Multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome: case study

Abstract

Background: Intracerebral hemorrhage is the most feared complication of intravenous thrombolysis for acute ischemic stroke. Such hemorrhage usually occurs within or at the margin of ischemic or manifestly infarcted brain tissue. A patient with Trousseau syndrome who developed multiple extra-ischemic hemorrhages following intravenous thrombolysis is described.

Case description: An 80-year-old Japanese man with no other underlying disease was diagnosed with unresectable advanced lung cancer (stage IV) without brain metastasis and had not yet been treated. The patient suddenly presented with disturbance of consciousness, right hemiplegia, and total aphasia, and was admitted to our hospital. Magnetic resonance imaging revealed acute cerebral infarction extending from the basal ganglia to the corona radiata of the left cerebrum and multiple small areas of bilateral cerebral cortices. Cardiogenic cerebral embolism was considered among the differential diagnoses, but the brain natriuretic peptide level was within the normal range, and no arrhythmias such as atrial fibrillation were observed. With no other causes, the patient was diagnosed with Trousseau syndrome due to hypercoagulability associated with the advanced lung cancer. The patient received intravenous tissue plasminogen activator (t-PA) at 96 minutes after onset of symptoms. His symptoms partially improved, but they suddenly deteriorated at 84 minutes after the thrombolysis. A computed tomography (CT) scan immediately after the neurological deterioration revealed a subcortical hemorrhage in the left occipital lobe. A repeat CT scan the day after onset showed enlargement of the left occipital hemorrhage and two new subcortical hemorrhages in the right frontal and right temporal lobes. These hemorrhages were located in areas remote from the acute ischemic lesions.

Conclusion: To the best of our knowledge, this is the first reported case of multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome. The course of this case suggests that intravenous t-PA administration for acute ischemic stroke with Trousseau syndrome may be associated with a higher risk of intracranial hemorrhage.

Keywords: Cerebral infarction; Intracerebral hemorrhage; Intravenous thrombolysis; Trousseau syndrome; Vascular disorders.

Figure 1

Head magnetic resonance imaging after onset. A: Diffusion-weighted image (DWI) showing a high-intensity area extending from the basal ganglia to the corona radiata of the left cerebrum and multiple small high-intensity areas at bilateral cerebral cortices. B: Fluid-attenuated inversion recovery showing several small high-intensity areas in the same locations detected on DWI (arrowheads). C: Magnetic resonance angiography demonstrating no steno-occlusive changes.

Figure 2

Head computed tomography (CT) scans after thrombolysis. A: CT scan right after the neurological deterioration showing a subcortical hemorrhage in the left occipital lobe. B: Repeat CT scan the day after onset showing enlargement of the left occipital hemorrhage and two subcortical hemorrhages in the right frontal and right temporal lobes.