J Neurocrit Care.  2017 Dec;10(2):107-111. 10.18700/jnc.170015.

Aneurysmal Subarachnoid Hemorrhage Following Intravenous Thrombolysis in Acute Ischemic Stroke

• Kim HJ
• Kang DW
• Kwon SU
• Kim JS
• Jeon SB

• KMID: 2405765
• DOI: http://doi.org/10.18700/jnc.170015

Abstract

BACKGROUND
An incidental finding of unruptured aneurysm, which is a contraindication to the recombinant tissue plasminogen activator (rtPA), is common in patients with acute ischemic strokes. However, reports describing the rupture of intracranial aneurysm following the administration of rtPA are extremely rare.
CASE REPORT
A 51-year-old man presented to the emergency room with global aphasia. A computed tomography (CT) of the brain revealed no intracranial hemorrhage. Since global aphasia occurred in an hour, rtPA was administrated intravenously. A CT angiography was performed 2 hours after an infusion of rtPA, which despite the absence of neurological deterioration and blood pressure surge, revealed subarachnoid hemorrhage in the right cerebral hemisphere, in addition to a 3-mm saccular aneurysm with a bleb in the right middle cerebral artery.
CONCLUSIONS
Aneurysmal subarachnoid hemorrhage can develop following the infusion of rtPA. Hence, unruptured aneurysm may not simply be an "incidental finding" in stroke patients receiving rtPA.

Keyword

Cerebral infarction; Thrombolytic therapy; Cerebral aneurysm

MeSH Terms

Aneurysm*
Angiography
Aphasia
Blister
Blood Pressure
Brain
Cerebral Infarction
Cerebrum
Emergency Service, Hospital
Humans
Incidental Findings
Intracranial Aneurysm
Intracranial Hemorrhages
Middle Aged
Middle Cerebral Artery
Rupture
Stroke*
Subarachnoid Hemorrhage*
Thrombolytic Therapy
Tissue Plasminogen Activator
Tissue Plasminogen Activator

Figure

• 

  Figure 1. A brain computed tomography, performed before infusion of recombinant tissue plasminogen activator, shows no intracranial hemorrhage (A). Diffusion-weighted imaging shows acute infarction in the left middle cerebral artery territory (B).

• 

  Figure 2. A brain computed tomography (CT) shows subarachnoid hemorrhage predominant in the right cerebral hemisphere (A, B). CT angiography (C) and conventional angiography (D) reveal a saccular aneurysm with a bleb in the right middle cerebral artery and occlusion of the left middle cerebral artery (black arrows indicate subarachnoid hemorrhage; white arrows, a ruptured aneurysm).

• 

  Figure 3. Conventional angiography 7 days after aneurysmal clipping reveals no right middle cerebral artery occlusion or vasospasm.

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