Remote intracerebral hemorrhage in stroke patients treated with intravenous recombinant tissue-type plasminogen (IV-tPA) is a poorly understood entity with uncertain etiology. A 65 year old woman was treated with IV-tPA after presenting to our institution with a one hour history of right sided weakness and speech difficulty. Cerebral angiography showed occlusion of the left superior M2 division of middle cerebral artery (MCA). Mechanical thrombectomy of the left MCA clot was performed with confirmation of subsequent TICI-3a flow. Intraoperative left vertebral artery injection was performed to look for collateral flow, which revealed contrast extravasation from the left thalamoperforator arteries in real time. With no CT evidence of prior infarct in this region and a demonstrated lack of perfusion defect via angiography, this novel observation supports the hypothesis that remote intracerebral hemorrhage following IV-tPA is due to pre-existing small vessel disease, with or without microbleeds. As we enter the era of endovascular stroke treatment, our observation that pre-existing small vessel disease with or without microbleeds plays a role in the etiology of remote intracerebral hemorrhage indicates that risk factors for small vessel disease should be incorporated into future risk models for thrombolytic stroke therapy.
Disclosures P. Chamiraju: None. B. Kolb: None. H. Saber: None. P. Maddali: None. S. Narayanan: None.
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