Synchronous cardiocerebral infarction in the era of endovascular therapy: which to treat first?

Abstract

A cardiocerebral ischemic attack (CCI) or a concurrent acute ischemic stroke (AIS) and myocardial infarction (AMI) is a severe event with no clear recommendations for ideal management because of the rarity of the scenario. The narrow time window for treatment and complexity of the treatment decision puts immense pressure on the treating physician. We evaluated this challenging situation at our tertiary center. Using our prospective stroke database out of a total of 555 patients with acute ischemic stroke between 2009 and 2014, we identified five consecutive cases with CCI (incidence 0.009%). Demography, risk factor characteristics, vascular occlusions and treatment approach were recorded. Good functional outcome was defined by the modified Rankin scale (mRS) score of 0-2 points. Out of five patients, AIS was treated with endovascular treatment in three cases, while two were treated with intravenous thrombolysis only. One out of three patients had embolectomy of the brain performed prior to the coronary intervention, while the other two patients underwent coronary intervention first. One patient developed sudden cardiac arrest on day-2 and passed away. CCI is an uncommon and devastating clinical scenario, further research is needed for the ideal management strategy that provides the best outcomes. However, the rarity of the disease does not lend itself to the conduct of a trial easily. We have proposed a considered treatment algorithm based on the current literature and our experience.

Simultaneous acute cardio-cerebral infarction: is there a consensus for management?

“…The available evidence about this rare presentation has been mostly from reported case reports and case series. In their review paper, Yeo et al (9) reported that 6% of patients with acute stroke had ST segment elevation, but a closer look at the cited study (10) showed that none of these patients with ST segment elevations had dynamic changes consistent with evolving MI on serial electrocardiogram, nor were the creatine phosphokinase levels higher than patients without ST elevations, therefore rendering the inference of AMI incidence in the setting of acute stroke from this study unreliable. An autopsy on a patient with anterior ST elevation in setting of subarachnoid hemorrhage in this study however revealed focal areas of myocardial necrosis.…”

“…An intravenous bolus of alteplase 15 mg followed by infusion of 0.75 mg/kg for 30 minutes (maximum 50 mg), then 0.5 mg/kg (maximum 35 mg) over the next 60 minutes, not to exceed a total of 100 mg can be given up to 12 hours for qualifying AMI presentations (35). The lack of a clear guideline on the unifying dose for simultaneous CCI is a source of great controversy due to the fact that studies have shown an increased risk of hemorrhagic conversion of AIS when thrombolytics are administered at higher doses (36)(37)(38), and administration of lower than recommended dose of a thrombolytic for AMI may be considered under-dosing (9).…”

“…A combined endovascular approach with the use of PTCA for AMI and thrombectomy devices for AIS have been suggested (9). Advantages of this approach include the visualization of both coronary and cerebral artery occlusions which confirms a definite CCI diagnosis, and the effectiveness in treating a proximal cerebral artery occlusion which carries significantly lower mortality than intravenous thrombolysis alone (9,39).…”

“…Advantages of this approach include the visualization of both coronary and cerebral artery occlusions which confirms a definite CCI diagnosis, and the effectiveness in treating a proximal cerebral artery occlusion which carries significantly lower mortality than intravenous thrombolysis alone (9,39). While most clinical trials on endovascular therapy in AIS required the administration of IV-tPA alongside the use of endovascular therapy (40,41), the subgroup analysis of some clinical trials revealed that patients who received thrombectomy therapy without IV-tPA (due to contraindications) gained functional independence and had higher rates of recovery than patients receiving IV-tPA with endovascular therapy (42,43).…”

Simultaneous cardio-cerebral embolization associated with atrial fibrillation: a case report

“…We have presented herein a case of atrial fibrillation-associated CCI in which nearly simultaneous embolization of the cerebral and coronary arteries occurred. The term CCI was coined by Omar et al [1], and this rare condition has a reported frequency of 0.009-0.52% of ischemic strokes [7] In our case, cerebral embolism was treated first with intravenous tissue plasminogen activator (IV-tPA) and mechanical thrombectomy, followed by coronary angiography, which did not suggest any requirement for PCI. Coronary angiography suggested that alteplase at the dosage approved for ischemic stroke had resolved the coronary emboli.…”