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SIMULTANEOUS TREATMENT OF MULTIPLE CEREBRAL EMBOLI AND ACUTE EMBOLIC LIMB ISCHAEMIA BY INTRAVENOUS THROMBOLYSIS IN A PATIENT WITH NEW ATRIAL FIBRILLATION

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ESOC-2019

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Abstract

Background: Acute ischaemic stroke and acute ischaemic limb are potentially disabling clinical manifestations of arterial embolism. We present a case with rare occurrence of 4 simultaneous large emboli as a result of atrial fibrillation (AF), treated with intravenous thrombolysis. Case Description: An 83-year-old lady with history of dementia presented with sudden unresponsiveness. On admission, GCS was 9/15(E4V1M4) and NIHSS 34. She was found to have new AF. CT angiogram and CT perfusion showed a proximal left M1 occlusive embolus, a right M2 embolus and a non-occlusive distal basilar embolus with perfusion mismatch and penumbra in all corresponding territories. Her left leg was also pale, cold and pulseless. Leg ultrasound showed an occlusive clot in the popliteal artery. She received intravenous Alteplase 1 hour 30 minutes post-onset. During infusion, consciousness improved and the popliteal pulse and colour of her leg returned to normal and repeat leg ultrasound showed complete reperfusion of the occluded artery. Repeat CT head showed a small infarct in the left MCA territory. At the time of discharge to a residential home, she had normal motor function with a degree of dysphasia and dysphagia. Discussion: In this unique case, intravenous thrombolysis led to full resolution of 3 out of 4 emboli. Although catheter-directed thrombolysis or embolectomy are preferred treatments for acute arterial limb ischaemia, intravenous thrombolysis was successful in our case. This case highlights the importance of awareness of simultaneous multi-territorial emboli in patients with AF, as prompt recognition and treatment can avoid catastrophic clinical outcomes. A small study in 2011 (n=16) had shown clinical improvement in 75% of patients and no haemorrhagic complications in the first 30 days post intravenous thrombolysis for acute limb ischaemia (ALI). Another small study in 2015 (n=38) suggested that there was no significant difference between intravenous and catheter directed thrombolysis with t-PA in terms of 6-month clinical outcome. Nevertheless, literature suggests that intravenous thrombolysis for acute limb ischaemia still carries high morbidity and mortality risk and poor outcome. A systematic review in 2018 concludes that there is currently no evidence favouring initial thrombolysis (intraarterial/ catheter directed thrombolysis) over initial surgery in terms of short-term or long-term outcome from ALI. In our patient who had multi-territorial brain stroke and acute limb ischaemia, intravenous t-PA was enough to restore the blood flow to her leg and brain, without haemorrhagic complications. This suggests that response to intravenous thrombolysis is still individualised especially for those with ALI. However, the main message is to be aware that AF may cause multiple vascular site embolism and to be prompt in recognising the signs and symptoms so an immediate treatment can be given in order to save the threatened organs from imminent death.

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© Copyright 2020 Morressier GmbH.
All rights reserved.