CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 3, May/June 2010
AFRICA
157
compared with aspirin alone, there were five fewer deaths (
p
=
0.03) and three fewer recurrent infarctions (
p
=
0.04), at the
expense of three major bleeds (
p
=
0.001).
11
It is now clear that fibrinolysis recanalises thrombotic occlu-
sions associated with STEMI, restores coronary flow, reduces
infarct size and improves myocardial function and survival over
both the short and long term.
1,12,13
In patients receiving fibrinolysis
for STEMI, the overall incidence of haemorrhagic complications
is about 10%, and the incidence of intracranial haemorrhage is
about 0.8%. Atrial fibrillation predisposes to atrial thrombus,
and Crenshaw
et al
.
14
demonstrated an increased risk for throm-
botic strokes with atrial fibrillation in MI treated with TT.
In the present case, neurological signs were noted two hours
after TT. It was assumed that the patient had had an intracranial
haemorrhage. A cranial CT scan was immediately obtained, but
haemorrhage was excluded and no abnormality was detected.
In the second cranial CT scan, which was performed 12 hours
later, a left frontal embolic infarction was detected. This is a
rare condition. We continued to treat the STEMI and cerebral
infarction, together with a neurologist/neurosurgeon consultant.
On the follow up, the neurological problems progressed, conges-
tive heart failure developed, clinical deterioration occurred, and
subsequently the patient died.
In this case, although a thrombus was not detected during
echocardiographic examination, it is likely that the TT induced
lysis and fragmentation of an undetected microthrombus and
the subsequent dislodging and embolisation of pre-existing
cardiac microthrombi, which caused the cerebral infarction.
Distal embolisation secondary to lysis of arterial thrombi in an
aortic graft occlusion has been reported. It was speculated that
this complication occurred when a combination of fresh and
old thrombus was present.
15
Rapid lysis of the fresh clot, along
with arterial pulsations, may liberate older and more resistant
clot fragments. When peripheral embolisation occurs, TT can be
continued as long as the patient is clinically stable.
There is only one other case report in the literature describing
embolic cerebral infarction following TT for STEMI.
1
Conclusion
This case represents an extremely rare clinical condition, which
we report on to show the importance of the treatment of STEMI
with TT. We deduced that the fact that the patient was in AF was
a major contributing factor to her CVA. In conclusion, patients
receiving TT for the treatment of STEMI should have constant
neurological and cardiovascular re-evaluation and clinicians must
be prepared to handle such complications in a timely manner.
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