Dual antiplatelet therapy in a patient with simultaneous aneurysmal subarachnoid hemorrhage and myocardial infarction
- Department of Neurosurgery, Sina Hospital, Tehran, Iran.
- Tehran Heart Center, Department of Interventional Cardiology, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Neurosurgery, Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
Department of Neurosurgery, Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
DOI:10.25259/SNI_472_2019Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Abolghasem Mortazavi, Sina Jelodar, Keyvan Edraki, Sima Narimani, Mohammad Ghorbani, Koroush Karimi-Yarandi, Sina Asaadi. Dual antiplatelet therapy in a patient with simultaneous aneurysmal subarachnoid hemorrhage and myocardial infarction. 21-Mar-2020;11:49
How to cite this URL: Abolghasem Mortazavi, Sina Jelodar, Keyvan Edraki, Sima Narimani, Mohammad Ghorbani, Koroush Karimi-Yarandi, Sina Asaadi. Dual antiplatelet therapy in a patient with simultaneous aneurysmal subarachnoid hemorrhage and myocardial infarction. 21-Mar-2020;11:49. Available from: https://surgicalneurologyint.com/surgicalint-articles/9920/
Background: Electrocardiography (ECG) changes after subarachnoid hemorrhage (SAH) are well described. However, concurrent myocardial infarction (MI) and SAH are rarely reported, and its management remains a dilemma. We report a patient with traumatic SAH concurrent with acute MI that managed successfully by endovascular intervention and dual antiplatelet therapy.
Case Description: A 47-year-old man was admitted to the emergency department with a complaint of severe headache. Diffuse SAH, with a Hunt and Hess score of 5, was noticed. ECG showed ST elevation in anterior leads, and cardiac troponin became positive. On brain computed tomography angiogram, a 6 mm anterior communicating artery aneurysm was seen. Considering the possibility of MI and SAH simultaneously, endovascular obliteration of the aneurysm was done, and then, the patient received dual antiplatelet medications until coronary angiography was done. Coronary angiography revealed normal epicardial coronary arteries. The patient was discharged with a Glasgow Coma Scale score of 15 and was visited 2 months after discharge without any new episodes of intracranial hemorrhage with a modified Rankin scale score of 2.
Conclusion: Cerebral aneurysm coiling could be considered as the first choice of treatment in the case of acute MI with hemodynamic stability, before carrying out cardiac endovascular intervention or antiplatelet medication to reduce the risk of rebleeding from a brain aneurysm.
Keywords: Antiplatelet therapy in subarachnoid hemorrhage, Myocardial infarction, Subarachnoid hemorrhage
Electrocardiography (ECG) and echocardiographic changes such as nonspecifc ST deviations, T-wave inversion, prolonged QT interval, and transient segmental hypokinesis of the left ventricular wall frequently report in accompany with subarachnoid hemorrhage (SAH). However, the association between SAH and acute myocardial infarction (MI) is rarely reported.[
We report a patient with traumatic SAH concurrent with acute MI that managed successfully by endovascular intervention and dual antiplatelet therapy.
A 47-year-old cocaine-addicted man with a history of severe headache following falling was referred to the emergency department with a complaint of decreased level of consciousness and intubated with a Glasgow Coma Scale (GCS) score of 4. No lateralizing signs were observed, and the pupils were symmetrical and midsize. Brain computed tomography (CT) scan showed diffuse SAH with a Hunt and Hess score of 5 and the World Federation of Neurosurgical Societies (WFNS)
Brain CT angiogram that performed after admission of the patient to the neurosurgical intensive unit, revealed a 6 mm AComA aneurysm. Single antiplatelet therapy was started on the 1st day after the ictus with no new episode of rebleeding from the AComA aneurysm. Given the evidence of SAH and aneurysm on CT, the administration of dual antiplatelet drugs and anticoagulants imposed a high risk of rebleeding and deteriorating neurologic condition on our patient. Therefore, considering the stability of our patient’s hemodynamic, we decided to close the aneurysm first. Cerebral angiography was performed to obtain anatomical data required for endovascular treatment [
After successful endovascular closure of brain aneurysm, dual antiplatelet therapy was started with no evidence of rebleeding on follow-up brain CT. The patient underwent coronary angiography that revealed normal epicardial coronary arteries that result in discontinuing antiplatelet therapy. Five days later, the patient was discharged with a GCS score of 15 and was visited 2 months after discharge without any new episodes of intracranial hemorrhage and modified Rankin scale score of 2.
