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Ann Indian Acad Neurol
Ann Indian Acad Neurol
AIAN
Ann Indian Acad Neurol
Annals of Indian Academy of Neurology
0972-2327
1998-3549
Wolters Kluwer - Medknow India

AIAN-27-438
10.4103/aian.aian_285_24
Letters to the Editor
Remote Intracerebral Haemorrhage Secondary to Vessel Rupture Following Bridging Intravenous Thrombolysis (Causal or Incidental) with Successful Endovascular Treatment: A Rare Case Report
Ojha Piyush
Goel Gaurav 1
Waghralkar Mandar 1
Mahajan Anshu 1
Department of Neurology and Neurointervention, Fortis Memorial Research Institute, Gurugram, Haryana, India
1 Department of Neurointervention Surgery, Medanta Institute of Neurosciences, Medanta – The Medicity, Gurugram, Haryana, India
Address for correspondence: Dr. Anshu Mahajan, Department of Neurointervention Surgery, Medanta Institute of Neurosciences, Medanta – The Medicity, Sector 38, Gurgaon - 122 001, Haryana, India. E-mail: anshunph@gmail.com
Jul-Aug 2024
23 8 2024
27 4 438440
10 4 2024
30 6 2024
07 7 2024
Copyright: © 2024 Annals of Indian Academy of Neurology
2024
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pmcDear Editor,

Intravenous thrombolysis (IVT) using recombinant tissue plasminogen activator (r-tPA) has been considered as a core treatment for patients with acute ischaemic stroke. One of the important complications associated with IVT is intracerebral haemorrhage (ICH). Majority of the ICHs associated with intravenous (IV)-tPA are located within or at the margin of ischaemic or infarcted brain tissue.[1] Uncommonly, ICH can also occur in brain areas remote from the primary stroke, and without any apparent acute ischaemia.[2]

Remote intracerebral haemorrhage after IV r-tPA for acute ischaemic stroke is a rare complication (1.3%–3.7%), which has been suggested to be due to different mechanisms, such as undiagnosed coagulopathies, multiple acute embolic ischaemic areas, cerebral vasculopathy, etc.[123] Here we report a case, where vessel rupture was diagnosed in a remote territory from the primary vessel occlusion site during mechanical thrombectomy following IV thrombolysis and was successfully treated using endovascular therapy. To the best of our knowledge, this is the first case in the literature, which demonstrates vessel rupture following IV thrombolysis remotely from the site of primary vessel occlusion and was successfully treated.

A previously healthy young male presented with acute-onset right sided weakness (motor power 2/5) and global aphasia with National Institute of Health Stroke Scale (NIHSS) score of 10 for last 2h. Non-contrast computed tomography (CT) of the head [Figure 1a] did not reveal any evidence of acute early ischaemic changes. CT-perfusion [Figure 1b] showed areas of perfusion mismatch involving the left frontotemporoparietal cortex. CT-angiography [Figure 1c-e] revealed left M1 segment middle cerebral artery (MCA) occlusion. There was no evidence of any significant flow-limiting stenosis involving any other vessels.

Figure 1 (a) NCCT Head - no evidence of early ischemic changes. (b) CT-perfusion showing perfusion-mismatch involving left fronto-temporo-parietal cortex. (c-e) CT-angiography suggestive of left M1-MCA occlusion. No gross abnormality in the bilateral pericallosal arteries. NCCT = Non-contrast computed tomography, CT = Computed tomography, MCA = Middle cerebral artery

Since the patient was within the time window for IV thrombolysis, he was thrombolysed using tenectaplase (0.25 mg/kg) after taking written informed consent and was immediately shifted for mechanical thrombectomy.

After placing an 8F short sheath in the right femoral artery, Neuron Max guiding catheter was parked in the left internal carotid artery (ICA). Distal cervical ICA contrast run [Figure 2a] showed non-recanalised left M1 segment MCA occlusion. Following this, using 014 microwire, occlusion was crossed and using the microcatheter, Solitaire-X (4 × 40 mm) stent retriever was deployed across the clot [Figure 2b]. Using Solumbra technique (stent and aspiration), stent retrieval was done gently. Single pass was taken. Final contrast run showed Thrombolysis in cerebral infarction (TICI)-2b recanalisation of the left MCA territory [Figure 2c].

