Address for Correspondence
Dr. V.Udaya Bhaskaran, Associate Professor, Department of Medicine, Calicut Medical College
E-Mail:nithinub@sancharnet.in 

Abstract

Infarctions involving two different vascular territories is a rare phenomenon. This is a case report of  two infarctions which occurred possibly simultaneously in two different vascular territories in a 40 year old male.

Keywords: Cerebral Infarction,Thalamic Syndrome, Occipital Lobe Syndrome, Myocardial Infarction, Thrombolysis,

Introduction

Timely reperfusion is the only way to establish oxygen supply to the myocardium, so that as much muscle as possible is saved from necrosis - time is muscle theory. Since GISSI trial in 1986, thrombolytic therapy is accepted as the standard treatment in acute myocardial infarction(1). Intravenous thrombolysis is the most popular because it is relatively inexpensive and could be carried out easily even in transit inside an ambulance. Thrombolysis is also gaining momentum in the management of ischaemic stroke(2,3,4,5). Regarding Intravenous (IV) thrombolysis, the NINDS study (1995) established the efficacy of 0.9 mg/kg of rtPA in patients treated within 3 hours, without causing any excess mortality. In the part 2 of this trial, the good outcome rate is 39% (vs 26% in the placebo group) and the parenchymal hematoma rate is 7%. What happens If infarctions co-exists in brain and heart?

Case Report

We present a case of a 40-year-old male from Malappuram , asymptomatic till 30th of July 2003. At around 12 noon he was found unconscious in the bed. There was profuse sweating also. He was taken to a local hospital where an ECG showed features of acute inferior wall infarction with complete heart block. (Fig.1, 2, 3). 

Fig.1, 2, 3 [Click to Enlarge]

He was thrombolysed immediately with streptokinase. ECG taken after thrombolysis showed accelerated idioventricular rhythm, which later got corrected to sinus rhythm possibly due to reperfusion. Next day when he regained consciousness it was observed that he has clumsiness of right hand. The hand over shoots when he tried to take food to mouth. He needed support to stand and tended to fall to right side. He was unable to see objects on the right side of the visual field. There were visual hallucinations in the form of flashes of bright light and formed objects and persons. There was no seizures or cranial symptoms. No sensory symptoms were noted at that time. At this point a CT head was taken, which showed hypo dense lesion involving left parieto occipital and medial temporal lobes and thalamus. Hyper density was noted in the anterior aspect of the infarct , suggestive of haemorrhage into the infarct. ( Fig.4) .

Fig.4 CT head showing hypo dense lesion involving left parieto occipital and medial temporal lobes and thalamus. Hyper density was noted in the anterior aspect of the infarct , suggestive of haemorrhage into the infarct.

Patient was discharged on aspirin and clopidogrel. Over the next week patient's level of consciousness deteriorated progressively and he developed urinary incontinence. He was referred to our hospital and on admission he was drowsy and was unable to recognize relatives. Vital signs were normal. His general condition improved with mannitol and dexamethasone. Three days after admission patient regained consciousness He was alert , co-operative and had a good rapport with Doctors. There was no hallucination or delusion. He had insight into his present illness. He was oriented in time and person. Judgment was good and long-term memory was intact. Memory registration was intact but recall was defective. He had a forward digit span of 4.

Patient was right handed. He had a Mini Mental Scale Examination ( MMSE) score of 18/30.Speech was fluent and well articulated, without any paraphasia or neologism. Comprehension was preserved and repetition was normal. There was alexia without agraphia i.e. visual agnosia for words.

He had prosapagnosia i.e. was unable to identify pictures of famous persons and animals. He had occipital lobe involvement in the form of right homonymous hemianopsia, visual object agnosia, central achromatopsia and prosapagnosia.(6,7) There were no simultagnosia or visual anosognosia , nor features of Balint syndrome. Other cranial functions were normal. In the motor system bulk was normal on both sides. Tone was reduced in right upper and lower limbs. When movement is attempted using right hand it went into a writhing movement with abnormal posturing.(Fig.5).

Fig.5 Abnormal posturing when movement was attempted.Face masked to maintain privacy.

