―Case Reports―

Hemothorax after the Intravenous Administration
of Tissue Plasminogen Activator in a Patient with
Acute Ischemic Stroke and Rib Fractures
Kazutaka Shirokane1, Katsuya Umeoka1, Masahiro Mishina2,
Takayuki Mizunari1, Shiro Kobayashi1 and Akira Teramoto3
1

Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital
2

Department of Neurological Science, Nippon Medical School
3

Department of Neurosurgery, Nippon Medical School

Abstract
A 79-year-old man experienced sudden-onset left hemiparesis and disturbance of
consciousness. Diffusion-weighted magnetic resonance imaging showed an acute ischemic
stroke in the territory of the right middle cerebral artery. He underwent systemic
thrombolysis via the intravenous administration of tissue plasminogen activator (t-PA). Chest
radiography and computed tomography performed the following day showed severe
hemothorax with atelectasis of the left lung and multiple rib fractures; the initial chest
radiogram had revealed rib fractures but we did not recognize them at the time. Conservative
treatment with the placement of chest tubes was successful, and the patient recovered
without further deterioration. Although systemic thrombolysis with t-PA is an accepted
treatment for acute cerebral ischemic stroke, posttreatment intracranial hemorrhage has a
negative effect on prognosis. Extracranial bleeding is a rare complication, and our search of the
literature found no reports of hemothorax after treatment with t-PA in patients with cerebral
ischemic stroke. We have reported a rare case of severe hemothorax after systemic
thrombolysis with t-PA. This important complication indicates the need to rule out thoracic
trauma with radiography and computed tomography of the chest.
(J Nippon Med Sch 2014; 81: 43―47)
Key words: cerebral infarction, thrombolysis, tissue plasminogen activator, hemothorax, rib
fracture

cerebral
Introduction

infarction.

improves

Although

neurological

such

treatment

1―3

severe

deficits ,

complications, such as bleeding and intracranial
Systemic thrombolysis with tissue plasminogen
activator (t-PA) is widely used to treat patients with

hemorrhage,

develop

in

some

patients

and

1

negatively affects prognosis . Extracranial bleeding

Correspondence to Kazutaka Shirokane, Department of Neurosurgery, Graduate School of Medicine, Nippon Medical
School, 1―1―5 Sendagi, Bunkyo-ku, Tokyo 113―8603, Japan
E-mail: kazutaka-shirokane@nms.ac.jp
Journal Website (http:!
!
www.nms.ac.jp!
jnms!
)
J Nippon Med Sch 2014; 81 (1)

43

K. Shirokane, et al

Fig. 1 Imaging studies performed on the day of admission.
A CT scan shows a right hyperdense middle cerebral artery sign (A) but no other
abnormalities, such as an early hypodense area. Diffusion-weighted magnetic resonance
imaging (C) reveals a hyperintense area in the territory of the right middle cerebral
artery. The T2-weighted image (D) demonstrates an old ischemic lesion without
evidence of a fresh stroke.

is a rare, life-threatening complication2,4. We report a

hyperdense middle cerebral artery (MCA) sign but

rare case of hemothorax with rib fractures after

no bleeding or early hypodense area (Fig. 1-A).

intravenous administration of t-PA

Electrocardiography

to

address

cerebral infarction.
Case Report

showed

fibrillation.

Magnetic

demonstrated

acute

partial

arterial

resonance

cerebral

imaging

infarction

in

the

territory of the right MCA (Fig. 1-B, C). We did not
note rib fractures on a chest radiogram obtained at

A 79-year-old man lost consciousness and fell. He
was admitted to our hospital 40 minutes later. At

admission (Fig. 2-A).
Cardiogenic

embolism

was

diagnosed,

and

the time of admission he manifested a disturbance of

systemic thrombolysis with t-PA (0.6 mg!
kg) was

consciousness with a Glasgow Coma Scale score of 5

performed according to Japanese guidelines 110

(E1VTM4). We noted severe left hemiparesis, and

minutes

the results of the manual muscle test for both the

consciousness improved slightly (Glasgow Coma

upper and lower extremities were 1!
5. There were

Scale score: 7, E2VTM5) the paresis showed no

no signs of bodily trauma. Because respiration was

change. There was no further deterioration of

unstable, oral intubation was performed. Computed

neurological

tomography (CT) of the brain revealed a right

administered edaravone7,8 and glycerol starting on

44

after

onset 5,6.

status

or

Although

vital

the

signs.

level

We

of

also

J Nippon Med Sch 2014; 81 (1)

Hemothorax after t-PA Treatment

Fig. 2

A chest X-ray film obtained before t-PA was administered shows a fracture of the left 7th rib (black
arrow, A). A chest X-ray film obtained 1 day after treatment with t-PA reveals a decrease in the
permeability of the left lung (B). A CT scan of the chest (C) demonstrates pleural fluid collection on the
left side, severe atelectasis of the left inferior lobe of the lung, and multiple rib fractures (white arrow).

intracranial hemorrhage, defined as any cerebral

the day of admission.
A CT scan of the brain obtained at the time of

bleeding with a clinical deterioration of more than 4

admission showed cerebral infarction in the territory

points on the National Institutes of Health Stroke

of

hemorrhagic

Scale, develops in 4%2. In Japan the reported

were

not

incidence of symptomatic intracranial hemorrhage

administered. Despite diminished breath sounds in

after the administration of t-PA (0.6 mg!
kg) is 5.8%6.

the left lung, respiratory function did not deteriorate.

