Remedy Publications LLC., | http://anncaserep.com/

Annals of Clinical Case Reports

2019 | Volume 4 | Article 15941

BackgroundIntravenous Thrombolysis (IVT) with alteplase is approved for Acute Ischemic Stroke (AIS)

patients. Nevertheless, IVT use is limited not only by its short therapeutic window, but also by the numerous contraindications. Having a platelet count of less than 100,000/µL is considered an absolute contraindication for IVT, according to trial selection criteria and expert opinions [1]. As unsuspected thrombocytopenia is rare, the 2013 American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend clinicians not to wait for the platelet count results before administering intravenous alteplase to AIS patients unless there is a suspected bleeding thrombocytopenia [2]. The rate of unsuspected platelet count <100,000/µL of patients at stroke presentation was reported to be 0.3% by prior studies [3,4]. However, there are two issues. First, the two prior studies were conducted in the U.S population, which may differ in clinical characteristics from populations of other countries. For instance, people residing in Southwestern part of China such as Chengdu, have an average platelet count below 100,000/µL [5]. Second, the two studies both excluded patients with a history of thrombocytopenia. In fact, very few of such patients are reported in the English literature. Whether a platelet count of 100,000/µL is a justified threshold for withholding IVT remains unclear. So, we report the case of an AIS patient with thrombocytopenia who received IVT, hoping to provide some advice for the management of such patients.

Case PresentationA 57-year-old male patient with a history of hypertension presented with left-sided weakness

and transient loss of vision in the right eye for the past three hours. The patient denied any neck pain or trauma. Vital signs were notable for a blood pressure of 163/88 mmHg and a heart rate of 58 bpm. Neurological examination revealed left-sided central facial palsy, left hypoglossal nerve palsy, left limb weakness, and left Babinski sign with a National Institutes of Health Stroke Scale (NIHSS) score of 4. Head Computed Tomography (CT) showed no evidence of acute stroke. The

Intravenous Thrombolysis in a Severely Thrombocytopenic patient with Internal Carotid Artery Dissection

OPEN ACCESS

*Correspondence:Jie Yang, Department of Neurology,

The First Affiliated Hospital of Chengdu Medical College, No.278, Baoguang

Dadao Zhongduan Road, Xindu District, Chengdu 610500, China, Tel:

8602883017170;E-mail: yangjie1126@163.com

Received Date: 12 Jan 2019Accepted Date: 05 Feb 2019

Published Date: 07 Feb 2019

Citation: Yu J, Zheng D, Xu F, Yan D, Yang J.

Intravenous Thrombolysis in a Severely Thrombocytopenic patient with Internal

Carotid Artery Dissection. Ann Clin Case Rep. 2019; 4: 1594.

ISSN: 2474-1655Copyright © 2019 Jie Yang. This is an

open access article distributed under the Creative Commons Attribution

License, which permits unrestricted use, distribution, and reproduction in

any medium, provided the original work is properly cited.

Case ReportPublished: 07 Feb, 2019

AbstractBackground: Thrombocytopenia is considered an absolute contraindication for Intravenous Thrombolysis (IVT), according to trial selection criteria and expert opinions. Cases of stroke patients with mild thrombocytopenia who received IVT were occasionally reported, but reports of patients with platelet count below 80,000/µL are scarce.

Case Presentation: We report an ischemic stroke patient with a platelet count of 56,000/µL who received IVT. The patient did not have any hemorrhagic symptoms before stroke and no symptomatic hemorrhagic complications after IVT. The stroke was caused by internal carotid artery dissection, and stenting of the right internal carotid artery was performed to prevent cerebral infarction recurrence.

Conclusion: This case exemplifies the need to reassess the threshold of platelet count for withholding intravenous thrombolysis. We often encounter cases with management uncertainties, having no available high-quality evidence. In these cases, clinical decisions must be made on an individual basis.

Keywords: Thrombocytopenia; Acute ischemic stroke; Intravenous Thrombolysis; Tissue plasminogen activator

Jianping Yu1, Danni Zheng2,3, Fan Xu4, Dengfu Yan1 and Jie Yang1*1Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, China

2Centre for Big Data Research in Health, University of New South Wales, Australia

3The George Institute for Global Health, University of New South Wales, Australia

