Paradoxical Ischemic Stroke Following Streptokinase Fibrinolysis in STEMI: A Cardio-Cerebral Infarction Series from a Limited-Resource Setting

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: ST-segment Elevation Myocardial Infarction (STEMI) (n=2). Intervention: Streptokinase fibrinolysis. Primary outcome: Paradoxical acute ischemic stroke (lacunar infarction) following fibrinolysis.

Q: What does this research mean for the field?

Streptokinase fibrinolysis in STEMI can precipitate paradoxical acute lacunar ischemic stroke, likely secondary to microthrombi embolization. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Wilbert Huang; Ryzufar Altarif Farsal; Harold Jefferson Matthew Charlex; Hendrianus Hendrianus

doi:10.30701/ijc.2135

October 25, 2026Indonesian Journal of CardiologyOpen Access

Paradoxical Ischemic Stroke Following Streptokinase Fibrinolysis in STEMI: A Cardio-Cerebral Infarction Series from a Limited-Resource Setting

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Key result

Streptokinase fibrinolysis is linked to rare paradoxical acute ischemic stroke in STEMI patients.

n=2

Why the study?

Ischemic stroke is a rare and paradoxical complication in patients with STEMI undergoing fibrinolysis, and its definitive diagnosis is challenging in a resource-limited setting.

Key Points

To describe two cases of paradoxical ischemic stroke occurring as cardio-cerebral infarctions following streptokinase fibrinolysis for ST-segment elevation myocardial infarction in a resource-limited setting.
Clinical evaluation and management of two patients presenting with acute STEMI who underwent streptokinase fibrinolysis in a setting lacking percutaneous coronary intervention.
Brain computed tomography (CT) imaging performed following the emergence of new-onset neurological signs during or after fibrinolytic infusion.
In the first patient presenting with inferior STEMI, acute focal neurological deficits emerged 4 hours post-fibrinolysis; brain CT showed an acute lacunar infarction in the left pons, followed by clinical deterioration and death from catastrophic multisystem bleeding.
In the second patient presenting with anterolateral STEMI, a seizure occurred during infusion, prompting immediate cessation; brain CT revealed a lacunar infarct in the left hypothalamus and right middle cerebral artery calcification, with no progression of neurological deficits.

Study Design

Type

Case Report (n=2)

Multicenter

No

Structured PICO

P

Population

2 male patients (aged 45 and 68 years) presenting with STEMI in a resource-limited setting without PCI access, treated with streptokinase fibrinolysis and followed during hospitalization.

E

Exposure

Fibrinolytic therapy with streptokinase (1.5 million units in Case 1; 270,000 units administered before termination due to seizure in Case 2) alongside dual antiplatelet loading (aspirin 325 mg and clopidogrel 400 mg in Case 1; aspirin 300 mg and clopidogrel 300 mg in Case 2) and standard medical therapy.

O

Outcome

Paradoxical acute ischemic lacunar stroke following streptokinase fibrinolysis (acute lacunar infarction in the left pons 4 hours post-fibrinolysis in Case 1; lacunar infarct in the left thalamus/hypothalamus with generalized seizures during fibrinolysis in Case 2).safety

This case series highlights that paradoxical acute ischemic lacunar stroke is a rare but serious complication of streptokinase fibrinolysis for STEMI, requiring prompt neuroimaging and individualized multidisciplinary management.

Limitations

Echocardiographic evaluation was not performed to confirm left ventricular thrombus or intracardiac shunting (e.g., patent foramen ovale)
Absence of magnetic resonance imaging (MRI) as the gold standard for lacunar stroke diagnosis
No follow-up head CT scan was performed in the second case due to financial limitations
No autopsy was performed to confirm the definitive cause of death in the first case
Small sample size of two cases limits ability to determine the definitive pathophysiologic mechanism
Echocardiographic evaluation was not performed, limiting the ability to confirm left ventricular thrombus or assess for intracardiac shunting (such as patent foramen ovale)
Absence of magnetic resonance imaging (MRI) as a gold standard for lacunar stroke diagnosis
Follow-up CT scan could not be performed in the second case due to financial limitations
No autopsy was performed to confirm the cause of death in the first case

Implication

Requires vigilance for paradoxical stroke after streptokinase in STEMI; leaves open whether microthrombi embolization explains this rare event.

Abstract

Background: Ischemic stroke is a rare and paradoxical complication in patients with ST-segment Elevation Myocardial Infarction (STEMI) undergoing fibrinolysis. Definitive diagnosis is challenging in a resource-limited setting. Case Illustration: We report two cases of STEMI treated with streptokinase fibrinolysis in a setting where Percutaneous Coronary Intervention (PCI) was unavailable. The first patient presented with an inferior myocardial infarction and developed neurological symptoms 4 hours after fibrinolysis, including acute focal neurological deficits. Brain Computed Tomography (CT) demonstrated an acute lacunar infarction in the left pons. The second patient presented with an anterolateral myocardial infarction and developed a seizure during fibrinolysis treatment, in which the treatment was immediately terminated. Brain CT revealed a lacunar infarct in the left hypothalamus and calcification of the right Middle Cerebral Artery (MCA). In both cases, the lacunar pattern of infarction raised suspicion of ischemic stroke due to embolization of microthrombi following fibrinolysis of coronary or intracardiac thrombi, with subsequent migration to the cerebral circulation. The first patient subsequently deteriorated and died due to catastrophic multisystem bleeding, whereas the second patient showed no progression of neurological deficits. Conclusions: Ischemic stroke following fibrinolytic therapy in patients with STEMI is an uncommon but serious complication that requires high clinical vigilance. Early recognition and individualized multidisciplinary management are essential to minimize neurological sequelae and optimize overall outcomes.

Discussion

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Cite This Study

Huang et al. (2026) conducted a case report in ST-segment Elevation Myocardial Infarction (STEMI) (n=2). Streptokinase fibrinolysis was evaluated on Paradoxical acute ischemic stroke (lacunar infarction) following fibrinolysis. Streptokinase fibrinolysis in 2 male STEMI patients was complicated by paradoxical acute lacunar ischemic stroke, resulting in 1 fatal multisystem hemorrhage and 1 neurological recovery.

synapsesocial.com/papers/6ae28f09cbadf70daf6c43f1 https://doi.org/10.30701/ijc.2135

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Paradoxical Ischemic Stroke Following Streptokinase Fibrinolysis in STEMI: A Cardio-Cerebral Infarction Series from a Limited-Resource Setting

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Paradoxical Ischemic Stroke Following Streptokinase Fibrinolysis in STEMI: A Cardio-Cerebral Infarction Series from a Limited-Resource Setting

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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