Iv thrombolysis for stroke due to cervicocephalic arterial dissection: What is the right practice?
Alsrouji OK, Affan M, and Mitsias P. Iv thrombolysis for stroke due to cervicocephalic arterial dissection: What is the right practice? Neurology 2019; 92(15).
Objective: NA Background: Cervicocephalic arterial dissection (CCAD) is one of the common causes of acute ischemic stroke (AIS) in the young. It is defined as a defect in the structure of the arterial wall forming an intramural hematoma. Mechanisms of cerebral ischemia after dissection include artery-to-artery embolization and hypo-perfusion from vessel occlusion. Safety and efficacy of IV thrombolysis (IVT) for AIS due to CCAD has been an area of controversy due to fear of enlargement of the intramural hematoma leading to more thromboembolism or total occlusion. We here report a patient with clinical and vessel imaging proven worsening of vertebral dissection after IV r-tPA. Design/Methods: NA Results: A 31-year-old woman presented with sudden onset of vertigo and dysarthria preceded by self-manipulation of the neck. NIHSS score was 3. Head CT scan was normal. CT Angiography (CTA) revealed abrupt caliber change of the left vertebral artery beginning at the distal V2 segment with significant luminal narrowing within the V3 segment and reconstitution of a normal caliber at the distal V3 segment, all suggestive of dissection. She was considered eligible for and received IV r-tPA. Within minutes into r-tPA infusion, she reported worsening severe cervico-occipital headache and diplopia. Infusion was stopped immediately. Exam showed left facial hypoesthesia, Horner's syndrome as well as left hemi-ataxia. Repeat CTA showed expansion of left vertebral artery dissection, which now included the V4 segment and caused complete occlusion of the vertebral and left posterior inferior cerebellar arteries. Conclusions: Our case proves IVT can cause expansion of intramural hematoma and associated neurological deterioration in symptomatic CCAD, especially of the vertebral arteries. Although IVT is the standard of care, supported by major rtPA clinical trials, which included patients with CCAD, our case points that there is need for a dedicated study to assess the safety and efficacy of IVT in this specific patient population.