Management of Acute Ischemic Stroke in a Patient with a Past History of Intracranial Hemorrhage

Intravenous thrombolysis remains the gold standard in the management of acute ischemic stroke if the patient presents within the window period. Endovascular thrombectomy is another line of therapy in selected cases. Nonetheless, one of the most devastating complications of IV thrombolysis is intracranial hemorrhage (ICH); in such cases, the previous history of ICH is considered a potential contraindication to thrombolysis. Evidence regarding the safety of thrombolysis administration in patients with a previous history of ICH is scarce. We encountered a patient with acute ischemic stroke with a past history of hypertensive ICH. A 59-year-old female, presented with complete right-sided body weakness, global aphasia and gaze preference. A computed tomography (CT) brain perfusion scan revealed a mismatch suggestive of left middle cerebral artery (MCA) ischemic stroke. The patient received intravenous thrombolysis and showed significant clinical improvement with no subsequent complications or ICH. In reporting this case, we aim to provide evidence supporting the safety of thrombolytic therapy in selected cases with a previous history of ICH when no alternative line of management is available.


Introduction
Despite the recent labeling of a history of intracranial hemorrhage (ICH) as a potential contraindication of intravenous thrombolysis in acute ischemic stroke Neuroscience & Medicine management guidelines, evidence regarding its clinical safety is still limited. We report a rare case that involved a new practice of managing a patient with a prior history of intracranial hemorrhage who presented with acute ischemic stroke.
From this case, we aim to provide clinical data that supports the safety of intravenous thrombolysis in selected cases of patients with a past history of intracranial hemorrhage, who present later with acute ischemic stroke, and who are deemed unfit for thrombectomy. Early administration of intravenous thrombolysis can be justifiable in similar cases, resulting in significant favorable outcomes.

Case Presentation
We report a case of a 59-year-old right-handed, Saudi female who presented to the emergency department with acute complete right-sided body weakness and inability to speak for 30 minutes' duration. Her past medical history was remarkable for diabetes, hypertension, dyslipidemia, and left basal ganglia bleed one year prior to this presentation, followed by complete recovery (Figure 1).

Discussion
Acute ischemic stroke (AIS) continues to be a major disease burden resulting in myriad neurological deficits, depending on the degree of arterial occlusion [1].
Acute ischemic stroke is a heterogeneous spectrum of sudden neurological deficits resulting from a vascular occlusion to the brain, spinal cord or retina [2].
Evidence has shown that IV thrombolysis can lessen the extent of neurological damage if administered within the window before complete infarction occurs [1]. Intravenous thrombolysis remains the most approved line of therapy in   [7]. Results in the National Institute of Neurologic Disorders (NINDS) trials, using (rt-PA), recorded 11% -15% absolute benefit regardless of the increased risk of symptomatic ICH (SICH) [8]. The rate of developing total ICH following IV thrombolysis, according to NINDS trial, is 10%, including both SICH and fatal ICH. A similar percentage has been found in other prospective studies. The rate of ICH may be affected by the time of administering thrombolytic therapy, its type and dose, the CT findings of hypodensity, and the current use of anticoagulant or anti-platelets agents [9]. Other predictors include initial CT scan of early and advanced ischemic changes, cardioembolic stroke, the extent of stroke and pulse pressure [9]. Although multiple studies have investigated the safety of IV thrombolysis in patients with a past history of ICH, data addressing the proper time interval between the ICH and AIS is lacking. Moreover, current evidence does not show whether it is safe in chronic ICH cases with underlying vascular abnormalities or with recurrent cases [10].

Conclusion
A past history of intracranial hemorrhage may not be an absolute contraindication for intravenous thrombolysis. In some patients, administration of IVtPA has shown tremendous clinical improvement with no significant increase in the risk of symptomatic intracranial hemorrhage, or mortality rate. Our analysis of this case, leads us to recommend that clinicians reconsider administration of IVtPA on selected patients who present with AIS and who have a previous history of ICH. Further randomized controlled trials are needed to study the safety and efficacy of thrombolysis in similar cases.

Consent
Informed consent for publication of the clinical details was obtained from the patient.

Availability of Data and Materials
Data available upon request.

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