, Gray WA, Higashida RT. Current status of endovascular stroke treatment. Circulation. 2011 Jun 7; 123(22): 2591-601.
In article      View Article  PubMed
 
[4]  Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute ischemic stroke: a review of complications, risk factors, and newer technologies. The Neurohospitalist. 2011 Jul; 1(3): 138-47.
In article      View Article  PubMed
 
[5]  Mehta RH, Cox M, Smith EE, et al. Race/Ethnic differences in the risk of hemorrhagic complications among patients with ischemic stroke receiving thrombolytic therapy. Stroke. 2014 Aug; 45(8): 2263-9.
In article      View Article  PubMed
 
[6]  Brown DL, Barsan WG, Lisabeth LD, Gallery ME, Morgenstern LB. Survey of emergency physicians about recombinant tissue plasminogen activator for acute ischemic stroke. Annals of emergency medicine. 2005 Jul 1; 46(1): 56-60.
In article      View Article  PubMed
 
[7]  Broderick J, Connolly S, Feldmann E, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 Update: A Guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 Jun 1; 38(6): 2001-23.
In article      View Article  PubMed
 
[8]  Goldstein JN, Marrero M, Masrur S, et al. Management of thrombolysis-associated symptomatic intracerebral hemorrhage. Archives of neurology. 2010 Aug 1; 67(8): 965-9.
In article      View Article
 
[9]  Wijdicks EF, Louis ES. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology. 1997 Nov 1; 49(5): 1342-6.
In article      View Article  PubMed
 
[10]  Sloan MA, Sila CA, Mahaffey KW, et al. Prediction of 30-day mortality among patients with thrombolysis-related intracranial hemorrhage. Circulation. 1998 Oct 6; 98(14): 1376-82.
In article      View Article  PubMed
 
[11]  Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993 Jul; 24(7): 987-93.
In article      View Article  PubMed
 
[12]  Balci K, Asil T, Kerimoglu M, Celik Y, Utku U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clinical neurology and neurosurgery. 2005 Dec 1; 108(1): 36-9.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2021 Stella Onyi, Chukwuemeka A. Umeh and Frederick White

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Stella Onyi, Chukwuemeka A. Umeh, Frederick White. Thrombolytic Associated Pontine Hemorrhage in a Stroke Patient. American Journal of Medical Case Reports. Vol. 9, No. 12, 2021, pp 739-742. http://pubs.sciepub.com/ajmcr/9/12/20
MLA Style
Onyi, Stella, Chukwuemeka A. Umeh, and Frederick White. "Thrombolytic Associated Pontine Hemorrhage in a Stroke Patient." American Journal of Medical Case Reports 9.12 (2021): 739-742.
APA Style
Onyi, S. , Umeh, C. A. , & White, F. (2021). Thrombolytic Associated Pontine Hemorrhage in a Stroke Patient. American Journal of Medical Case Reports, 9(12), 739-742.
Chicago Style
Onyi, Stella, Chukwuemeka A. Umeh, and Frederick White. "Thrombolytic Associated Pontine Hemorrhage in a Stroke Patient." American Journal of Medical Case Reports 9, no. 12 (2021): 739-742.
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  • Figure 3. Axial brain computer tomography through the level of the pons 2 hours after tissue plasminogen activator (tPA) administration demonstrating pontine hemorrhage
  • Figure 4. Sagittal brain computer tomography through the level of the pons 2 hours after tissue plasminogen activator (tPA) administration demonstrating pontine hemorrhage
[1]  CDC. Stroke facts. Accessed on June 18, 2021 from https://www.cdc.gov/stroke/facts.htm.
In article      
 
[2]  Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial. Jama. 1999 Dec 1; 282(21): 2003-11.
In article      View Article  PubMed
 
[3]  Meyers PM, Schumacher HC, Connolly Jr ES, Heyer EJ, Gray WA, Higashida RT. Current status of endovascular stroke treatment. Circulation. 2011 Jun 7; 123(22): 2591-601.
In article      View Article  PubMed
 
[4]  Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute ischemic stroke: a review of complications, risk factors, and newer technologies. The Neurohospitalist. 2011 Jul; 1(3): 138-47.
In article      View Article  PubMed
 
[5]  Mehta RH, Cox M, Smith EE, et al. Race/Ethnic differences in the risk of hemorrhagic complications among patients with ischemic stroke receiving thrombolytic therapy. Stroke. 2014 Aug; 45(8): 2263-9.
In article      View Article  PubMed
 
[6]  Brown DL, Barsan WG, Lisabeth LD, Gallery ME, Morgenstern LB. Survey of emergency physicians about recombinant tissue plasminogen activator for acute ischemic stroke. Annals of emergency medicine. 2005 Jul 1; 46(1): 56-60.
In article      View Article  PubMed
 
[7]  Broderick J, Connolly S, Feldmann E, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 Update: A Guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 Jun 1; 38(6): 2001-23.
In article      View Article  PubMed
 
[8]  Goldstein JN, Marrero M, Masrur S, et al. Management of thrombolysis-associated symptomatic intracerebral hemorrhage. Archives of neurology. 2010 Aug 1; 67(8): 965-9.
In article      View Article
 
[9]  Wijdicks EF, Louis ES. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology. 1997 Nov 1; 49(5): 1342-6.
In article      View Article  PubMed
 
[10]  Sloan MA, Sila CA, Mahaffey KW, et al. Prediction of 30-day mortality among patients with thrombolysis-related intracranial hemorrhage. Circulation. 1998 Oct 6; 98(14): 1376-82.
In article      View Article  PubMed
 
[11]  Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993 Jul; 24(7): 987-93.
In article      View Article  PubMed
 
[12]  Balci K, Asil T, Kerimoglu M, Celik Y, Utku U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clinical neurology and neurosurgery. 2005 Dec 1; 108(1): 36-9.
In article      View Article  PubMed