6/11/2017 Intracranial Hemorrhage After Thrombolytic Therapy for MI | 1997-05-01 | AHC Media: Continuing Medical Education Publishing

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Home Intracranial Hemorrhage After Thrombolytic Therapy for MI

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6/11/2017 Intracranial Hemorrhage After Thrombolytic Therapy for MI | 1997-05-01 | AHC Media: Continuing Medical Education Publishing

Intracranial Hemorrhage After Thrombolytic

Therapy for MI
May 1, 1997
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Intracranial Hemorrhage After Thrombolytic

Therapy for MI
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Abstract & Commentary

Source: Conrad AR, et al. Intracranial hemorrhage complicating acute myocardial infarction in the era of thrombolytic
therapy. South Med J 1997;90:5-12.

Conrad et al at nassau county medical center in New York report a case of fatal hemorrhagic stroke
complicating thrombolytic therapy for acute myocardial infarction (MI); they also review the literature in an
attempt to identify risk factors and possible preventive measures for this devastating complication. Their
patient was a previously healthy 71-year-old man who received 1.5 million units of streptokinase
intravenously over a one-hour period after presenting with chest pain and ECG evidence of an acute
inferolateral MI. He also received aspirin and, beginning four hours after the streptokinase infusion,
subcutaneous heparin at 12,500 units every 12 hours.

Fifteen hours after completion of the thrombolytic therapy, the patient became confused and progressively
obtunded. There were no focal neurologic findings, but an emergent head CT revealed large intracerebral left
frontal and right temporal hemorrhages. Despite infusion of cryoprecipitate and fresh frozen plasma, the
patients condition deteriorated. His hemorrhages were not considered operable, and he died the following
day.

COMMENT BY DAVID J. PIERSON, MD

Thromboembolic stroke is reported to occur in about 2% of MI patients, typically 3-14 days after the event
and predominantly after large anteroseptal or anterior infarctions in patients with akinetic or dyskinetic areas
of cardiac wall motion. In contrast, when intracanial hemorrhage (ICH) occurs following acute MI, it
typically presents during or shortly after administration of thrombolytic therapy, in the hours following initial
presentation. The incidence of the ICH has ranged between 0.1% and 1.4% in large reported series of MI
patients. Conrad et al provide a concise discussion of the factors that have been associated with an increased
incidence of ICH, along with possible reasons and/or mechanisms for each. (See Table 1.)

Table 1

Risk Factors for Intracranial Hemorrhage with Thrombolytic

Therapy
Low body weight

Female sex

Advanced age

Oral anticoagulation therapy

Severe hypertension

Use of a fibrin-specific thrombolytic agent (e.g., t-PA)

Activated PTT > 70 sec with intravenous heparin

The specific thrombolytic agent used may be an important factor, with fibrin-specific substances such as
alteplase tissue plasminogen activator (t-PA) and anistreplase (APSAC) reported in some series to have twice
the incidence of ICH as streptokinase (although not all large studies have documented this difference). The
dosage of thrombolytic used is also a factor, and this may explain the fact that patients with low body weight
and women are at increased risk. For example, in the TIMI Phase II trial (TIMI Study Group. N Engl J Med
1989;320:618-627), the rate of ICH fell from 1.9% to 0.5% of patients when the dose of t-PA was reduced
from 150 to 100 mg.

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Advanced age has also been a significant risk factor in several studies, presumably because of the increased
prevalence of vascular disease in elderly persons. Other risk factors include the use of oral anticoagulants
prior to thrombolytic therapy, although reported studies have differed as to whether early heparin therapy
also makes ICH more likely. Hypertension (diastolic BP > 110 mmHg) at the time of the thromobolytic
therapy has been found to increase the incidence of this complication in at least some studies.

Simoons et al (Lancet 1993;342:1523-1528) analyzed the results of several large trials of thrombolytic
therapy and developed a model to predict the occurrence of ICH. They identified four independent risk
factors: age greater than 65 years, body weight less than 70 kg, systolic BP higher than 170 mmHg and/or
diastolic BP higher than 95 mmHg on admission, and the use of alteplase rather than another thrombolytic
agent. According to the multivariate analysis performed by those investigators, if the overall incidence of
ICH is 0.75%, for a patient with none of these risk factors it would be 0.26% as compared to 5% in the
presence of all four.

Conrad et al point out that advanced age should not by itself be a contraindication to thrombolytic therapy in
patients with acute MI, since the benefits of this therapy may be more pronounced in the elderly. However,
when fibrin-specific agents such as t-PA are used, weight-adjusting the dosage is advisable in order to reduce
the likelihood of ICH.

Patients receiving thrombolytic agents for acute MI should be monitored closely for changes in neurologic
status. If these are observed (particularly an intense steady headache or changes in sensorium), the
thrombolytic agent should be discontinued immediately along with any concomitant anticoagulant or
antithrombolitic agent, and an emergency head CT obtained. If an ICH is documented, the authors of this
review recommend the infusion of 10 bags of cryoprecipitate, to be repeated if the plasma fibrinogen level is
not raised above 100 mg/dL, and the administration of 2 units of fresh frozen plasma if other factors are also
depleted. Platelet transfusions are indicated if bleeding time is prolonged, as is the use of protamine sulfate to
reverse the effects of heparin (1.0 mg protamine per 100 units heparin infused in the previous 4 hours).
Neurosurgical consultation should be obtained promptly, because emergency evacuation of the ICH may be
indicated. (Dr. Pierson is Professor of Medicine at the University of Washington and Medical Director of
Respiratory Care at Harborview Medical Center in Seattle.)

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