Massive cerebral edema after recanalization post-thrombolysis.
BACKGROUND
Intravenous thrombolysis with tissue plasminogen activator is an approved and effective therapy for acute ischemic stroke within the first 3 hours from onset. In addition to the risk of hemorrhage, there is a risk of postrecanalization cerebral edema. The authors present the case of a patient with an ischemic stroke treated successfully with intra-arterial thrombolysis who subsequently developed massive brain edema in the face of clinical improvement.


METHODS
An 81-year-old man presented within 1 hour of developing a full right middle cerebral artery (MCA) syndrome. Computed tomography (CT) was normal. A cerebral angiogram demonstrated an occlusion of the M1 segment of the right MCA. The patient was treated with intra-arterial urokinase 750,000 units. He recovered during the procedure. Serial CT scans demonstrated progressive edema with mass effect in the right MCA distribution. The patient remained asymptomatic except for a mild sensory deficit.


CONCLUSIONS
Postrecanalization cerebral edema is an uncommon but potentially lethal complication of thrombolysis. It is postulated that the edema is due to ischemic injury aggravated by reperfusion with vasogenic edema. The presence of this massive edema is usually associated with clinical worsening. The present case illustrates that this disorder can be associated with good outcome.
Cruz-Flores
S
S
Souers Stroke Institute, Department of Neurology, Saint Louis University Health Sciences Center, 3635 Vista Avenue, St. Louis, MO, USA. cruz-fls@slucare1.sluh.edu
Thompson
D W
DW
Boiser
J R
JR
D000368:Aged; D000369:Aged, 80 and over; D001929:Brain Edema / Q000139:chemically induced* / Q000000981:diagnostic imaging; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002533:Cerebral Angiography; D006801:Humans; D007269:Injections, Intra-Arterial; D008297:Male; D010960:Plasminogen Activators / Q000009:adverse effects* / Q000627:therapeutic use; D015912:Thrombolytic Therapy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D014568:Urokinase-Type Plasminogen Activator / Q000009:adverse effects* / Q000627:therapeutic use
D010960:Plasminogen Activators; D014568:Urokinase-Type Plasminogen Activator