4Department of Public Health, Chengdu Medical College, China

Jie Yang, et al., Annals of Clinical Case Reports - Neurology

Remedy Publications LLC., | http://anncaserep.com/ 2019 | Volume 4 | Article 15942

patient was given IVT with alteplase immediately after physical examination at 3.5 h from symptom onset, without waiting for blood test result (which later revealed a platelet count of 56,000/µL). After IVT, the symptom of left-side facial palsy and hemiplegia disappeared with an improvement of NIHSS score to 0, but a partial right-side Horner’s syndrome with right mitosis and right ptosis was observed. To clarify the cause and artery stenosis, the patient had brain Magnetic Resonance Imaging (MRI) and cerebral Digital Subtraction Angiography (DSA) at 24 hr after symptom onset. MRI showed AIS in the head of the right anterior limb of the internal capsule (Figure1). DSA disclosed mild stenosis and dissecting aneurysm in the initial position of the right Internal Carotid Artery (ICA) (Figure 2). The dissecting aneurysm was confirmed by cervical Magnetic Resonance Angiography (MRA) (Figure 3). 24 hr after IVT, anti-platelet therapy was strengthened with 100 mg of aspirin and 75 mg of clopidogrel per day for 3 months. Subsequently, stenting of the right ICA was performed to avoid recurrence of cerebral infarction. The Horner’s

syndrome disappeared, and the blood flow of right ICA normalized after the stenting (Figure 2). The patient had later resumed work without neurological deficits after being discharged. Three months later the platelet count had increased to 88,000/µL and anti-platelet therapy was changed to aspirin 100 mg daily for lifelong.

Discussion and ConclusionPrior studies reported the rate of having unsuspected platelet

count of less than 100,000/µL at stroke presentation to be only 0.3% [3,4]. However, both of these studies were conducted in the U.S population and excluded known thrombocytopenia patients. Another Chinese study showed that having a platelet count of below 100,000/µL was common in Southwestern part of China, such as Chengdu [5]. The mechanism leading to normalization of platelet count after stroke in our patient with thrombocytopenia was unclear. It is possible that thrombocytopenia was acutely caused by stroke. More detailed investigation is needed on the incidence of thrombocytopenia in

Figure 1: Magnetic Resonance Imaging (MRI) of the brain at 24 hr after symptom onset. An acute infarct was showed in the head of the right anterior limb of the internal capsule (indicated with red arrows). (A) Transverse section of T2 weighted imaging. (B) Transverse section of Diffusion Weighted Imaging (DWI). (C) Transverse section of Apparent Diffusion Coefficient imaging (ADC).

Figure 2: Cerebral Digital Subtraction Angiography (DSA) imaging before and after stenting therapy. (A) The anteroposterior radiograph of the right internal carotid artery pre-stent setting. Double lumen and intimal flap were indicated with red arrow. (B) The lateral projection imaging of the right internal carotid artery pre-stent setting. The retention of the contrast agents is indicated with red arrow. (C) The anteroposterior radiograph of the right internal carotid artery post-stent setting. The dissecting aneurysm disappeared, and the blood flow became normal.

Figure 3: Cervical magnetic resonance angiography imaging.Double lumen was showed at the right internal carotid artery (indicated with red arrows) and atheromatous plaque at the left internal carotid artery (indicated with yellow arrows). (A) Transverse section of T2 turbo spin echo sequences. (B) Transverse section of T2 turbo inversion recovery magnitude sequences. (C) Transverse section of TOF 3D multi slab mtc sequences.

Jie Yang, et al., Annals of Clinical Case Reports - Neurology

Remedy Publications LLC., | http://anncaserep.com/ 2019 | Volume 4 | Article 15943

Chinese stroke patients.

Platelet count is associated with the risk of bleeding. Generally, those with platelet counts between 30,000 and 50,000/µL may note easy bruising, whereas platelet counts above 50,000/µL are usually discovered incidentally [6]. Considering the risk of bleeding complications, thrombocytopenic patients are usually excluded from IVT and hence there is very limited data regarding the safety of IVT in thrombocytopenic stroke patients. Whether a platelet count of 100,000/µL is a justified threshold for withholding IVT remains unclear. We often encounter cases with uncertainty regarding management, for which high-quality data are not available. For these cases, clinical decisions must be made on an individual basis. Based on the scanty literature available on this subject, we would recommend thrombolytic therapy for an ischemic stroke patient with a platelet count of between 50,000/µL and 100,000/µL, provided there is no evidence of a bleeding diathesis.

References1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC,

Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e110.

2. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.

3. Rost NS, Masrur S, Pervez MA, Viswanathan A, Schwamm LH. Unsuspected coagulopathy rarely prevents IV thrombolysis in acute ischemic stroke. Neurology. 2009;73(23):1957-62.

4. Cucchiara BL, Jackson B, Weiner M, Messe SR. Usefulness of checking platelet count before thrombolysis in acute ischemic stroke. Stroke. 2007;38(5):1639-40.

5. Cong YL, Jin DM, Wang HL, Okada T, Peng ZH. Investigating Chinese platelet parameter in vein blood. Chinese J Laboratory Med. 2004;27(6):368-70.

6. De Piazza C, Raudino F. Thrombolysis in thrombocytopenic stroke patients: A case report. Acta Neurol Belgica. 2016;117(3):749-51.

Grants Details i) Clinical Vascular Grant In Chinese Physician (No. 2017-CCA-VG-029); ii) Independent Fundation of the First Affiliated Hospital of Chengdu Medical College (No. CYFY2017DL06); iii) National Natural Science Foundation of China (No. 81870940); iv) Sichuan Science and Technology Program (No. 2018JY0026)