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Background <p>Patients with acute ischemic stroke (AIS) due to acute aortic dissection (AAD) may receive inappropriate intravenous thrombolysis (IVT). Management in this situation, particularly regarding the timing of aortic surgery, remains unclear. We present a case of delayed aortic surgery after IVT for AIS due to AAD, which highlights the unusual consequences of IVT in AAD.</p> Clinical presentation <p>An 87-year-old woman with left upper limb paralysis presented to a local hospital. Magnetic resonance imaging (MRI) identified a cerebral infarction in the right frontal lobe. Despite intravenous administration of alteplase 0.6&#xa0;mg/kg (nationally approved dose in Japan), the paralysis remained unchanged. Subsequent MRI revealed extensive infarction in the right watershed area and another left cerebellar hemisphere infarction. Upon transfer to our hospital, computed tomography (CT) aortogram confirmed AAD with an entry and false lumen thrombus in the ascending aorta. Although emergency aortic surgery was indicated, we delayed surgery because of the risks of excessive bleeding and thrombolysis-related intracerebral hemorrhage (ICH). Brain CT 24&#xa0;h after IVT did not reveal ICH. However, new infarctions were detected, suggesting embolism from fragments of a false lumen thrombus. The fibrinogen level below the measurable limit at that time recovered 38&#xa0;h after IVT, guiding the surgery timing. Aortic surgery was completed without hemostasis difficulty. The patient recovered uneventfully with neurological improvement.</p> Conclusions <p>This case illustrates the complex challenges in managing AAD following inappropriate IVT, highlighting the importance of monitoring fibrinogen levels and paying attention to new cerebral infarction in similar cases. For patients who have received IVT and develop hypofibrinogenemia, delaying surgery until the recovery of fibrinogen levels may be viable in selected cases. However, this approach must be weighed against the risks of untreated AAD during the waiting period.</p>

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Unusual consequences of intravenous thrombolysis in a patient undergoing delayed aortic surgery for aortic dissection presenting as acute ischemic stroke: a case report

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  • 发表日期：

    2025年10月31日

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  • Tomokazu Kosuga,
  • Yukio Hosokawa,
  • Hidetsugu Hori,
  • Keiichiro Tayama

摘要

Background

Patients with acute ischemic stroke (AIS) due to acute aortic dissection (AAD) may receive inappropriate intravenous thrombolysis (IVT). Management in this situation, particularly regarding the timing of aortic surgery, remains unclear. We present a case of delayed aortic surgery after IVT for AIS due to AAD, which highlights the unusual consequences of IVT in AAD.

Clinical presentation

An 87-year-old woman with left upper limb paralysis presented to a local hospital. Magnetic resonance imaging (MRI) identified a cerebral infarction in the right frontal lobe. Despite intravenous administration of alteplase 0.6 mg/kg (nationally approved dose in Japan), the paralysis remained unchanged. Subsequent MRI revealed extensive infarction in the right watershed area and another left cerebellar hemisphere infarction. Upon transfer to our hospital, computed tomography (CT) aortogram confirmed AAD with an entry and false lumen thrombus in the ascending aorta. Although emergency aortic surgery was indicated, we delayed surgery because of the risks of excessive bleeding and thrombolysis-related intracerebral hemorrhage (ICH). Brain CT 24 h after IVT did not reveal ICH. However, new infarctions were detected, suggesting embolism from fragments of a false lumen thrombus. The fibrinogen level below the measurable limit at that time recovered 38 h after IVT, guiding the surgery timing. Aortic surgery was completed without hemostasis difficulty. The patient recovered uneventfully with neurological improvement.

Conclusions

This case illustrates the complex challenges in managing AAD following inappropriate IVT, highlighting the importance of monitoring fibrinogen levels and paying attention to new cerebral infarction in similar cases. For patients who have received IVT and develop hypofibrinogenemia, delaying surgery until the recovery of fibrinogen levels may be viable in selected cases. However, this approach must be weighed against the risks of untreated AAD during the waiting period.