Thrombolysis and percutaneous coronary intervention in cardio-cerebral ischemia: A case for a combined strategy

Abstract

Co-occurrence of acute ischemic stroke and acute myocardial infarction, named concomitant cerebrocardiac infarction, is a rare yet critical medical challenge. Optimal management strategies remain undefined, particularly for ST-segment elevation myocardial infarction. This editorial discusses a case report by Zheng and Liu, where a 27-year-old male with simultaneous acute transmural anterior myocardial infarction and acute ischemic stroke was treated with urgent thrombolysis followed by elective percutaneous coronary intervention. We offer a perspective on the rationale behind this combined approach, discussing the delicate balance of addressing acute stroke and myocardial infarction. This commentary highlights the critical need for further research and clinical discussion to develop evidence-based strategies for optimal patient care in these complex, time-sensitive cases, encouraging critical evaluation of current practices.

Key Words: Acute myocardial infarction; Acute ischemic stroke; Percutaneous coronary intervention; Thrombolysis therapy; Cerebrocardiac infarction

Core Tip: Management of concomitant cardio-cerebral infarction requires balancing the need for rapid reperfusion in both stroke and myocardial infarction; this editorial discusses a case using initial thrombolysis and subsequent percutaneous coronary intervention to address this complexity. It emphasizes the need for clear, evidence-based protocols and calls for further research to support timely and effective interventions in complex, high-risk situations to improve patient outcomes.

INTRODUCTION

Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are life-threatening medical emergencies that require timely intervention to avoid poor outcomes. The co-occurrence of these conditions, termed concomitant cerebrocardiac infarction (CCI), involves either simultaneous (synchronous) or sequential (metachronous) infarctions in the cerebral and coronary vascular territories. This phenomenon, though rare, was initially defined by Omar et al[1] in 2010. The reported incidence of CCI is approximately 0.009%, with an even lower occurrence rate among young individuals[2]. Optimal management strategies for concurrent AIS and AMI remain undefined, particularly for ST-segment elevation myocardial infarction (MI). Currently, there are no established evidence-based guidelines or comprehensive clinical studies to guide effective treatment[3]. This report discusses the case of a 27-year-old male who experienced simultaneous acute CCI, highlighting the use of urgent thrombolysis followed by elective percutaneous coronary intervention (PCI) as a relatively appropriate management strategy[4].

SUMMARY OF THE CASE

Zheng and Liu[4] described a 27-year-old man admitted to the emergency department after suddenly losing consciousness, experiencing right hemiplegia, and exhibiting dense aphasia. He was diagnosed with both acute transmural anterior MI and AIS simultaneously. Initial treatment involved urgent thrombolysis followed by elective PCI. An electrocardiogram showed ST-segment elevation in leads V1-V5, indicating anterior MI. Brain computed tomography scans showed no signs of acute ischemic lesions or bleeding. After thrombolysis, his condition improved, with partial recovery of limb strength and speech. Diffusion-weighted magnetic resonance imaging identified ischemic changes in the right frontal lobe and both parietal lobes. Coronary angiography found a 100% blockage of the mid-left anterior descending artery, which was treated with PCI. Two years after treatment, he returned to normal daily activities with only minor residual hypesthesia.

COMBINED TREATMENT APPROACH

Rationale for thrombolysis first

Zheng and Liu[4] discuss thrombolysis performed with recombinant tissue plasminogen activator (tPA). Although guidelines for managing CCI are lacking, rapid reperfusion remains critical for treating AIS and AMI, as noted in the literature[5]. A recent case series by Chong et al[5] found that 40% of CCI patients who were administered IV tPA achieved an excellent modified Rankin scale score at the three-month follow-up. This result was observed despite three patients having proximal large vessel occlusions and two presenting significantly high National Institute of Health Stroke Scale (NIHSS) scores[5]. However, careful interpretation is required, given the retrospective nature of the evidence and the potential risk of biases in case series.

While some guidelines state that a recent AMI within the last three months poses a relative contraindication for IV tPA during an acute stroke, both the Safe Implementation of Thrombolysis in strokemonitoring study registry and the simplified management of acute stroke study have shown comparable outcomes for patients receiving IV tPA, irrespective of their AMI history[6-8]. Immediate thrombolysis as the primary treatment for both AIS and AMI can be selected due to the advantages of early IV tPA administration[9]. For AIS, this approach resulted in favorable functional outcomes despite elevated NIHSS scores, and for AMI, it outperformed placebo when given right after symptom onset[5].

Rationale for delayed PCI

Although PCI is the recommended approach for AMI, postponing it in simultaneous CCI cases is advisable. A key reason for this delay is the heightened risk of hemorrhagic complications associated with dual antiplatelet therapy during and after the procedure[10]. In the stent anticoagulation restenosis study, the rates of major hemorrhagic complications ranged from 1.8% to 6.2% among patients receiving various antithrombotic treatments[11]. Furthermore, the PLATO trial indicated an incidence of intracranial hemorrhage between 0.19% and 0.34% in patients on different antiplatelet regimens[12]. These studies provide significant evidence to support delayed PCI in simultaneous CCI.

Balancing risks and benefits

There are multiple factors to evaluate before choosing treatment options for CCI patients. These factors include the occlusion’s location in the heart and brain, as well as the responsiveness of cardiologists and neurointerventionists[2]. Recent literature indicates that immediate thrombolysis is the preferred initial treatment due to its advantages in enhancing AIS and AMI[13]. However, physicians must assess the possible risks of performing thrombolysis initially in patients with inferior ST-segment elevation MI, low ejection fraction, and hemodynamic instability, as these conditions suggest the need for early revascularization[2].

In this case report, the high NIHSS score, stable hemodynamic status, and lack of chest pain highlighted the importance of immediate thrombolysis in improving neurological deficits. This improvement wouldn’t have been achievable with the initial PCI due to the risk of hemorrhagic complications. Instead, a delayed elective PCI using drug-eluting stents successfully restored the completely occluded coronary circulation.

IMPLICATIONS AND FUTURE DIRECTIONS

Managing simultaneous CCI presents a complex clinical challenge, requiring a strategy that addresses cerebral and cardiac infarctions. The absence of definitive guidelines or clinical trials underscores the need for individualized treatment approaches. In this case, the decision to proceed with urgent thrombolysis followed by elective PCI was influenced by the need to urgently address the AIS while considering the risks and benefits of immediate PCI in the context of thrombolysis. The successful outcome in this case supports the feasibility of this approach in carefully selected patients. However, the optimal therapeutic strategy for synchronous acute CCI remains an area for further investigation. Future studies should focus on identifying patient subgroups that may benefit from specific treatment sequences, such as direct thrombectomy followed by PCI in patients with major artery occlusion.

CONCLUSION

The case reported by Zheng and Liu[4] highlighted the complexity of managing simultaneous CCI. While immediate thrombolysis offers advantages in treating both AIS and AMI, the decision to proceed with delayed elective PCI balances the risks of hemorrhagic complications. Individualized treatment strategies are crucial, and further research is essential to determine the optimal management of CCI and improve patient outcomes.