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Abstract Details

Clinical Improvement Despite post-rtPA Subarachnoid Hemorrhage
Cerebrovascular Disease and Interventional Neurology
P8 - Poster Session 8 (8:00 AM-9:00 AM)
4-006
To describe a case of sulcal subarachnoid hemorrhage (SAH) that developed during intravenous (IV) recombinant tissue-type plasminogen activator (rtPA) infusion and subsequently resolved within 24 hours.
A 53-year-old right-handed woman with a history of hypertension, hyperlipidemia, insulin dependent diabetes mellitus, and active smoking presented within 45 minutes of last known well (LKW) with NIHSS=14 (questions, facial, left hemiparesis, and dysarthria). IV rtPA was administered 1 hour and 6 minutes after LKW. During the rtPA infusion she developed a severe right-sided retro-orbital headache and worsened to an NIHSS=16 (new gaze deviation and inattention). The infusion was discontinued. Emergency head CT showed a small right frontal sulcal SAH.
The EMR and relevant imaging were reviewed.
MRI Brain obtained 3 hours and 26 minutes after symptom onset showed multiple, punctate, cortical infarcts in the right temporal and parietal regions and redemonstrated the known right frontal SAH. The 24-hour post-alteplase head CT showed no evidence of SAH. She gradually improved and was discharged to acute inpatient rehab with a NIHSS=6 (mild facial, left upper extremity weakness and sensory loss, mild dysarthria, and inattention).
Our case illustrates the fact that minor bleeding may remain undetected on 24-hour head CT, suggesting that the prevalence of minor ICH following IV thrombolysis may be underestimated. Although ICH can carry significant morbidity, physicians should not let fear of an event with low probability prevent timely treatment of ischemic stroke because treatment can improve overall outcomes, as illustrated by this patient.
Authors/Disclosures
Claribel D. Wee, MD (SUNY Upstate Medical University)
PRESENTER 		Dr. Wee has nothing to disclose.
Karen C. Albright, DO, DO, PhD, MS, MPH (FDA) Dr. Albright has nothing to disclose.