title: Fatal multiple systemic emboli after intravenous thrombolysis for cardioembolic stroke.
abstract: Our objective is to present a case of fatal multiple systemic emboli after intravenous thrombolysis for cardioembolic stroke. A 64-year-old woman with atrial fibrillation was admitted for evaluation of sudden consciousness disturbance, right hemiplegia, and aphasia. Diffusion-weighted imaging showed no early ischemic changes of the brain, and magnetic resonance angiography (MRA) showed occlusion of the left middle cerebral artery (MCA). One hour after initiation of 0.6 mg/kg of intravenous alteplase, the MCA was partially recanalized. Her symptoms disappeared the following day. We began intravenous heparin for secondary prevention of cardioembolic stroke. However, on the third day (52 hours after thrombolysis), she suddenly developed a coma and left hemiplegia. MRA showed acute occlusion of the right internal carotid artery (ICA). She developed acute kidney injury and sudden shock and then died of fatal cardiorespiratory arrest on the fourth day. Autopsy revealed occlusion of the mitral valve orifice by a spherical fresh red thrombus that led from the left atrial appendage. Acute embolic infarcts were identified in the spleen and right kidney, the latter secondary to occlusion of the right renal artery with fresh red thrombus. Intravenous thrombolysis and subsequent anticoagulation therapy may destabilize pre-existing intracardiac thrombus, potentially leading to recurrent stroke, multiple systemic embolisms, and the fatal "hole-in-one" effect.
authors.affiliation: Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Koji
authors.initials: K
authors.lastname: Tanaka
authors.affiliation: Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. Electronic address: ohatomo@hsp.ncvc.go.jp.
authors.forename: Tomoyuki
authors.initials: T
authors.lastname: Ohara
authors.affiliation: Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Akiko
authors.initials: A
authors.lastname: Ishigami
authors.affiliation: Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Yoshihiko
authors.initials: Y
authors.lastname: Ikeda
authors.affiliation: Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Toshinori
authors.initials: T
authors.lastname: Matsushige
authors.affiliation: Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Tetsu
authors.initials: T
authors.lastname: Satow
authors.affiliation: Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Hatsue
authors.initials: H
authors.lastname: Ishibashi-Ueda
authors.affiliation: Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Koji
authors.initials: K
authors.lastname: Iihara
authors.affiliation: Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
authors.forename: Kazunori
authors.initials: K
authors.lastname: Toyoda
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D061605:Administration, Intravenous; D000925:Anticoagulants / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications* / Q000175:diagnosis; D016893:Carotid Stenosis / Q000209:etiology; D002533:Cerebral Angiography / Q000379:methods; D038524:Diffusion Magnetic Resonance Imaging; D017809:Fatal Outcome; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D006349:Heart Valve Diseases / Q000209:etiology; D006493:Heparin / Q000009:adverse effects; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D020766:Intracranial Embolism / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D018810:Magnetic Resonance Angiography; D008875:Middle Aged; D012008:Recurrence; D012078:Renal Artery Obstruction / Q000209:etiology; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D006493:Heparin; D010959:Tissue Plasminogen Activator
keywords: Acute stroke; autopsy; cardioembolism; ischemic stroke; systemic embolism; thrombolysis