Hidden Fracture, Urgent Thrombolysis: Intravenous Alteplase for Acute Ischemic Stroke With an Occult Proximal Femoral Fracture After a Fall

An 89-year-old woman with chronic atrial fibrillation fell to the right side and was found to have right-sided weakness and impaired consciousness. Initial evaluation, including Focused Assessment with Sonography for Trauma (FAST), head computed tomography (CT), cervical CT, and thoracoabdominal CT, showed no intracranial hemorrhage, cervical epidural hematoma, aortic dissection, or thoracoabdominal bleeding. Brain magnetic resonance imaging (MRI) showed acute ischemic lesions in the left middle cerebral artery territory with a diffusion-weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch. Intravenous tissue plasminogen activator (IV tPA) was administered for acute ischemic stroke. After IV tPA initiation, retrospective review of the initial thoracoabdominal CT revealed an occult right proximal femoral fracture on the paretic side. Although no intracranial hemorrhage occurred, the patient developed right lower limb swelling and progressive anemia requiring red blood cell transfusion. This case illustrates that proximal femoral fractures may be overlooked in patients with acute ischemic stroke presenting after a fall, particularly when pain localization and voluntary limb movement are impaired. Systematic evaluation of the pelvis, hip, and proximal femur before thrombolysis, followed by careful monitoring for extracranial bleeding after treatment, is important.