Extracranial bleeding complications after treatment

Chest radiography showed a decrease in the

with t-PA has been reported in 3% of patients2 and

permeability of the left lung (Fig. 2-B), and a CT

include

scan of the chest (Fig. 2-C) revealed pleural fluid

subcutaneous hemorrhage; hematuria; or, in rare

collection on the left side with severe atelectasis of

instances,

aortic

the left inferior lobe and multiple rib fractures (Fig.

cardiac

tamponade 12 ;

the

right

transformation.

MCA

with

slightly

Anticoagulants

retroperitoneal,

gastrointestinal,

dissection9,10;
14

cardiac

rupture 11 ;

hematoma 13 ;

neck

or

spinal

hematoma15.

2-C). We reviewed the chest radiogram obtained at

epidural hematoma ;

the time of admission and now noted several rib

Extracranial bleeding does not tend to inflict critical

fractures on the left side (Fig. 2-A). Although

damage.

oxygenation was adequate with intubation, a chest

Hemothorax

after

and

subdural

treatment

with

t-PA

is

tube was introduced because of marked fluid

extremely rare; to our knowledge the only case

collection. Hemothorax was confirmed, and 700 mL

previously reported was that by Varnholt et al.16.

of fluid was drained in the course of 1 day. Eight

They

days later left-sided pneumothorax was detected,

thrombosis of the femoral and iliac veins and inferior

and another chest tube was placed for 18 days. The

vena cava in a young patient with pleuropneumonia

patientʼs condition improved, and 35 days after

who had predisposing factors for thrombophilia and

admission he was transferred to a rehabilitation

a congenital deficiency in antithrombin III. However,

clinic.

the patient did not have cerebral infarction despite

administered

t-PA

to

address

extensive

many underlying disorders. To our knowledge,
Discussion

hemothorax during thrombolysis with t-PA to treat
cerebral ischemic stroke has not been previously

Systemic thrombolysis with t-PA is an accepted
1―4

treatment for acute cerebral ischemic stroke .

reported.
Reported rates of rib fracture
19.6% ,

18

in cases of
26.8% 19.

However, among patients treated with t-PA, early

hemothorax

cerebral bleeding develops in 18%, and symptomatic

Hemothorax tends to be due to laceration of the

J Nippon Med Sch 2014; 81 (1)

are

17

52% ,

and

45

K. Shirokane, et al

pleura, the lung, or the chest wall and is usually

fractures, often do not examine chest X-ray films.

associated with rib fractures or the rupture of major

Furthermore,

20―22

mediastinal blood vessels or both

. In our patient,

aortic

dissection

had

received

widespread attention, and we took care the chest X-

exacerbated

ray but rib fractures are usually unconsidered.

bleeding from a lung contusion or a minor vascular

Because CT scans are more effective than routine

injury in the pleural space due to rib fracture. The

chest

amount of bleeding was so small that we did not

pneumothorax, hemothorax, and rib fractures29, the

detect it on the first chest X-ray film. Delayed

risk of complications after t-PA treatment can be

hemothorax has been reported in a few cases of

reduced by first performing CT to rule out rib

systemic

thrombolysis

blunt thoracic trauma

may

23―25

have

X-rays

for

detecting

lung

contusion,

fractures and hemothorax.

.

In the present case treatment with t-PA was

On the basis of our experiences in the present

curative but also induced hemothorax. Systemic

case we recommend that patients with suspected rib

thrombolysis is effective in patients with acute

fractures undergo CT of the chest. The presence or

cerebral ischemic stroke; rib fracture does not

progression of hemothorax in patients treated with

constitute a contraindication for treatment with t-

t-PA must be carefully monitored. Also, the entire

PA. However, hemothorax may be life-threatening if

body must be checked for signs of trauma before

the hematoma progresses during the administration

the start of treatment with t-PA because patients

of t-PA. Rib fracture is a predictor of severe

with a disturbance of consciousness or hemiparesis

respiratory

due to stroke are susceptible to falls and cannot

disorder

due

to

hemothorax,

and

report pain. Finally, we must remember that

attention must be paid to thoracic trauma.
Before performing systemic thrombolysis with tPA for acute cerebral infarction, we recommend a

extremities

with

fractures

occasionally

mimic

paralyzed extremities.

chest x-ray film be obtained to rule out aortic
dissection as an etiologic factor9,10,26. Rib fracture

Conclusion

should also be ruled out because it can result in
hemothorax, lung contusion, bronchial damage, and
17,27,28

injury to the great vessels
In

a

series

reported

after systemic thrombolysis with t-PA in a patient

.

by

We have reported a case of severe hemothorax

Trupka

et

28

al. ,

with

cerebral

infarction

and

rib

fractures.

intrathoracic injury was missed in 65% of cases

Hemothorax is an important potential complication

when only chest X-ray films were obtained; they

of systemic thrombolysis, and before starting such

recommended that CT scans of the chest should also

treatment, thoracic trauma must be ruled out with

be obtained. A large percentage of rib fractures are

radiograms or CT scans or both.

due to motor vehicle accidents, and 30% of patients
had fallen17. In the present case a CT scan of the

Conflict of Interest: The authors declare no conflict of

chest performed after treatment with t-PA revealed

interest associated with this paper.

several fractures on the ribs on the left side, but we
did not note these fractures on the initial chest

References

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the patient did not complain of pain because of a
disturbance of consciousness. Treatment with t-PA
requires

immediate

intervention

and

careful

observation. Under such conditions we frequently
fail to diagnose rib fractures, and neurologists and
neurosurgeons, who do not normally deal with rib
46

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(Received, February 5, 2013)
(Accepted,

March 1, 2013)

47