Fatal Contralateral Cardioembolic Stroke Promoted by Systemic Thrombolysis with rtPA in Ischemic Stroke

Background and Purpose: Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is the most effective and the only approved causal treatment in acute ischemic stroke. Summary of Case: We treated an 88-year-old hale woman with atrial fibrillation and acute left middle cerebral artery (MCA) infarction with intravenous thrombolysis. Directly thereafter, she developed an epileptic status. Immediate CT scan was normal. Fourteen hours later, it showed a normal left hemisphere but a fatal space-occupying contralateral MCA and anterior cerebral artery (ACA) infarction. Autopsy revealed thrombi in atria, large right MCA and ACA ischemia, and occlusion of two major visceral arteries. Conclusion: RtPA, though effective for the initial infarction, caused a rarely observed fatal adverse event, i.e. cardioembolism by detachment of atrial thrombi fragments, with an uncommon presentation as epileptic status. Stroke physicians’ awareness of this potential course will allow treatment in time.