SOS! STEMI OR STROKE? Therapeutic dilemmas in the simultaneous treatment approach of the STEMISTROKE- PULMONARY EMBOLISM triad in a patient with occipital meningioma

Introduction: Both acute myocardial infarction with ST-segment elevation (STEMI) and ischemic stroke are two pathologies with a time-limited therapeutic window, being burdened by numerous complications and having a poor prognosis without a prompt therapeutic intervention. The simultaneous or rapid-sequence occurrence of stroke and STEMI is explained by multiple mechanisms, the consensus being that, in most cases, myocardial infarction is the one that precedes the cerebral infarction. The simultaneous therapeutic approach of the two diseases is rarely found in clinical practice. Usually, the first diagnosed condition is approached by the standard treatment, according to current guidelines. However, a preferential intervention in one infarcted area to the detriment of the other can lead to irreversible sequelae and even death. The presence of a concomitant neurological tumor (meningioma) represents an additional challenge, because thrombolysis, as a standard treatment for acute stroke, become totally contraindicated. In addition, neurological pathology significantly increases the pro-thrombotic risk, both directly (prolonged bed rest, hemiplegia-consequences of stroke) and indirectly (procoagulant status caused by the tumor).

Case presentation: A 64-year-old patient, hypertensi-ve, with poor therapeutic and dietary compliance, presents for recently installed chest pain and progressive dyspnea, accompanied by headache and feeling of pressure in the occipital area. The patient was hemodynamically stable at admission (BP = 110/70 mmHg, HR = 80 / min). However, the ECG reveals a suggestive aspect for infero-posterior STEMI, the coronary angiography performed in emergency showing an acute thrombotic occlusion of LCX I, with TIMI 0 distal flow, a reason for which a DES 3.0 / 38 mm stent was implanted, obtaining a post-procedural TIMI 3 flow. A few hours later, the patient suddenly installed total motor deficit with loss of strength, doubled by expression and comprehension disorders, the patient being susbsequently transferred to the Neurology Clinic. Cranio-cerebral CT scan highlighted right acute fronto-insular ischemic stroke, but also a tumoral formation at the left suboccipital level, with a suggestive appearance of meningioma. Thrombolysis with alteplase for acute ischemic stroke was not performed in the context of the presence of CNS tumor (absolute contraindication). In addition, due to the worsening of dyspnea, thoracic angio-CT revealed moderate thrombosis in the right branch of the pulmonary artery. After the initiation of anticoagulant and dual antiplatelet therapy, a slightly favorable evolution was observed. Three months later the patient underwent a tumor resection intervention, with a subsequent improvement in functional status.

Particularity: The peculiarity of the case is given by the extremely rare association of some very severe cardiovascular and neurological pathologies. Basically, STEMI, stroke and pulmonary embolism (PE) are among the top causes of mortality worldwide, their therapeutic approach can not be performed independently, according to the guidelines dedicated to each pathology, but requiring a multidisciplinary approach in a narrow temporal therapeutic window. The presence of meningioma is a therapeutic challenge per se, especially since it has a compressive, mass effect, on structures of vital importance (brainstem), but also being an inducer of procoagulant status. MRI exploration of the brain tumor was also delayed due to the presence of the DES stent, while the tumor biopsy being delayed in the context of anticoagulant treatment for recent PE. The diagnostic succession determined a standard therapeutic approach in the case of STEMI (angioplasty with stent implantation), while for the stroke a conservative attitude was chosen. The impossibility of thrombolysis, absolutely contraindicated in the presence of a CNS tumor, prevented a rapid improvement of the patient’s functional status (remaining bedrest), aspects that contributed to the appearance of PE.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)