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

Abstract

Background: 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. Case Description: 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. Conclusion: 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.

Ruptured brain aneurysm‐induced subarachnoid hemorrhage with concurrent myocardial infarction in a rhesus monkey (Macaca mulatta)

“…SAH mimics an acute ST-elevation myocardial infarction, according to Cima K et al 12 Another favorable case was a patient who had aneurysmal SAH and MI at the same time and was treated with cerebral aneurysm coiling, cardiac endovascular intervention, and antiplatelet medication successively and finally got healed. 13 This case may provide veterinarians with some suggestions on the nursing of old monkeys, especially those with cardiovascular and cerebral conditions. Monkeys over 10 years old should undergo complete physical examinations every other year.…”

“…If a patient has both aSAH and MI simultaneously, the therapeutic schedule should be contemplated carefully because both the diseases are emergent, lethal, and conflicting in medication. SAH mimics an acute ST‐elevation myocardial infarction, according to Cima K et al 12 Another favorable case was a patient who had aneurysmal SAH and MI at the same time and was treated with cerebral aneurysm coiling, cardiac endovascular intervention, and antiplatelet medication successively and finally got healed 13 …”

Diagnosis and Management of Takotsubo Syndrome in Acute Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

“…Coronarography, performed only for diagnostic purposes, has few benefits and also delays the definitive treatment of the aneurysm. Successful endovascular treatment of the aneurysm allows the administration of anticoagulants and antiplatelet agents for coronary intervention [ 77 ]. However, further neurosurgical procedures may become necessary in the following days and weeks (e.g., placement of an external ventricular drain or ventriculoperitoneal shunt), which require the reversal of anticoagulation and antiplatelet therapy, even if a coronary stent was previously inserted, placing these patients at high risk of stent thrombosis.…”

ST-segment elevation myocardial infarction with normal coronary arteries secondary to anterior communicating cerebral artery aneurysmal rupture: a case report

“…Consensus by authors of similar case reports of CAA rupture and haemorrhage complicated with simultaneous acute coronary event favours initial cerebral aneurysmal coiling before endovascular cardiac intervention if clinically stable and feasible. 7 , 8 Additionally, a cohort analysis by Ahmadian et al ., 9 questioned the helpfulness of coronary angiography in this populace given the reversibility and catecholamine mediation of cardiac insult. The postulated theories supporting the relationships between brain damage and heart dysfunction include catecholamine mediation via epinephrine and norepinephrine and also the direct effect of sympathetic and parasympathetic nervous system.…”