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Cerebral hemorrhage from amyloid angiopathy and coronary thrombolysis
R Leblanc1, G Haddad, Y Robitaille
1Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Canada.
Insights
Coronary thrombolysis for heart attack can cause brain bleeds, especially in older patients with cerebral amyloid angiopathy. This condition makes blood vessels fragile, increasing hemorrhage risk during treatment.
Area of Science:
- Neurology
- Cardiology
- Pathology
Background:
- Coronary thrombolysis is a critical treatment for acute myocardial infarction.
- Hemorrhagic complications, particularly cerebral hemorrhage, are known risks, especially in elderly patients.
- Contraindications include conditions predisposing to cerebral bleeding.
Observation:
- A case of cerebral hemorrhage occurred in a patient treated with thrombolysis and heparin for myocardial infarction.
- The hemorrhage was linked to cerebral amyloid angiopathy, confirmed by histological examination.
- The amyloid-laden cortical vessels showed impaired vasoconstriction due to amyloid beta protein replacement.
Findings:
- The cerebral hematoma enlarged despite normal coagulation parameters, necessitating surgical evacuation.
- Histology confirmed cerebral amyloid angiopathy with characteristic Congo red staining and birefringence.
- Intracranial hemostasis was challenging due to the non-contractile nature of amyloid-laden vessels.
Implications:
- Cerebral amyloid angiopathy is a critical consideration for cerebral hemorrhage risk in elderly patients undergoing cardiac thrombolysis.
- This condition poses significant challenges due to compromised cardiac function, altered coagulation, and difficult hemostasis.
- Increased awareness and diagnostic vigilance are crucial for managing thrombolysis in at-risk elderly populations.
Abstract:
Coronary thrombolysis with streptokinase or tissue plasminogen activator is useful for the treatment of acute myocardial infarction in selected patients. This treatment is associated with local hemorrhagic complications and age-related cerebral hemorrhage. Coronary thrombolysis is contraindicated in patients with transient cerebral ischemia and stroke, arterial hypertension, cerebral trauma, cerebral aneurysms, and arteriovenous malformations, because of the risk of cerebral hemorrhage. We report the occurrence of a cerebral hemorrhage related to cerebral amyloid angiopathy in a patient who underwent thrombolysis and treatment with heparin for acute myocardial infarction. Despite normal coagulation parameters, the cerebral hematoma enlarged over 36 hours, as documented by sequential computed tomographic scans, to produce significant mass effect, which prompted surgical evacuation. Histological examination of the resected specimen demonstrated the strong affinity for Congo red and yellow-green birefringence that are characteristic of cerebral amyloid angiopathy. Hemostasis was difficult to achieve, as the divided or disrupted amyloid-laden cortical vessels failed to vasoconstrict, their contractile elements replaced by amyloid beta protein. The patient died of recurrent myocardial ischemia 3 days postoperatively. The incidence of cerebral amyloid angiopathy increases with advancing age. It must be considered as a potential source of cerebral hemorrhage in elderly patients undergoing thrombolysis for cardiac ischemia. Such an occurrence presents a difficult challenge because cardiac function is compromised, the coagulation profile may be altered, the cerebral hematoma is life threatening, and intracranial hemostasis is difficult to achieve.