Cerebral Aneurysm Rupture after r-TPA Thrombolysis for Acute Myocardial Infarction A. Lagares,* P.A. Go ´ mez,* R.D. Lobato,* J.F. Ale ´n,* J. Campollo,** and J. Benito–Leo ´n† *Neurosurgical Service and **Neuroradiological Service, Hospital 12 de Octubre, Madrid, Spain, †Neurological Service, Hospital General de Mo ´stoles, Madrid, Spain Lagares A, Go ´ mez PA, Lobato RD, Ale ´n JF, Campollo J, Benito– Leo ´ n J. Cerebral aneurysm rupture after r-TPA thrombolysis for acute myocardial infarction. Surg Neurol 1999;52:623– 6. BACKGROUND Intracranial hemorrhage is the most dreaded risk of thrombolytic therapy for acute myocardial infarction be- cause of the high mortality and disability rates associated with this complication. Brain structural lesions may pre- dispose a patient to bleeding. To date, aneurysm rupture has not been described as a complication of such therapy. CASE DESCRIPTION A 66-year-old hypertensive woman was admitted because of chest pain. Myocardial infarction was diagnosed and fibrinolytic therapy with recombinant tissue plasminogen activator (r-TPA) was initiated. Eight hours after admis- sion she became unconscious. Brain computed tomogra- phy scan showed subarachnoid hemorrhage, and a cere- bral arteriography showed an anterior communicating artery aneurysm. Because of her poor clinical condition treatment was postponed. Death occurred 7 days later because of multiorgan failure. CONCLUSIONS Cerebral aneurysms should be considered as a possible contributing factor to intracranial bleeding after throm- bolytic therapy. © 1999 by Elsevier Science Inc. KEY WORDS Thrombolysis, myocardial infarction, cerebral aneurysm, subarachnoid hemorrhage. M yocardial infarction, for which thrombolysis has proved to be a very effective treatment, diminishing death rates and improving patients’ re- covery, is one of the leading causes of death in developed countries. Intracranial hemorrhage is the most dreaded risk of thrombolytic therapy for acute myocardial infarction because of the high mortality and disability rates associated with this complication. Several factors such as age, gender, hypertension, or previous central nervous system disease [3–5,10,11] have been related to an in- creased bleeding risk after thrombolytic therapy. On the other hand, brain structural lesions may also predispose a patient to bleeding. Amyloid an- giopathy and arteriovenous malformations [9,11] are the only structural lesions that have been re- ported in association with this complication. To our knowledge cerebral aneurysm rupture has not been previously described as a complication of r-TPA thrombolysis. We present a case of a patient who suffered rupture of an anterior communicating ar- tery aneurysm during r-TPA thrombolysis. Case Report A 66-year-old hypertensive woman was admitted to another hospital because 4 hours before she had noticed central chest pain radiating to the inter- scapular area, neck, and left arm, accompanied by nausea and vomiting. On examination, pulse rate was 60 and blood pressure 105/60 mmHg. An ECG was compatible with a posterior myocardial infarc- tion. She was given 100 mg of recombinant tissue plasminogen activator (r-TPA) and heparin perfu- sion was initiated. Eight hours after admission she suddenly became unconscious. The patient was intu- bated and heparin was withdrawn. A brain computed tomography (CT) scan showed massive subarach- noid hemorrhage (Fisher grade III), intraventricular hemorrhage, and a frontobasal interhemispheric hematoma (Figure 1). With the suspicion of a rup- tured anterior communicating artery aneurysm the patient was transferred to the ICU at our hospital. On admission, the patient was comatose but re- sponded to pain; the pupils were reactive and equal. A four-vessel cerebral angiogram demonstrated an Address reprint requests to: Dr Go ´ mez, Hospital 12 de Octubre, Car- retera de Andalucı ´a km. 5.400, 28041 Madrid, Spain. Received June 7, 1999; accepted June 29, 1999. © 1999 by Elsevier Science Inc. 0090-3019/99/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0090-3019(99)00147-0