Successful use of Alteplase during cardiopulmonary resuscitation following massive PE in a patient presenting with ischaemic stroke and haemorrhagic transformation

Abstract

The management of patients with acute stroke regarding treatment of thromboembolism is supported by a limited evidence base. We present the case of a 55-year-old female patient who initially presented with an ischaemic cerebral infarct with haemorrhagic transformation. Her clinical recovery was complicated by cardiac arrest secondary to massive pulmonary embolism. This was successfully treated with cardiopulmonary resuscitation and thrombolysis using Alteplase, which led to a full recovery to the pre-arrest state with no evidence of haemorrhagic complication. The patient was successfully discharged to a specialist centre for on-going stroke rehabilitation with no additional neurological impact. Despite the limited evidence base we believe this case highlights that thrombolysis can be used in select patients with haemorrhagic transformation of stroke and serious thromboembolic complications to achieve a positive outcome.

Figure 1

Contrast CT head scan on admission demonstrating an area of low attenuation in the left frontoparietal lobe (arrow), with an area of increased attenuation within this (*). There is mild mass effect with effacement of the left lateral ventricle and a 4 mm midline shift to the right. Appearances are typical of a subacute basal ganglia infarct with haemorrhagic transformation, usually caused by transient occlusion of the M1 branch of the middle cerebral artery.

Figure 2

Head CT following thrombolysis demonstrates original infarct, albeit slightly increased in size (arrow). The area of infarction is now of uniform density, with resolution of the previously demonstrated haemorrhagic transformation. Mild mass effects remain. There is no evidence of any new intracranial bleeding.

Figure 3

CT pulmonary angiography 5 h following thrombolysis demonstrating bilateral pulmonary emboli (arrows). (A) ascending aorta, (B) descending aorta, (C) superior vena cava, (D) pulmonary trunk, (E) left pulmonary artery branch, (F) right pulmonary artery, (G) left bronchus, (H) right bronchus, (I) left upper pulmonary vein and (J) small wedge infarct.