Case Report Carotid Ultrasonography Can Identify Stroke Patients Ineligible for Intravenous Thrombolysis Therapy due to Acute Aortic Dissection Yuka Hama, MD, Masatoshi Koga, MD, Keisuke Tokunaga, MD, Hotake Takizawa, MD, Kotaro Miyashita, MD, Yutaka Iba, MD, Kazunori Toyoda, MD From the Department of Cerebrovascular Medicine (YH, KT, KT); Division of Stroke Care Unit (MK); Department of Neurology (HT, KM); and Department of Cardiovascular Surgery (YI), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
ABSTRACT Acute aortic dissection is the most common acute aortic condition requiring urgent surgical therapy. Due to lack of typical symptoms, it is sometimes difficult to identify acute aortic dissection causing ischemic stroke. We report a case of a patient with acute ischemic stroke who was deemed ineligible for intravenous recombinant tissue plasminogen activator treatment based on a finding of acute aortic dissection detected by carotid ultrasonography. After urgent aortic replacement surgery, the patient recovered with no neurological deficit. This case underscores the crucial role of carotid ultrasonography for the investigation of possible underlying acute aortic dissection when considering the use of intravenous recombinant tissue plasminogen activator therapy for hyperacute stroke.
Keywords: Acute stroke, aortic dissection, recombinant tissue plasminogen activator, carotid ultrasound. Acceptance: Received February 12, 2014, and in revised form June 19, 2014. Accepted for publication August 17, 2014. Correspondence: Address correspondence to Masatoshi Koga, MD, Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, 5-71 Fujishirodai, Suita, Osaka 565-8565, Japan. E-mail: [email protected] No grant support. J Neuroimaging 2015;25:671-673. DOI: 10.1111/jon.12186
Introduction Intravenous recombinant tissue plasminogen activator (IV rtPA) administered within 4.5 hours after the onset of stroke symptoms improved clinical outcomes in patients with acute ischemic stroke.1,2 In 2007, ten Japanese patients with acute ischemic stroke due to acute aortic dissection (AAD) died after being treated with IV rt-PA. As a result, AAD was added as contraindication to rtPA therapy in the revised version of the Japanese guidelines.3 It is sometimes difficult to identify AAD, and some patients may be asymptomatic or have atypical symptoms. We routinely perform carotid ultrasonography at bedside before IV rt-PA to assess for common carotid artery (CCA) dissection extending from the aorta as well as for carotid steno-occlusive lesions. This report describes a case in which carotid ultrasonography detected AAD in a patient who was being considered for IV rt-PA therapy.
Case Report A 52-year-old man fell down while mowing and was emergently transferred to our hospital 85 minutes later. On
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admission, his blood pressure (BP) was 135/110 mmHg in the right arm and 116/77 mmHg in the left arm. He had mild consciousness disturbance, right unilateral spatial neglect, and mild right hemiparesis. He did not complain of any pain. Chest auscultation was unremarkable. Diffusion-weighted magnetic resonance imaging revealed slight hyperintensities, indicating early ischemic change in the left parieto-occipital lobe. The right internal carotid artery was poorly depicted probably due to retrograde collateral flow via the anterior communicating artery on magnetic resonance angiography. A chest X-ray taken in the recumbent position showed mild cardiomegaly. We filled a syringe with dissolved alteplase while performing routine carotid ultrasonography. However, ultrasonography revealed a short duration biphasic flow (backward flow dominant) without diastolic flow indicating a proximal right CCA occlusion which caused a compensation between forward and backward flows (Fig 1A–C) and double lumens with an intimal flap of the left CCA (Fig 1D). This finding led us to terminate any consideration of IV rt-PA therapy. Urgent contrast-enhanced computed tomography (CT) confirmed Stanford type A AAD (Fig 1E) extending to the bilateral CCA. The patient underwent urgent total aortic arch replacement 5 hours after stroke onset,
◦ 2014 by the American Society of Neuroimaging C
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Fig 1. A to D: Ultrasound of the bilateral common carotid artery. A to C: B-mode (A), color Doppler (B), and pulse Doppler (C) images of the right common carotid artery showing reversed systolic flow without any morphological changes; D: a B-mode image of the left common carotid artery demonstrating an intimal flap (arrow) and double lumens; E: an axial contrast-enhanced computed tomography image of the chest showing an intimal flap (arrow heads) separating the ascending and descending aorta into two channels.
and was discharged home without any neurological deficit on day 26.
