London, United Kingdom 2013 26 Interesting and challenging cases MULTIPLE INTRACRANIAL HEMORRHAGES AND VERY LOW FIBRINOGEN AFTER I.V. THROMBOLYSIS B. Censori1, T. Partziguian2, M. Rossi3, P. Filisetti4, O. Valoti5, M Poloni6 Neurology Unit, Ospedale Papa Giovanni XXIII, Bergamo, ITALY1, Neurology Unit, Ospedale Papa Giovanni XXIII, Bergamo, ITALY2, Emergency Dept., Ospedale Papa Giovanni XXIII, Ber-gamo, ITALY3, Emergency Dept., Ospedale Papa Giovanni XXIII, Bergamo, ITALY4, Emergency Dept., Ospedale Papa Giovanni XXIII, Bergamo, ITALY5, Neurology Unit, Ospedale Papa Giovan-ni XXIII, Bergamo, ITALY6 Background. Alteplase is marketed as a fibrin-specific drug. However, it may also cause a systemic lytic state. We describe a patient who had multiple types of intracranial hemorrhages after i.v. throm-bolysis for stroke. Case report. A 71-year-old man was admitted for acute left hemiparesis. NIHSS score was 12 and CT ASPECT score was 10, so he was given i.v. alteplase at 0.9 mg/kg, total dose 63 mg, starting with a 6 mg bolus 100 minutes after symptom onset. Platelets were 108000/mmc, and fibrinogen 250 mg% before administration of alteplase. Five hours after the start of thromboly-sis he suddenly went into a coma. Repeat CT scan showed subarachnoid, subdural, and intraparen-chymal brain hemorrhages. Fibrinogen was 28 mg%, and platelets 82000/mmc. The patient died 24 hours after stroke onset. Conclusions. This case shows that alteplase given at the current therapeutic dose for ischemic stroke may cause a severe depletion of plasma fibrinogen, leading to fatal intracra-nial hemorrhages. This aspect of i.v. thrombolysis for stroke has not been adequately studied so far. E-Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854 607 25 Interesting and challenging cases A TCD “misleading vasospasm” in a rare case of familiar Moyamoya Disease presenting with Non-Aneurysmal Subarachnoid Hemorrhage (NASAH). F. Puledda1, M. Toscano2, E. Vicenzini3, G. Guidetti4, G.L. Lenzi5, V. Di Piero6 “Sapienza” Univeristy of Rome, Rome, ITALY1, “Sapienza” Univeristy of Rome, Rome, ITALY2, “Sapienza” Univeristy of Rome, Rome, ITALY3, “Sapienza” Univeristy of Rome, Rome, ITALY4, “Sapienza” Univeristy of Rome, Rome, ITALY5, “Sapienza” Univeristy of Rome, Rome, ITALY6 Background Moyamoya Disease (MMD) is a cerebrovascular condition that typically presents with ischemic or hemorrhagic cerebral lesions. However, NASAH is very rare in MMD. To date only 6 other cases have been described, only one of which was familiar. We describe a patient presenting with NASAH studied with repeated Transcranial Doppler (TCD) exams. Case Report A 57 year old woman developed sudden headache followed by a partial seizure with rapid gener-alization. Her family history revealed two cousins with MMD. CT scan, cerebral angiography and TCD were performed upon admission. CT scans revealed SAH over the right frontal cortex and pa-rieto- occipital cortex bilaterally. Cerebral angiography showed stenosis of the supraclinoid segment of both ICAs, bilateral occlusion of the ACA, hypoplasia of the left MCA and multiple tortuous ‘moyamoya vessels’ branching from the right MCA. No cerebral aneurysms or vascular malforma-tions were found. Baseline TCD showed the typical hemodynamic pattern of MMD in terms of high flow velocity and low flow resistance in all monitored intracranial vessels but the R-MCA, which presented very high flow velocity and normal flow resistance; this was initially attributed to MCA vasospasm. NASAH in a patient with familial MMD was then diagnosed and nimodipine therapy was started immediately. Nonetheless, subsequent TCD controls showed a paradoxical increasing in blood flow velocity without any clinical or radiological signs of vasospasm, and a progressive low-ering of resistance indices. We therefore considered this alteration as a return to a previous abnormal pattern typical of MMD, more than a true vasospasm due to NASAH. Conclusions NASAH in familial MMD is very rare, to our knowledge this is the second case reported in the lit-erature. It is also intriguing to speculate on the interpretation of TCD data, which could mimic a true vasospasm in a MMD patient presenting with NASAH, therefore resulting in a challenging diagnos-tic issue.
Karger_ESC London_2013
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