Fatal intracranial hemorrhage after intravenous thrombolytic therapy for acute ischemic stroke associated with cancer-related nonbacterial thrombotic endocarditis

Abstract

Nonbacterial thrombotic endocarditis (NBTE) is associated with hypercoagulability in patients with inflammatory states such as cancer and autoimmune diseases. Cardiac vegetations caused by NBTE often lead to life-threatening systemic thromboembolism that most frequently affects the brain, spleen, and kidneys. A 54-year-old woman diagnosed with ovarian cancer suddenly developed back pain and left hemiparesis. Although intravenous alteplase (rt-PA) therapy was administered to treat hyperacute ischemic infarction detected by magnetic resonance imaging, intracranial hemorrhage occurred in the left hemisphere several hours later as the patient started to lose consciousness. Transthoracic echocardiography then detected aseptic vegetations on the mitral and aortic valves, indicating NBTE associated with ovarian cancer. Because therapies for NBTE are limited to heparinization and control of underlying diseases, thrombolytic therapy for acute embolic stroke in NBTE has not yet been validated. We postulated that thrombolytic therapy for cancer-related NBTE might easily cause hemorrhagic complications because cancer-related NBTE is often similar to the state of disseminated intravascular coagulation.

Keywords: Nonbacterial thrombotic endocarditis; alteplase; disseminated intravascular coagulation; ischemic infarction; marantic endocarditis; thrombolytic therapy.