SAH can be associated with ECG changes.[
It is reported that elevated cardiac markers may be seen in patients with SAH.[
A review of the literature showed only three cases of concomitant MI and SAH in patients with a decreased level of consciousness.[
Nagahama et al. showed that treatment with an antiplatelet agent led to a decrease of vasospasm and poor outcome. Their results strongly suggest that antiplatelet reduces the risk of clinical vasospasm in patients with SAH without an increased risk of hemorrhagic complications.[
According to our experience, cerebral aneurysm coiling could be considered as the first choice of treatment in the case of confronting the possibility of MI and hemodynamic stability, before carrying out cardiac endovascular intervention or antiplatelet medication to reduce the risk of rebleeding from a brain aneurysm, and it should be performed in the first 72 h after the ictus. We followed this treatment strategy successfully, and our patient did not have any evidence of vasospasm. However, further studies with more patients are needed to identify actual outcomes and potential risks.
Discontinuation of life-saving anti-thrombotic agents or life-threatening worsening of neurological conditions without discontinuing these medications is a challenge in the management of myocardial infarction coincidence with subarachnoid hemorrhage. Our experience provides a suggestion that proceeding with anti-thrombotic agents after invasive management of brain pathology might show promising results.
1. Bárcena JP, Rota JI, Ramírez JH, Sala MF, Juve JI. Subarachnoid hemorrhage and acute myocardial infarction. Intensive Care Med. 2000. 26: 1160-1
2. Davies KR, Gelb AW, Manninen PH, Boughner DR, Bisnaire D. Cardiac function in aneurysmal subarachnoid haemorrhage: A study of electrocardiographic and echocardiographic abnormalities. Br J Anaesth. 1991. 67: 58-63
3. Deshpande A, Birnbaum Y. ST-segment elevation: Distinguishing ST elevation myocardial infarction from ST elevation secondary to nonischemic etiologies. World J Cardiol. 2014. 6: 1067-79
4. Horowitz MB, Willet D, Keffer J. The use of cardiac troponin-I (cTnI) to determine the incidence of myocardial ischemia and injury in patients with aneurysmal and presumed aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien). 1998. 140: 87-93
5. Nagahama Y, Allan L, Nakagawa D, Zanaty M, Starke RM, Chalouhi N. Dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage: Association with reduced risk of clinical vasospasm and delayed cerebral ischemia. J Neurosurg. 2018. 129: 702-10
6. Sommargren CE, Zaroff JG, Banki N, Drew BJ. Electrocardiographic repolarization abnormalities in subarachnoid hemorrhage. J Electrocardiol. 2002. 35: 257-62
7. Tan JH, Uddin A, Fernandez JP. Concurrent subarachnoid haemorrhage and ST elevation myocardial infarction. JRSM Open. 2017. 8: 2054270416685207-
8. Tung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton MT. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004. 35: 548-51
9. van der Velden LB, Otterspoor LC, Schultze Kool LJ, Biessels GJ, Verheugt FW. Acute myocardial infarction complicating subarachnoid haemorrhage. Neth Heart J. 2009. 17: 284-7
10. Zouaoui A, Sahel M, Marro B, Clemenceau S, Dargent N, Bitar A. Three-dimensional computed tomographic angiography in detection of cerebral aneurysms in acute subarachnoid hemorrhage. Neurosurgery. 1997. 41: 125-30