Dual antiplatelet therapy in a patient with simultaneous aneurysmal subarachnoid hemorrhage and myocardial infarction

Electrocardiography (ECG) changes after subarachnoid hemorrhage (SAH) are well described. However, concurrent myocardial infarction (MI) and SAH are rarely reported, and its management remains a dilemma. We report a patient with traumatic SAH concurrent with acute MI that managed successfully by endovascular intervention and dual antiplatelet therapy.

A 47-year-old man was admitted to the emergency department with a complaint of severe headache. Diffuse SAH, with a Hunt and Hess score of 5, was noticed. ECG showed ST elevation in anterior leads, and cardiac troponin became positive. On brain computed tomography angiogram, a 6 mm anterior communicating artery aneurysm was seen. Considering the possibility of MI and SAH simultaneously, endovascular obliteration of the aneurysm was done, and then, the patient received dual antiplatelet medications until coronary angiography was done. Coronary angiography revealed normal epicardial coronary arteries. The patient was discharged with a Glasgow Coma Scale score of 15 and was visited 2 months after discharge without any new episodes of intracranial hemorrhage with a modified Rankin scale score of 2.

Cerebral aneurysm coiling could be considered as the first choice of treatment in the case of acute MI with hemodynamic stability, before carrying out cardiac endovascular intervention or antiplatelet medication to reduce the risk of rebleeding from a brain aneurysm.