Recurrent Embolization During Intravenous Administration of Tissue Plasminogen Activator in Acute Cardioembolic Stroke

Treatment with recombinant tissue plasminogen activator (rt-PA) has been applied in acute cardioembolic stroke to reopen the occluded vessel and improve the patient's neurologic deficit. However, the effect of this therapy on intracardiac thrombus has not been documented previously. A forty-five-year-old man with dilated cardiomyopathy developed acute cardioembolic stroke with disturbance of consciousness, right hemianopia, right hemiplegia, and global aphasia. Cerebral angiography demonstrated occlusion of the left middle cerebral artery trunk. Intravenous administration of 30 megaunits (MU) of recombinant tissue plasminogen activator was commenced two hours after the ictus and completed within sixty minutes. Cerebral angiography was repeated just after this treatment and demonstrated a new occlusion of the left intracranial internal carotid artery along with occlusion of a branch of the left external artery. The authors subsequently performed two-dimensional echocardiography and found a mobile thrombus in the left ventricle. In patients with intracardiac mobile thrombi, recombinant tissue plasminogen activator seems to accelerate breakup or detachment of the thrombi and subsequent recurrent embolization. Therefore, it seems better to pay attention to the presence of mobile intracardiac thrombus before commencing intravenous infusion of rt-PA.