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Spontaneous hyperacute postischemic hemorrhage leading to death
Eric E Smith1, April L Fitzsimmons, Raul G Nogueira
1Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. eesmith@partners.org
Summary
Post-ischemic hemorrhage is a rare but serious complication of stroke, often misdiagnosed. Early brain imaging is crucial for accurate diagnosis and treatment decisions, especially concerning tissue plasminogen activator use.
Area of Science:
- Neurology
- Neuroradiology
- Stroke Medicine
Background:
- Post-ischemic parenchymal hemorrhage is a rare complication of ischemic stroke.
- It is frequently misdiagnosed as primary intracerebral hemorrhage.
- This condition can be catastrophic and unrelated to anticoagulation or coagulopathy.
Observation:
- Two patients experienced massive, fatal post-ischemic hemorrhages following ischemic events.
- Patient 1: 73-year-old female with frontal lobe infarction and subsequent hemorrhage.
- Patient 2: 52-year-old male with middle cerebral artery occlusion, basal ganglia infarction, and prior brain irradiation.
Findings:
- Initial gradient-echo MRI in Patient 2 revealed petechial hemorrhage and microbleeds within the infarct.
- Both patients developed massive hemorrhages hours after the initial ischemic event.
- These hemorrhages were unrelated to anticoagulation, thrombolytics, or known coagulopathy.
Implications:
- Early brain imaging is essential to differentiate post-ischemic from primary intracerebral hemorrhage.
- Specific MRI findings, like petechial hemorrhage or microbleeds, may predict subsequent hemorrhage risk.
- These findings have significant implications for the use of tissue plasminogen activator in stroke patients.