Discussion This report describes the case of a patient with acute ischemic stroke in which IV rt-PA was contraindicated after carotid ultrasonography detected underlying AAD. Neurologic complications occur in 17% to 40% of AAD patients, and AAD patients with neurologic compilations have higher mortality than those without.4,5 Pain accompanies AAD in 96% of overall patients6 but only in 67% of those with neurological symptoms.4 Ischemic stroke related to AAD was frequently referable to the carotid circulation, predominantly the right-sided circulation.4 Lack of pain and lack of right hemispheric symptoms made diagnosis of AAD difficult in our patient. The BP laterality in our patient appears to have important implications. Because BP measurement in both arms is a simple and fast “screening tool” for stroke patients lacking typical symptoms of AAD, BP measurement should be mandatory in both arms prior to IV rt-PA. If a considerable difference is found, carotid ultrasonography should be performed to look for CCA. Because the most common cause of CCA dissection was an extension from an aortic
672
dissection7 and nearly half of AAD patients had a dissection of at least one CCA,8 the detection of CCA dissection is crucial in assessing the presence of AAD. Although we routinely perform carotid ultrasonography simultaneously with the preparation of a syringe with dissolved alteplase, we are always paying attention not to spend wasted time and not to delay the start of IV rt-PA with a simple evaluation at bedside; eg, a short scanning just with B-mode and color images within minutes. Contrast CT imaging is the most frequently ordered diagnostic modality to detect AAD and is associated with high sensitivities and specificities.9 However, it is difficult to routinely perform contrast CT imaging in urgent clinical settings before judging eligibility for rt-PA therapy. Carotid ultrasonography is a useful and noninvasive technique for investigation of AAD extension to the carotid artery in patients with acute ischemic stroke who present within 4.5 hours of symptom onset.
Conclusion This case underscores the crucial role of carotid ultrasonography for the investigation of possible underlying AAD when considering the use of IV rt-PA therapy for hyperacute stroke.
Journal of Neuroimaging Vol 25 No 4 July/August 2015
References 1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587. 2. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:13171329. 3. Minematsu K, Toyoda K, Hirano T, et al. Guidelines for the intravenous application of recombinant tissue-type plasminogen activator (alteplase), the second edition, October 2012: a guideline from the Japan Stroke Society. J Stroke Cerebrovasc Dis 2013;22:571-600. 4. Gaul C, Dietrich W, Friedrich I, et al. Neurological symptoms in type A aortic dissections. Stroke 2007;38(2):292-297.
5. Blanco M, D´ıez-Tejedor E, Larrea, JL, et al. Neurologic complications of type I aortic dissection. Acta Neurol Scand 1999;99:232-235. 6. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897-903. 7. Humphrey PW, Keller MP, Spadone DP, et al. Spontaneous common carotid artery dissection. J Vasc Surg 1993;18:95-99. 8. Zurbrugg HR, Leupi F, Schupbach P, et al. Duplex scanner study of carotid artery dissection following surgical treatment of aortic dissection type A. Stroke 1988;19:970-976. 9. Hayter RG, Rhea JT, Small A, et al. Suspected aortic dissection and other aortic disorders: multi-detector row CT in 373 cases in the emergency setting. Radiology 2006;238:841-852.
Hama et al: Carotid Ultrasonography to Avoid IV t-PA in Acute Aortic Dissection
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ABSTRACT Acute aortic dissection is the most common acute aortic condition requiring urgent surgical therapy. Due to lack of typical symptoms, it is sometimes difficult to identify acute aortic dissection causing ischemic stroke. We report a case of a patient with acute ischemic stroke who was deemed ineligible for intravenous recombinant tissue plasminogen activator treatment based on a finding of acute aortic dissection detected by carotid ultrasonography. After urgent aortic replacement surgery, the patient recovered with no neurological deficit. This case underscores the crucial role of carotid ultrasonography for the investigation of possible underlying acute aortic dissection when considering the use of intravenous recombinant tissue plasminogen activator therapy for hyperacute stroke.
Keywords: Acute stroke, aortic dissection, recombinant tissue plasminogen activator, carotid ultrasound. Acceptance: Received February 12, 2014, and in revised form June 19, 2014. Accepted for publication August 17, 2014. Correspondence: Address correspondence to Masatoshi Koga, MD, Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, 5-71 Fujishirodai, Suita, Osaka 565-8565, Japan. E-mail: [email protected] No grant support. J Neuroimaging 2015;25:671-673. DOI: 10.1111/jon.12186
Introduction Intravenous recombinant tissue plasminogen activator (IV rtPA) administered within 4.5 hours after the onset of stroke symptoms improved clinical outcomes in patients with acute ischemic stroke.1,2 In 2007, ten Japanese patients with acute ischemic stroke due to acute aortic dissection (AAD) died after being treated with IV rt-PA. As a result, AAD was added as contraindication to rtPA therapy in the revised version of the Japanese guidelines.3 It is sometimes difficult to identify AAD, and some patients may be asymptomatic or have atypical symptoms. We routinely perform carotid ultrasonography at bedside before IV rt-PA to assess for common carotid artery (CCA) dissection extending from the aorta as well as for carotid steno-occlusive lesions. This report describes a case in which carotid ultrasonography detected AAD in a patient who was being considered for IV rt-PA therapy.
