Concurrent inferior stemi with third-degree AV block and acute intracranial haemorrhage: how we overcame this clinical challenge-a case report

Abstract

Background: The concurrent management of ST-elevation myocardial infarction (STEMI) and acute intracerebral haemorrhage (ICH) poses a significant clinical challenge due to conflicting treatment goals. While the management of STEMI requires coronary reperfusion with antithrombotic agents (anticoagulants and antiplatelets), such treatments are contraindicated in cases of ICH. The coexistence of STEMI and ICH is exceedingly rare in the literature and is associated with high mortality rates. Furthermore, no specific guidelines currently exist for managing such cases.

Case summary: We report a case of a 67-year-old male presenting with acute ICH who subsequently developed inferior STEMI complicated by third-degree atrioventricular block. The patient underwent a deferred percutaneous coronary intervention (PCI) strategy, involving only balloon angioplasty and thrombectomy without stent placement, to restore coronary flow while minimizing the risk of exacerbating the intracranial haemorrhage. Three days later, ischaemia progressed to recurrent myocardial infarction, at which point reassessment revealed stabilization of the ICH, allowing for stent placement in the right coronary artery (RCA) and the administration of antithrombotic therapy.

Discussion: The deferred PCI strategy, involving initial thrombectomy and balloon angioplasty without stent placement, facilitated temporary restoration of coronary flow and provided a critical time window for the stabilization of the ICH. This approach enabled subsequent stent implantation and the reintroduction of antithrombotic therapy (anticoagulants and antiplatelets). This strategy demonstrates its effectiveness in managing patients with concurrent STEMI and ICH by balancing the risks of ischaemia and haemorrhage, thereby improving clinical outcomes.

Keywords: Acute intracranial Haemorrhage; Case report; Deferred PCI; ST-elevation Myocardial Infarction.

Figure 1

(A) Brain MRI showing acute ICH in the left basal ganglia with a volume of 31 mm³ (dimensions: 24 × 43 × 30 mm). Microbleeds were observed in the left basal ganglia, pons, thalamus, subcortical white matter, and right cerebellar hemisphere, suspected to be hypertension-related. (B): ECG taken at the neurology department 1 h later showed ST elevation in leads II, III, and aVF, with third-degree atrioventricular block and a ventricular rate of 60 beats per minute.

Figure 2

(A) Coronary angiography showing total occlusion of the mRCA (culprit lesion), with normal LAD and LCx. (B): IVUS of the mRCA revealed a 360° thrombus extending from the mid to distal RCA and a pRCA lesion with a plaque burden of 61% and an MLA of 7.19 mm². (C): Extracted thrombus from the RCA (left image). Post-aspiration and balloon angioplasty of the RCA, angiography showed partial thrombus resolution with TIMI II flow (right image).

Figure 3

(A) Follow-up MRI on day 3 showing a subacute haematoma in the left basal ganglia, reduced in size to 26 mm³ (dimensions: 20 × 43 × 30 mm). (B): ECG on day 3 showing recurrent ST elevation in leads II, III, and aVF, along with advanced second-degree AV block alternating with third-degree AV block.

Figure 4

(A) Deployment of an everolimus synergy XD stent (3.5 × 48 mm, 16 atm) in the mid-RCA and an Everolimus Megatron stent (5.0 × 20 mm, 12 atm) in the proximal RCA. (B): IVUS post-stenting revealed incomplete stent apposition with a gap of 0.84 mm between the stent and the vessel wall. (C): Final IVUS check showed complete stent apposition, residual thrombus protrusion, and a minimal stent area of 10.0 mm².

Figure 5

(A) Follow-up IVUS after 14 days showing well-apposed stents with a CSA of 11.58 mm², no edge dissection. (B) Angiography confirmed TIMI III flow without residual thrombus.