CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 5, September/October 2010
262
AFRICA
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Letter to the Editor
Dear Sir
Commenting on the article ‘Cerebral embolism following
thrombolytic therapy for acute myocardial infarction: the second
reported case’ by M Bostan,
et al
.,
1
I note that the captions for
Figs 1 and 2 are reversed. I would also like to comment on the
description of the second brain CT performed on the patient
presented in this case report.
The authors report that after two hours of intravenous throm-
bolytic therapy (TT) administration, a brain CT was performed
on the patient, which showed ‘no pathological abnormality’.
They state that in the second brain CT 12 hours later ‘extensive
infarction of the left frontal area was seen (Fig. 2)’.
Careful examination of this second brain CT (Fig. 2) shows
that the pathology was not as homogeneous as portrayed and
reveals (1) a darker parasagittal, medial wedge-shaped lesion,
suggesting an ‘older’ infarct in the territory of the anterior
cerebral artery (ACA), and (2) effacement of the left frontal sulci
and gyri, as well as blurring of the gray/white matter interface,
suggesting oedema, which could be related to a recent, acute
ischaemia within the territory of the left middle cerebral artery
(MCI).
Without the benefit of the images of the first brain CT (which
was described as normal), it is difficult to be more categorical.
However, the image of the second brain CT (Fig. 2) suggests
that there might have been two different ischaemic events, (1)
an older left parasagittal infarct within the vascular territory
of the ACA, already showing signs of encephalomalacia, and
(2) a larger oedema of the left frontal lobe, suggesting a recent,
acute cerebrovascular incident within the vascular territory of
the MCA.
Older patients (such as the one described in this case report)
who are at a higher risk of potentially life-threatening vascular
disease should be carefully evaluated (within the short time
frame for decision making) before instituting TT to restore
antegrade flow of an acutely occluded coronary artery, or alter-
natively, be treated by percutaneous coronary intervention (PCI).
Attention to detail will hopefully avert a third case report, while
remembering that the doctor’s most basic tenet is: ‘primum non
nocere’ – first, do no harm.
To elucidate this diagnostic interpretation of the second brain
CT (Fig. 2), I would appreciate the comments of the authors
of this case report and especially of the radiologist(s) who
performed the first brain CT, who have the benefit of being able
to compare both brain scans.
MARIO P ITURRALDE,
Emeritus Professor of Nuclear Medicine (retired)
University of Pretoria
Reference
1. Bostan, M, Kanat A, Sen M, Kazdal H, Bostan H. Cerebral embolism
following thrombolytic therapy for acute myocardial infarction: the
second case report.
Cardiovasc J Afr
2010;
21
: 155–157.
