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Fatal or severely disabling cerebral infarction during hospitalization for stroke or transient ischemic attack
G W Petty1, T K Tatemichi, R L Sacco
1Department of Neurology, Neurological Institute of New York, New York.
Insights
A small percentage of patients admitted for stroke or TIA experienced severe in-hospital cerebral infarction. This complication, potentially linked to heparin withdrawal and large artery disease, occurred after initial improvement.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Internal Medicine
Background:
- Cerebral infarction and transient ischemic attack (TIA) are significant causes of morbidity and mortality.
- In-hospital complications can arise even after initial patient stabilization.
Purpose of the Study:
- To investigate the occurrence and characteristics of fatal or severely disabling in-hospital cerebral infarction.
- To identify potential risk factors and triggers for these late-onset, severe events.
Main Methods:
- Retrospective analysis of 578 patients admitted for cerebral infarction or TIA.
- Detailed review of clinical presentation, imaging, autopsy findings, and treatment records for six identified cases.
- Focus on timing of events relative to initial diagnosis, heparin therapy, and heparin withdrawal.
Main Results:
- Six patients (1%) experienced severe in-hospital cerebral infarction after initial improvement.
- Infarcts were associated with sudden stupor/coma, herniation (carotid/MCA territory), or brain-stem infarction (basilar occlusion).
- Four patients had documented large-vessel disease; all events occurred days after initial insult, during heparin therapy, and shortly after its discontinuation.
Conclusions:
- Fatal or disabling in-hospital cerebral infarction can occur in patients with initially mild/moderate deficits after stabilization.
- Patients with large artery disease may be at increased risk.
- A potential association between heparin withdrawal and cerebral infarction warrants further investigation.
Abstract:
Six (1%) of 578 patients admitted for cerebral infarction or transient ischemic attack (TIA) suffered a fatal or severely disabling in-hospital cerebral infarction following a period of stabilization or improvement lasting more than 1 day. These infarctions were characterized by the sudden onset of stupor or coma and subsequent development of transtentorial herniation due to carotid or middle cerebral artery territory infarction, or widespread brain-stem infarction due to basilar occlusion. Only one patient survived. Four patients had large-vessel disease documented by Doppler, angiography, or at autopsy. Each of these six infarcts occurred during the morning hours, 4-9 days after the initial event, 3-8 days after initiation of intravenous heparin, and within 4-8 h after intravenous heparin had been discontinued. No coagulation abnormalities were documented. We believe that these cases indicate that among patients admitted for cerebral infarction or TIA, fatal or severely disabling in-hospital cerebral infarction after a period of stabilization or improvement may occur in patients having an initially mild to moderate clinical deficit, that those suffering large artery disease may be at greater risk, and that there may be a relationship between heparin withdrawal and cerebral infarction in some patients.