Unusual consequences of intravenous thrombolysis in a patient undergoing delayed aortic surgery for aortic dissection presenting as acute ischemic stroke: a case report
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Background Patients with acute ischemic stroke (AIS) due to acute aortic dissection (AAD) may receive inappropriate intravenous thrombolysis (IVT). Management in this situation, particularly regarding the timing of aortic surgery, remains unclear. We present a case of delayed aortic surgery after IVT for AIS due to AAD, which highlights the unusual consequences of IVT in AAD. Clinical presentation An 87-year-old woman with left upper limb paralysis presented to a local hospital. Magnetic resonance imaging (MRI) identified a cerebral infarction in the right parietal lobe. Despite full-dose IVT, the paralysis remained unchanged. Subsequent MRI revealed extensive infarction in the right watershed area and another left cerebellar hemisphere infarction. Upon transfer to our hospital, computed tomography (CT) confirmed AAD with an entry and false lumen thrombus in the ascending aorta. Although emergency aortic surgery was indicated, we delayed surgery because of the risks of excessive bleeding and thrombolysis-related intracerebral hemorrhage (ICH). Brain CT 24 hours after IVT did not reveal ICH. However, new infarctions were detected, suggesting embolism from fragments of a false lumen thrombus. The fibrinogen level below the measurable limit at that time recovered 37 hours after IVT, guiding the surgery timing. Aortic surgery was completed without hemostasis difficulty. The patient recovered uneventfully with neurological improvement. Conclusions Inappropriate IVT in patients with AIS due to AAD may lead to cerebral embolism and severe hypofibrinogenemia. For patients having received IVT, especially those developing hypofibrinogenemia, delaying surgery for approximately 36 hours while monitoring fibrinogen levels with vigilance for ICH may be viable. However, this approach must be weighed against the risks of untreated AAD and potential embolisms during this waiting period.
