Left ventricular apical thrombus after systemic thrombolysis with recombinant tissue plasminogen activator in a patient with acute ischemic stroke.
BACKGROUND
Thrombolysis with recombinant tissue plasminogen activator (rtPA) is an established treatment in acute stroke. To prevent rethrombosis after rtPA therapy, secondary anticoagulation with heparin is commonly performed. However, the recommended time-point and extent of heparin treatment vary and are not well investigated.


METHODS
We report a 61-year-old man who developed an acute global aphasia and right-sided hemiparesis. Cranial CT was normal and systemic thrombolytic therapy with tPA was started 120 minutes after symptom onset. Low-dose subcutaneous heparin treatment was initiated 24 hours later. Transthoracic echocardiography (TTE) 12 hours after admission showed slightly reduced left ventricular ejection fraction (LVEF) but was otherwise normal. 48 hours later the patient suddenly deteriorated with clinical signs of dyspnea and tachycardia. TTE revelead a large left ventricular apical thrombus as well as a reduction of LVEF to 20 %. Serial further TTE investigations demonstrated a complete resolution of the thrombus and normalisation of LVEF within two days.


CONCLUSIONS
Our case demonstrates an intracardiac thrombus formation following rtPA treatment of acute stroke, probably caused by secondary hypercoagulability. Rethrombosis or new thrombus formation might be an underestimated complication of rtPA therapy and potentially explain cases of secondary stroke progression.
Doepp
Florian
F
Department of Neurology, University Hospital Charité, Berlin, Germany. florian.doepp@charite.de
Sanad
Wasiem
W
Schreiber
Stephan J
SJ
Baumann
Gert
G
Borges
Adrian C
AC
D000208:Acute Disease; D002545:Brain Ischemia / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy; D005343:Fibrinolytic Agents / Q000009:adverse effects; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D013927:Thrombosis / Q000139:chemically induced* / Q000517:prevention & control*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects* / Q000627:therapeutic use; D016896:Treatment Outcome; D014463:Ultrasonography; D018487:Ventricular Dysfunction, Left / Q000139:chemically induced* / Q000517:prevention & control*
D005343:Fibrinolytic Agents; D006493:Heparin; D010959:Tissue Plasminogen Activator