Cardiocerebral Infarction Presenting in a Neurosurgical Emergency: A Case Report and Literature Review

Abstract

Cardiocerebral infarction (CCI), the simultaneous occurrence of acute ischemic stroke and acute myocardial infarction (AMI), is a rare but critical condition. However, the optimal treatment strategy, particularly regarding the use of tissue plasminogen activator (t-PA), remains unclear. This case report describes a patient with CCI diagnosed during a neurosurgical emergency. A 67-year-old man with a history of hypertension presented with sudden right hemiparesis and sensory aphasia 30 minutes prior to hospital arrival. Diffusion-weighted magnetic resonance imaging revealed acute cerebral infarction in the left middle cerebral artery territory but without large-vessel occlusion. Routine electrocardiography (ECG) showed ST-T elevation in leads V1, V2, II, III, and aVF (augmented vector foot). Subsequent blood tests confirmed positive troponin T and elevated creatine kinase levels. Despite the absence of reported AMI symptoms, the patient received a diagnosis of CCI. Due to the uncertain time of AMI onset and to expedite transfer to the percutaneous coronary intervention (PCI) unit, t-PA administration was withheld. Upon transfer, dual antiplatelet therapy with aspirin (200 mg) and clopidogrel (300 mg) was initiated. Emergency coronary angioplasty successfully treated a 99% stenosis of the left anterior descending artery (#7). The patient's post-procedure course was uneventful. After 18 days, he was transferred to a rehabilitation hospital with a modified Rankin Scale score of 3. This case highlights the importance of routine 12-lead ECG in neurosurgical emergencies, regardless of presenting symptoms like chest pain. While guidelines support the use of t-PA in CCI, its administration requires careful consideration due to specific risks, including cardiac rupture and limitations on antithrombotic therapy within the first 24 hours.

Keywords: 12-lead ecg; acute ischemic stroke; acute myocardial infarction; cardiocerebral infarction; t-pa; thrombolysis.

Figure 1. Initial imaging studies.

Diffusion-weighted imaging (DWI) showed acute ischemic stroke (AIS) in the left middle cerebral artery (MCA) territory with a DWI-ASPECTS (Alberta Stroke Program Early CT Score) score of 10/11 (A, arrow). T2 star-weighted imaging revealed a susceptibility vessel sign on the left parietal artery (B, arrow). Magnetic resonance angiography did not show any stenosis or occlusion of the main MCA trunk (C). Arterial spin labeling perfusion imaging demonstrated reduced blood flow in the territory of the left MCA (D, arrow).

Figure 2. Electrocardiography (ECG) and percutaneous coronary intervention.

ECG revealed ST-T wave elevation in leads V1, V2, II, III, and aVF (augmented vector foot), and negative T waves in leads V2–V5 (A). Coronary angiography showed 99% stenosis in the left anterior descending artery (#7) (B, arrow). Emergency plain old balloon angioplasty was successfully performed (C, arrow).