Reversal of locked-in syndrome with anticoagulation, induced hypertension, and intravenous t-PA
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Introduction: Widespread use of intravenous tissue plasminogen activator (t-PA) for acute ischemic stroke is limited by multiple contraindications to its use.
Case report: This article describes a patient with stuttering symptoms of pontine ischemia caused by vertebrobasilar dissection who suddenly deteriorated into a locked-in state 32 hours after symptom onset. The quadriparesis was successfully reversed within 3 hours of onset with the combination of pharmacologically induced hypertension, anticoagulation, and intravenous t-PA.
Discussion: Even in the face of numerous contraindications (including hypertension, anti-coagulation, and treatment beyond 3 hours of symptom onset), intravenous t-PA can be used successfully in carefully selected cases.
- The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995). Tissue plasminogen activator in acute ischemic stroke. NEJM 1995;333:1581–1587. CrossRef
- Gasecki AP, Graffagnino C, Hachinski V. Tissue plasminogen activator in vertebral artery dissection. Can J Neurosci 1997;24:151–154.
- Derex L, Nighoghossian N, Turjman F, et al. Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection. Neurology 2000;54:2159–2161.
- Arnold M, Nedeltchev K, Sturzenegger M, et al. Thrombolysis in patients with acute stroke caused by cervical artery dissection. Arch Neurol 2002;59:549–553. CrossRef
- Leistner S, Hartmann A, Marx P, Koennecke HC. Successful thrombolytic treatment of intracranial carotid occlusion due to dissection. Eur Neurol 2001;45:284,285. CrossRef
- Rudolf J, Neveling M, Grond M, Schmulling S, Stenzel C, Heiss WD. Stroke following internal carotid artery occlusion—a contraindication for thrombolysis. Eur J Neurol 1999;6:51–55. CrossRef
- Rordorf G, Koroshetz WJ, Ezzeddine MA, Segal AZ, Buonanno F. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology 2001;55:1210–1213.
- Wojner AW, Gerami Z, Nosser EA, Shaw S, Malkoff M, Alexandrov AV. Heads down: lower head position is better in acute ischemic stroke [abstract]. Stroke 2003;34:278.
- Lewandowski CA, Frankel M, Tomsick TA, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke 1999;30:2598–2605.
- IMS Study Investigators. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 2004;35:904–911. CrossRef
- Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Systemic Review 2000;(4):CD00025.
- Schevink WI. The treatment of spontaneous carotid and vertebral artery dissections. Curr Opin Cardiol 2000;15:316–321. CrossRef
- Koch S, Romano JG, Bustillo IC, Concha M, Forteza AM. Anticoagulation and microembolus detection in a case of internal carotid artery dissection. J Neuroimag 2001;11:63–66. CrossRef
- Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. 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;282:2019–2026. CrossRef
- Rother J, Schellinger PD, Gass A, et al. Effect of intravenous thrombolysis on MRI parameters and functional outcome in acute stroke <6 hours. Stroke 2002;33:2438–2445. CrossRef
- Stapf C, Marshall RS, Mohr JP, et al. Late intra-arterial thrombolysis. Eur J Med Res 2000;5:303–306.
- Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ. Intra-arterial thromblytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke 1988;19:1216–1222.
- Brandt T, von Kummer R, Muller-Kuppers M, Hacke W. Thrombolytic therapy of acute basilar artery occlusion. Variables affecting recanalization and outcome. Stroke 1996;27:875–881.
- Reversal of locked-in syndrome with anticoagulation, induced hypertension, and intravenous t-PA
Volume 2, Issue 3 , pp 296-299
- Cover Date
- Print ISSN
- Online ISSN
- Humana Press
- Additional Links
- vertebral artery
- basilar artery
- thrombolytic therapy
- locked-in syndrome
- Industry Sectors
- Author Affiliations
- 1. The Neurological Intensive Care Unit, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY
- 3. Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY