A25-22 Cardio-Cerebral Infarction: Navigating Dual Reperfusion in a Race Against Time

Abstract Introduction Simultaneous presentation of an Acute Ischemic Stroke and Acute Coronary Syndrome represent represents a rare but critical therapeutic dilemma. The optimal sequencing of reperfusion strategies remains unclear, as interventions for one condition may exacerbate the other. Case Presentation A 66-year-old female with a medical history significant for hypertension and paroxysmal atrial fibrillation (not on anticoagulation) presented with acute-onset left-sided weakness one hour prior to arrival. NIHSS score was 15. CTA head revealed a right M2 superior division occlusion and moderate (50-69%) stenosis at the origin of the RICA. CT perfusion demonstrated a small penumbra. TNK was administered within the therapeutic window. During transport to the CT scanner, the patient developed chest pain. EKG demonstrated anterior ST-segment elevations with reciprocal inferior ST depressions, and troponin levels were elevated to 10,000 ng/L. STEMI code called, decision was made for TNK administration given the dual indication for acute ischemic stroke and STEMI. Repeat EKG post-TNK showed improvement in ST elevations. The patient was transferred to our hospital for neurointervention; angiography demonstrated a right M1 occlusion. Mechanical thrombectomy achieved TICI 3 reperfusion. The patient was successfully extubated the following day with notable improvement in left-sided strength. A multidisciplinary discussion ensued regarding antithrombotic management, particularly the timing of aspirin and anticoagulation for atrial fibrillation. Neurology recommended MRI brain prior to initiating anticoagulation. Serial head CTs over two days were inconclusive for hemorrhagic transformation; aspirin was resumed. The patient experienced recurrent episodes of atrial fibrillation with RVR, managed initially with intravenous amiodarone, followed by rate control using intravenous metoprolol (10 mg Q4Hours), and later transitioned to her home dose of metoprolol 100 mg twice daily. On hospital day 3, MRI revealed stable stroke, no hemorrhagic conversion. After interdisciplinary consultation among neurology, cardiology, and critical care teams, intravenous heparin infusion was initiated. Coronary angiography on day 5 revealed a critical LAD lesion successfully stented with a drug-eluting stent. She started dual antiplatelet therapy and guideline-directed medical therapy for newly diagnosed HFrEF. The patient was discharged with no residual left-sided weakness. Discussion Concurrent cardio-cerebral infarction challenges clinicians to balance rapid reperfusion with hemorrhagic risk. Limited evidence and absence of standardized protocols necessitate individualized, multidisciplinary decision-making. This case underscores the importance of integrated neurologic, cardiologic, and critical care collaboration in managing simultaneous ischemic events. Broader registry data and multicenter studies are needed to develop unified algorithms for thrombolysis, antithrombotic timing, and procedural sequencing in dual vascular emergencies. This abstract is funded by: None