Thrombolytic therapy for acute extra-cranial artery dissection: report of two cases

Abstract

-Extra-cranial arterial dissection accounts for 10% of strokes in young people. Information on safety of thrombolytic administration in this group is limited. The literature, however, does not favor use of thrombolytics for myocardial ischemia when peripheral arterial dissection coexists. Based on the clinical and radiological features, two patients who presented with acute stroke secondary to arterial dissection were considered for thrombolysis. One of them received intra-venous recombinant tissue plasminogen activator (rtPA), and the other patient received intra-arterial rtPA. There were no post thrombolysis complications. This report supports feasibility of administering thrombolytics in acute ischemic strokes resulting from extra-cranial arterial dissection. Future larger studies are necessary to determine the efficacy, safety and long-term outcome in this patient population.KEY WORDS: thrombolysis, stroke, dissection, internal carotid artery. Terapia trombolítica em dissecções arteriais cérvico-cefálicas agudas: relato de dois casosRESUMO -Dissecção arterial cérvico-cefálica corresponde a 10 % dos acidentes vasculares cerebrais (AVC) em jovens. Informação sobre a segurança da administração de trombolíticos neste grupo é limitada. A literatura médica, entretanto, não favorece o uso de trombolíticos em isquemia miocárdica na coexistência de dissecção arterial periférica. Baseado nas características clínicas e radiológicas, dois pacientes com AVC agudo secundário a dissecção arterial foram considerados para terapia trombolítica. Um deles recebeu rtPA intravenoso e o outro paciente recebeu rtPA intra-arterial. Não houve complicações pós-trombólise. Este relato suporta a possibilidade do tratamento destes pacientes com terapia trombolítica. Estudos maiores são necessários para determinar a eficácia, segurança e resultados a longo prazo nesta população de pacientes. PALAVRAS-CHAVE: trombólise, acidente vascular cerebral, dissecção, artéria carótida interna.

Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects

“…In spite of providing insufficient data for assessment of efficacy, four non-randomised studies of intravenous thrombolysis showed that complication rates were no greater than thrombolysis for other ischemic stroke etiologies, suggesting that this treatment should not be withheld in patients with suspected SCAD [48][49][50][51] . regarding intra-arterial thrombolysis (IAT), few case reports have been published and showed no rupture of the dissected vessel, intracranial or subarachnoid hemorrhage or peri-interventional arterial embolism 52,53 . Surgery or endovascular procedures have been described in patients with persistent or progressive symptoms despite adequate clinical therapy, in those with hemodynamically significant residual stenosis, or in the presence of contraindications to anticoagulant therapy 31,54 .…”

Management of Spontaneous Dissection of the Cervical Carotid Artery

“…In 6 patients with sICAD who underwent IAT, no rupture of the dissected vessel, cervical, subarachnoid or intracranial hemorrhage, or periinterventional (Furlan et al 1999) arterial embolism was described (Abboud et al 2005;Arnold et al 2002;Sampognaro et al 1999;Zaidat et al 2001). Nedeltchev et al (Nedeltchev et al 2005) reported a patient with sICAD causing symptomatic occlusion of the middle cerebral artery who underwent MT without adverse events.…”

Non-Atherosclerotic Vascular Disease in the Young

“…Small case series and case reports have documented the successful treatment of ischemic stroke associated with cervicocranial artery dissection with intravenous and intra-arterial thrombolysis [77][78][79][80][81]. Others advocate the use of endovascular or surgical therapy for stroke prevention in selected patients with persistent severe stenosis or occlusion after internal carotid artery dissection and recurrent cerebral ischemic symptoms despite medical therapy.…”