Case Report A 52-year-old man fell down while mowing and was emergently transferred to our hospital 85 minutes later. On
Copyright
admission, his blood pressure (BP) was 135/110 mmHg in the right arm and 116/77 mmHg in the left arm. He had mild consciousness disturbance, right unilateral spatial neglect, and mild right hemiparesis. He did not complain of any pain. Chest auscultation was unremarkable. Diffusion-weighted magnetic resonance imaging revealed slight hyperintensities, indicating early ischemic change in the left parieto-occipital lobe. The right internal carotid artery was poorly depicted probably due to retrograde collateral flow via the anterior communicating artery on magnetic resonance angiography. A chest X-ray taken in the recumbent position showed mild cardiomegaly. We filled a syringe with dissolved alteplase while performing routine carotid ultrasonography. However, ultrasonography revealed a short duration biphasic flow (backward flow dominant) without diastolic flow indicating a proximal right CCA occlusion which caused a compensation between forward and backward flows (Fig 1A–C) and double lumens with an intimal flap of the left CCA (Fig 1D). This finding led us to terminate any consideration of IV rt-PA therapy. Urgent contrast-enhanced computed tomography (CT) confirmed Stanford type A AAD (Fig 1E) extending to the bilateral CCA. The patient underwent urgent total aortic arch replacement 5 hours after stroke onset,
◦ 2014 by the American Society of Neuroimaging C
671
Fig 1. A to D: Ultrasound of the bilateral common carotid artery. A to C: B-mode (A), color Doppler (B), and pulse Doppler (C) images of the right common carotid artery showing reversed systolic flow without any morphological changes; D: a B-mode image of the left common carotid artery demonstrating an intimal flap (arrow) and double lumens; E: an axial contrast-enhanced computed tomography image of the chest showing an intimal flap (arrow heads) separating the ascending and descending aorta into two channels.
and was discharged home without any neurological deficit on day 26.
Discussion This report describes the case of a patient with acute ischemic stroke in which IV rt-PA was contraindicated after carotid ultrasonography detected underlying AAD. Neurologic complications occur in 17% to 40% of AAD patients, and AAD patients with neurologic compilations have higher mortality than those without.4,5 Pain accompanies AAD in 96% of overall patients6 but only in 67% of those with neurological symptoms.4 Ischemic stroke related to AAD was frequently referable to the carotid circulation, predominantly the right-sided circulation.4 Lack of pain and lack of right hemispheric symptoms made diagnosis of AAD difficult in our patient. The BP laterality in our patient appears to have important implications. Because BP measurement in both arms is a simple and fast “screening tool” for stroke patients lacking typical symptoms of AAD, BP measurement should be mandatory in both arms prior to IV rt-PA. If a considerable difference is found, carotid ultrasonography should be performed to look for CCA. Because the most common cause of CCA dissection was an extension from an aortic
672
dissection7 and nearly half of AAD patients had a dissection of at least one CCA,8 the detection of CCA dissection is crucial in assessing the presence of AAD. Although we routinely perform carotid ultrasonography simultaneously with the preparation of a syringe with dissolved alteplase, we are always paying attention not to spend wasted time and not to delay the start of IV rt-PA with a simple evaluation at bedside; eg, a short scanning just with B-mode and color images within minutes. Contrast CT imaging is the most frequently ordered diagnostic modality to detect AAD and is associated with high sensitivities and specificities.9 However, it is difficult to routinely perform contrast CT imaging in urgent clinical settings before judging eligibility for rt-PA therapy. Carotid ultrasonography is a useful and noninvasive technique for investigation of AAD extension to the carotid artery in patients with acute ischemic stroke who present within 4.5 hours of symptom onset.
Conclusion This case underscores the crucial role of carotid ultrasonography for the investigation of possible underlying AAD when considering the use of IV rt-PA therapy for hyperacute stroke.
Journal of Neuroimaging Vol 25 No 4 July/August 2015
References 1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587. 2. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:13171329. 3. Minematsu K, Toyoda K, Hirano T, et al. Guidelines for the intravenous application of recombinant tissue-type plasminogen activator (alteplase), the second edition, October 2012: a guideline from the Japan Stroke Society. J Stroke Cerebrovasc Dis 2013;22:571-600. 4. Gaul C, Dietrich W, Friedrich I, et al. Neurological symptoms in type A aortic dissections. Stroke 2007;38(2):292-297.
5. Blanco M, D´ıez-Tejedor E, Larrea, JL, et al. Neurologic complications of type I aortic dissection. Acta Neurol Scand 1999;99:232-235. 6. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897-903. 7. Humphrey PW, Keller MP, Spadone DP, et al. Spontaneous common carotid artery dissection. J Vasc Surg 1993;18:95-99. 8. Zurbrugg HR, Leupi F, Schupbach P, et al. Duplex scanner study of carotid artery dissection following surgical treatment of aortic dissection type A. Stroke 1988;19:970-976. 9. Hayter RG, Rhea JT, Small A, et al. Suspected aortic dissection and other aortic disorders: multi-detector row CT in 373 cases in the emergency setting. Radiology 2006;238:841-852.
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