Journal of the Neurological Sciences 341 (2014) 189–190 Contents lists available at ScienceDirect Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns Letter to the Editor Spontaneous sternocleidomastoid muscle hematoma following thrombolysis for acute ischemic stroke Nadia Mariagrazia Giannantoni, Giacomo Della Marca, Aldobrando Broccolini, Fabio Pilato, Paolo Profice, Roberta Morosetti, Pietro Caliandro, Giovanni Frisullo ⁎ Department of Neuroscience, Catholic University, Largo Agostino Gemelli, 8, 00168 Rome, Italy a r t i c l e i n f o Article history: Received 13 January 2014 Received in revised form 27 March 2014 Accepted 31 March 2014 Available online 13 April 2014 a b s t r a c t Spontaneous or traumatic bleeding is a common complication of systemic thrombolysis in patients with acute ischemic stroke. We report the case of an 83 y.o. woman with right facio-brachio-crural hemiparesis, left deviation of the head and aphasia who developed, after thrombolytic therapy, a spontaneous sternocleidomastoid muscle hematoma that regressed few days later. To our knowledge, this is the first case reported in the literature of asymptomatic and spontaneous skeletal muscle hematoma following thrombolysis for the treatment of acute ischemic stroke. The occurrence of lateral cervical tuberculosis lymphadenitis ipsilateral to sternocleidomastoid muscle hematoma may suggest a causal relationship between local chronic inflammation of active mycobacterial infection and thrombolysis-related extravasation. This case should suggest caution in thrombolytic treatment in patients with chronic immune dysregulation and vascular inflammation such as extra-pulmonary tuberculosis. © 2014 Elsevier B.V. All rights reserved. Dear Editor-in-Chief, Intravenous recombinant tissue plasminogen activator (IV rtPA), the only approved treatment for acute ischemic stroke, [1] can be associated with spontaneous or traumatic bleeding [2,3]. We report a case of sternocleidomastoid muscle hematoma following thrombolysis for ischemic stroke. To our knowledge, this is the first case reported in the literature of asymptomatic and spontaneous skeletal muscle hematoma secondary to thrombolysis. We describe an 83 y.o. woman with a history of hypertension, atrial fibrillation and tuberculosis lymphadenitis who presented with right facio-brachio-crural hemiparesis, left deviation of the head and aphasia. In the emergency room, neurological examination revealed right hemiparesis, right inferior facial palsy, dysphagia and global aphasia with National Institutes of Health Stroke Scale (NIHSS) score of 20. A brain computed tomography (CT) was negative for intracranial hemorrhages and an angiographic-CT showed an occlusion of the left internal carotid. Thus, in the absence of exclusion criteria, the patient started IV rtPA at the dose of 0.9 mg/kg bodyweight. After systemic thrombolysis a mild clinical benefit was observed (NIHSS = 16) with an improvement of right leg palsy and vigilance. After the thrombolytic infusion a huge cervical left-sided mass was evident and was immediately evaluated through a neck echography that displayed a no-pulsating inhomogeneous formation compatible with organizing hematoma. A neck CT scan with contrast was performed showing extravasation of the contrast medium within the left sternocleidomastoid muscle in the arterial phase, thus supporting the initial hypothesis of a spontaneous thrombolysis-induced muscle hematoma (Fig. 1A). No compression of the surrounding structures was found on CT and no evacuation of the hematoma was further needed. A week later the muscle hematoma regressed (Fig. 1B). During thrombolysis in addition to the most common sites of bleeding, clinicians should take into account the possibility of hemorrhages in unconventional sites, especially in the presence of patients with a clinical history of chronic hypertension [4]. In our patient, the occurrence of lateral cervical tuberculosis lymphadenitis ipsilateral to sternocleidomastoid muscle hematoma may suggest a causal relationship between local chronic inflammation of mycobacterial infection and thrombolysis-related extravasation. Indeed, functional and structural remodeling of the microcirculation secondary to the immunological dysregulation of active mycobacterial cervical lymphadenitis can be hypothesized [5]. The resulting increase of vascular permeability may induce a susceptibility to vascular ruptures that ultimately may have contributed to the thrombolysis-related extravasation at the lateral cervical lymph node level. This case should suggest caution in thrombolytic treatment in patients with chronic immune dysregulation and vascular inflammation such as systemic tuberculosis. Ethics ⁎ Corresponding author at: Institute of Neurology, Catholic University, 00168 Rome, Italy. Tel.: +39 06 30156321; fax: +39 06 35501909. E-mail address: giovannifrisullo@rm.unicatt.it (G. Frisullo). http://dx.doi.org/10.1016/j.jns.2014.03.059 0022-510X/© 2014 Elsevier B.V. All rights reserved. The work described is consistent with the Journal's guidelines for ethical publication. 190 Letter to the Editor Fig. 1. Neck CT scan 1 h (A) and 7 days (B) after thrombolysis. Panel A: Presence of extravasation of the contrast medium during arterial phase into the left sternocleidomastoid muscle (white arrow). After 7 days the hematoma disappeared (panel B). Disclosure of conflicts of interest None of the authors has any conflict of interest to disclose. References [1] The IST-3 collaborative group. Effect of thrombolysis with alteplase within 6 h of acute ischaemic stroke on long-term outcomes (the third International Stroke Trial [IST-3]): 18-month follow-up of a randomised controlled trial. Lancet Neurol 2013;12:768–76. [2] Wahlgren N, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007;369:275–82. [3] Califf RM, et al. Clinical risks of thrombolytic therapy. Am J Cardiol 1992;69:12–20. [4] Lyden PD. Hemorrhagic transformation during thrombolytic therapy and reperfusion: effects of age, blood pressure and matrix metalloproteinases. J Stroke Cerebrovasc Dis 2013;22:532–8. [5] Brighenti S, Andersson J. Local immune responses in human tuberculosis: learning from the site of infection. J Infect Dis 2012;205:316–24.