Figure 2 (a) Left ICA contrast run suggestive of left M1 MCA occlusion. (b) Solumbra technique for thrombectomy. (c) TICI 2b recanalization. (d and e) Late arterial contrast run showing contrast extravasation through the right pericallosal artery, suggestive of rupture. (f) Dyna CT showing diffuse SAH with focal haematoma in right medial frontal region. ICA = Internal carotid artery, MCA = Middle cerebral artery, TICI = Thrombolysis in cerebral infarction, CT = Computed tomography, SAH = Subarachnoid haemorrhage

The left ICA contrast run [Figure 2d-e] also showed dye extravasation from the right pericallosal artery (remotely from the site of endovascular treatment), suggestive of vessel rupture. Immediate Dyna-CT [Figure 2f] showed diffuse subarachnoid haemorrhage (SAH) with focal haematoma in the right medial frontal region.

After this, a distal access catheter was navigated in the right distal ICA. Repeat right ICA [Figure 3a] contrast run showed persistent dye extravasation from the distal right pericallosal branch, confirming acute rupture and ongoing bleed. Using Hybrid 008 microwire, Marathon microcatheter was navigated in the concerned branch. After confirming persistent dye extravasation by microcatheter contrast run [Figure 3b], glue (30%) embolisation was done to cause parent vessel occlusion [Figure 3c-d]. Repeat contrast run did not reveal any evidence of contrast extravasation.

Figure 3 (a) Right ICA contrast run showing persistent dye extravasation from the distal right pericallosal branch. (b) Microcatheter run showing persistent dye extravasation. (c) Glue (30%) embolization of the ruptured right pericallosal artery. (d) Glue Cast. (e and f) Repeat CT head after 72 hours showing interval decrease in the subarachnoid haemorrhage, along with subacute infarct in the left parietal cortex and insular region. A curvilinear hyperdensity noted in the right parasagittal region (? Artifact related to embolization agent). ICA = Internal carotid artery, CT = Computed tomography

On retrospective analysis of CT angiogram of the brain vessels, no abnormality was noted in the right pericallosal branch. Patient was then shifted to the intensive care unit for further management. He was also investigated for stroke aetiology. Routine blood tests were within normal limits. Echocardiogram did not reveal any evidence of regional wall motion abnormality, clots or any evidence of endocarditis. Holter monitoring was within normal limits. Vasculitis markers did not reveal any evidence of vasculitis. Repeat CT of the head after 72 h [Figure 3e-f] showed interval decrease in the subarachnoid haemorrhage, along with subacute infarct in the left parietal cortex and insular region. A curvilinear hyperdensity was also noted in the right parasagittal region (? artefact related to embolisation agent). Patient gradually improved during the course of hospitalisation and was discharged after a week with minimal right hemiparesis and motor aphasia.

ICH is a dreaded complication following IVT with r-tPA in acute ischaemic stroke patients. Most of the studies have focussed on risk factors associated with symptomatic and local parenchymal haemorrhage. Hence, there is limited literature about the frequency, risk factors and prognosis in patients with remote parenchymal haemorrhage (rPH).

The European Cooperative Acute Stroke Study defined rPHs as single or multiple haemorrhages that appear in brain areas without any visible ischaemic damage detected by CT, which is remote from the area causing the initial stroke symptoms.[34] Incidence of rPH is very low (1.3%–3.7%) and is usually associated with a poor outcome.[45]

The occurrence of rPH after IV-r-tPA has been hypothesised to be due to different mechanisms such as undiagnosed coagulopathies, multiple acute embolic ischaemic areas or a generalised cerebral vasculopathy such as cerebral amyloid angiopathy.[678] The deposition of amyloid fibrils in cortical and leptomeningeal blood vessels leads to structural and functional arterial changes that are possibly involved in the pathogenesis of vessel rupture.[678]

Our case also demonstrates rPH following IV thrombolysis in a patient of acute ischaemic stroke.

To the best of our knowledge, this is the first case in the literature which demonstrates vessel rupture following IV thrombolysis remotely from the site of primary vessel occlusion, which was successfully treated using enodovascular treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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