how to deal with cardio-cerebral infarction · clinical scenarios case ais ami recommendation 1...

HOW TO DEAL WITHCARDIO-CEREBRAL INFARCTION

Nguyen Thanh Nhut MD.

Dong Nai General Hospital

Heart Institute HCMC

CASE REPORT

• N.V.M 50 year-old male

• Risk factor:

• Hypertension: yes

• Diabetes mellitus: no

• Dyslipidemia: yes

• Smoke: no

• Family history: no

HISTORY

• A 50-year-old male presented to the emergency

department due to acute onset of left

hemiparesis and aphasia, which had started 1

hour previously.

• Suddenly, he had ventricular tachycardia while

diagnostic tests were performing, defibrillation

were performed.

LABORATORY FINDINGS

• Creatinine: 93 mol/L

• MDRD eGFR: 79 ml/min

• Na: 139 K: 3.3 mmol/L

• CRP: 59.9 mg/L

• AST: 22 ALT: 32 U/L

• Tropononin T: 279.2 → 4605 ng/L

• Hb: 14.2 g/dL Hct: 44.1%

• WBC: 8.04 K/uL Neu: 66.6%

CHEST X-RAY

ECHOCARDIOGRAPHY

• Hypokinetic septo-basal wall

• Normal heart valves

• LV: 51/39 mm

• EF: 44%

• No pericardial effusion

CT SCAN OF BRAIN - CTA

• A CT scan of the brain showed ischemic stroke in

right precentral gyrus and right occipital lobe, no

evidence of hemorrhagic.

• CT angiogram showed total occlusion right

internal carotid artery, circle of Willis was normal.

CT SCAN OF BRAIN

WHAT SHOULD WE DO NEXT?

• THROMBOLYSIS? YES OR NO?

• CORONARY ANGIOGRAM AND PRIMARY PCI?

• ENDOVASCULAR THERAPY?

STEMI ESC 2017

ED THERAPY

• Actilyse 50 mg/50mL 3.5 mL IV then 32.4 mL infusion in 1 hr

• Plavix 300 mg x 1

• Aspirin 81 mg x 2

• Crestor 10 mg x 2

• Pantoloc 40 mg IV

CLINICAL SCENARIOS

CASE AIS AMI RECOMMENDATION

1 SEVERE STROKE STEMI —> rTPA, following up with angiography and stents (IIa, AHA/SAS 2018)

2 SEVERE STROKE NSTEMI, high to very high risk

—> rTPA, following up with angiography and stents (IIa, AHA/SAS 2018)

3 SEVERE STROKE NSTEMI, low-moderate risk

—> rTPA only in acute setting

4 MODERATE-MILD STROKE

STEMI —> rTPA, following up with angiography and stents (IIa, AHA/SAS 2018)


NSTEMI, high to very high risk

—> rTPA, following up with angiography and stents (IIa, AHA/SAS 2018)


NSTEMI, low-moderate risk

—> consider rTPA

CCI TREATMENT ALGORITHM

CORONARY ANGIOGRAM

PCI RCA

JR 4.0 6F Guiding catheter Balloon 2.5x15 mm

PCI RCA

DES 3.5x43 mm

CEREBRAL ENDOVASCULAR THERAPY

STAGE PCI LAD

EBU 3.0 6F Guiding catheter Balloon 2.5x15 mm

STAGE PCI LAD

DES 3.0x40 mm

CARDIO-CEREBRAL INFARCTION

• Terminology introduced by Omar et al. in 2010.

• Definition: simultaneous appearance of both Acute Ischemic

Stroke (AIS) and Acute Myocardial Infarction(AMI)

• Rare co-occurrence.

• Findings from the Global Registry of Acute Coronary Event

(GRACE) trial reported an incidence of in-hospital stroke as

0.9% in a cohort of patients presenting with acute coronary

syndrome, and the incidence was much higher in patients

with STEMI than the non-STEMI.


• Acute ischemic stroke (AIS) and acute myocardial

infarction (AMI) are both life-threatening medical

conditions with narrow therapeutic time-window

that carry grave prognosis.

• A delayed intervention of one infarcted territory

for the other may result in permanent irreversible

morbidity or disability, and even death.


• Intravenous thrombolysis, approved for the acute

management of both conditions has been suggested as

the best approach to the treatment of simultaneous CCI if

there is no contraindication, and both presentations are

within the time frame for the administration of a

thrombolytic

• A combined endovascular approach with the use of PCI for

AMI and thrombectomy devices for AIS have been

suggested

CONCLUSION

• Very rare co-occurrence 0.9%

• No clear evidence-based guidelines

• Team work: Heart Team, Stroke Team and ED Team

• Individualization in management: timing (hyperacute, acute),

severity of AIS (severe, moderate, low), type of ACS (STEMI,

NSTEACS), hemodynamic (stable, instable) in reperfusion

therapy, Thrombolysis, PCI, cerebral endovascular therapy

• Antiplatelet: DAPT or MAPT based on hemorrhagic conversion

REFERENCES

1. Naruchorn Kijpaisalratana1, Aurauma Chutinet1,2 and Nijasri C. Suwanwela1,2*

Chulalongkorn Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand, 2

Faculty of Medicine, Department of Medicine, Division of Neurology, Chulalongkorn

University, Bangkok, Thailand:Hyperacute simultaneous cardiocerebral infarction: rescuing

the Brain or the Heart First. PersPective published: 07 December 2017 doi:

10.3389/fneur.2017.00664

2. Oluwaseun A. Akinseye, Muhammad Shahreyar, Mark R. Heckle, Rami N. Khouzam:

Simultaneous acute cardio-cerebral infarction: is there a consensus for management. Annals

of Translational Medicine, Vol 6, No 1 January 2018

3. Po-Jung Yuan and Wai-Kin Wong: Acute Myocardial Infarction and Concomitant Stroke as the

Manifestations in a Patient with Type A Aortic Dissection: A Case Report with Three Years of

Follow-Up. Acta Cardiol Sin 2018;34:104107

4. Truong Quang Binh MD, PhD, FSCAI University Medical Center University of Medicine and

Pharmacy at HCMC: Management of acute cardio-cerebral infarction. TSC 2019

how to deal with cardio-cerebral infarction · clinical scenarios case ais ami recommendation 1...

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