USE OF RECOMBINANT TISSUE PLASMA ACTIVATOR (RT-PA) IN SILENT AORTIC DISSECTION PRESENTING AS AN ISCHEMIC STROKE

The use of thrombolytic therapy in the management of acute ischemic stroke has increased since the National Institute of Neurological Disorders and Stroke (NINDS) established its efficacy in improving clinical outcome at three months in patients when treated within a three-hour window. However, a controversy exists in its use in patients with aortic dissection presenting with neurologic symptoms, mimicking an acute ischemic type of stroke, due to risk for further hemorrhage and interference with hemostasis. This is a case of a 60-year-old female who presented with an acute left sided hemiplegia, and was treated with recombinant tissue plasma activator (rt-PA) after inclusion criteria was met. MRI showed moderate embolic left middle cerebral artery infarct and a computed tomography angiography (CTA) performed post thrombolytic therapy showed a Stanford type A aortic dissection. Following rt-PA administration, the patient improved neurologically the next day, and underwent surgery for repair of the dissection. Despite the neurologic and clinical improvement after thrombolysis, the patient was not able to tolerate the surgery and expired a day after the operation. Nonetheless, this case still provides evidence that rt-PA is an appropriate an effective treatment in the case of an ischemic stroke secondary to an aortic dissection. Purpose (a): This is a case study demonstrating the use of recombinant tissue plasma activator (rt-PA) in the treatment of an ischemic stroke secondary to a silent aortic dissection. In light of recent studies on clinical outcomes, there is debate about the use of rt-PA to treat a questionable stroke with a high suspicion for aortic dissection. This purpose of this case is to show that such time-sensitive, potentially life-saving treatment can be delivered without any negative side effects towards an aortic dissection such as intracranial bleeding or an aortic rupture. This case provides further evidence that rt-PA should not be delayed as the clinical benefits of reducing stroke morbidity and mortality outweighs the potential risks. Methods (b): This case describes a 60 year old patient presenting to the emergency department with an ischemic stroke and treated with rt-PA. The patient initially presented with right sided gaze preference and left-sided hemiplegia. In further reassessing the patient, a Stanford Type A aortic dissection with right carotid artery involvement was discovered upon CTA. The decision was made to attempt a surgical repair of the dissection. During the surgery, the vessel defect was corrected, but the patient sustained right heart failure refractory to vasopressors. Following surgery, the patient was transferred to the ICU, intubated, and in critical condition. Despite being maintained on heparin, a repeat head CT showed no transformation from an ischemic to a hemorrhagic stroke. The patient died two days later due to complications from the surgery. Results (c): During the initial assessment of the ischemic stroke, no signs of hemorrhage were present so the decision to give rt-PA was made. Following administration of rt-PA, the patient subsequently improved; there were no gaze asymmetry and left sided movements were noted. The patient did not show any signs of intracranial bleeding with rt-PA and heparin therapy. It is also important to note that administration of rt-PA did not appear to worsen the aortic dissection. Conclusions (d): The results of this case study suggest that rt-PA, when indicated, is an appropriate and effective treatment in the case of ischemic stroke secondary to an aortic dissection. However, surgical corrections of aortic dissection in these cases do carry a high mortality rate, so clinical judgment must be carefully exercised for each individual case.