Tendon jerks were brisk on right side. Abdominal and cremasteric reflexes were absent on right side. Plantar was extensor on right, normal on other side. Touch position and vibration sense were impaired on right. Pain was preserved with hyperaestheia on stoking the skin. There were dysmetria and finger nose and heel knee incordination on right side. Romberg sign was positive.(8) Other systems were normal. Routine investigations done in the hospital were normal. CT scan of the head was repeated (Fig.6) which showed increase in haemorrhage, compared to previous infarction involving mainly left occipital lobe, and extending to thalamus, explaining the features of thalamic syndrome and occipital lobe syndrome present in this person. Colour Doppler echo cardiogram revealed no regional wall motion abnormalities or intracardiac clot.

The patient survived both insults and was discharged with residual disability.

(Fig.6) CT scan of the head which shows increase in haemorrhage, compared to previous infarction involving mainly left occipital lobe, and extending to thalamus, explaining the features of thalamic syndrome and occipital lobe syndrome present in this person.

Discussion

In this case two infarctions occurred possibly simultaneously in two different vascular territories. Acute inferior wall infarction is documented in the ECG, which also shows complete heart block. This is considered as an indication for thrombolysis, which was undertaken promptly as the patient was hospitalized immediately. But at that time patient was unconscious. So he would have had the cerebral insult at that time and a CT head taken later did show a posterior circulation infarct with a small haemorrhage in it. One of the important complication in thrombolysis is intra cerebral haemorrhage.(9 )
From the P1 segment of the posterior cerebral artery branches are given to subthalamic nuclei, mesencephalon, thalamus and basal ganglia. Involvement of the above structures can affect level of consciousness. This patient had features suggestive of thalamic involvement in the form of loss of vibration sense on the right side, and hand movements in a writhing pattern. Even though pain sensation is normal apparently, pain persists for along time after stroking the affected area. Patient also had extensor plantar response on right side.

Patient also had most of the features of occipital lobe involvement, indicating extensive involvement. Usually large area of infarction is considered as a contra indication for thrombolysis in Cerebro Vascular Disease ( CVD ) , since there is more chance of developing haemorrhagic complications(10). The question in this case is what are the guidelines if CVD is associated with acute myocardial infarction? In NINDS and ECASS I & II Studies it was found that early administration of rtPA leads to favorable outcome in stroke even though there is an increased risk(10) of intracranial haemorrhage. Studies with streptokinase were prematurely terminated due to associated increased mortality 

References

1) GISSI study Effectiveness of Intravenous thrombolytic therapy acute myocardial infarction Lancet 1986 Feb 22; 8478: 397 - 402.

2) Clark WM, Wissman S, Albers GW: Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999 Dec 1; 282(21): 2019-26. 

3) Larrue V, von Kummer R, Del Zoppo G, Bluhmki E. Hemorrhagic transformation in acute ischemic stroke: potential contributing factors in the European Cooperative Acute Stroke Study. Stroke. 1997; 205: 327-333.

4) Hacke W, Kaste M, Fieschi C: Randomised double-blind placebo- controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998 Oct 17; 352(9136): 1245-51

5) NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous 
t- PA therapy for ischemic stroke. Stroke. 1997; 28: 2109-2118.

6) Mohr JP, Leicester J, Stoddard LT: Right hemianopia with memory and color deficits in circumscribed left posterior cerebral artery territory infarction. Neurology 1971 Nov; 21(11): 1104-13

7) Georgiadis AL, Yamamoto Y, Kwan ES: Anatomy of sensory findings in patients with posterior cerebral artery territory infarction. Arch Neurol 1999 Jul; 56(7): 835-8

8)Georgiadis AL, Yamamoto Y, Kwan ES: Anatomy of sensory findings in patients with posterior cerebral artery territory infarction. Arch Neurol 1999 Jul; 56(7): 835- 842

9) Gore, J. M., Granger, C. B., Simoons, M. L., Sloan, M. A., Weaver, W. D., White, H. D., Barbash, G. I., Van de Werf, F., Aylward, P. E., Topol, E. J., Califf, R. M. (1995). Stroke After Thrombolysis : Mortality and Functional Outcomes in the GUSTO-I Trial. Circulation 92: 2811-2818

10) Larrue V, von Kummer R, Del Zoppo G, Bluhmki E. Hemorrhagic transformation in acute ischemic stroke: potential contributing factors in the European Cooperative Acute Stroke Study. Stroke. 1997; 205: 327-333.

11) Buchan AM, Barber PA, Newcommon N: Effectiveness of t-PA in acute ischemic stroke: outcome relates to appropriateness. Neurology 2000 Feb 8; 54(3): 679-84. 

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