ARTICLE IN PRESS

Successful mechanical thrombectomy in stroke
with thrombolysis-associated intracerebral
hemorrhage—a case report
D1X XJohannes M. Weller, D2XMD,
X * D3X XElke Hattingen, MD,
D4X X † D5X XGabor C. Petzold, D6XMD,
X *,‡
and D7X XFelix J Bode, MD
D8X X *,‡
Background: Intravenous thrombolysis and mechanical thrombectomy areD9X Xthe standard of care for patients with acute ischemic stroke with large vessel occlusion.
Intracerebral hemorrhage is a main complication of intravenous thrombolysis,
however, no data are available on the efficacy and safety of mechanical thrombectomy in patients with thrombolysis-associated intracerebral hemorrhage. This
constellation is expected to become more frequent as increasing numbers of
patients are treated under the drip-and-ship paradigm. Case report: A 75-year-D10Xold
X
male patient was admitted to an emergency department with acute onset dysarthria and left side hemiparesis due to right middle cerebral artery occlusion.
Intravenous thrombolysis was initiated and the patient transferred to our center
for mechanical thrombectomy. Upon arrival, cerebral imaging showed persistent
right middle cerebral artery occlusion and new onset left frontal, temporal, and
parietal intracerebral hemorrhage. Thrombectomy was performed and perfusion
completely re-established with excellent neurological outcome. Follow-up imaging revealed probable cerebral amyloid angiopathy. Conclusion: Mechanical
thrombectomy may be safe and effective in ischemic stroke with large vessel
occlusion and thrombolysis-associatied intracerebral hemorrhage.
Key Words: Stroke—Infarction—lDarge
1X X
vessel occlusion—tDhrombectomy—rtPA—
12X X
tDhrombolytic
13X X
therapy—iDntracerebral
14X X
hemorrhage—cDerebral
15X X
hemorrhage.
© 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Case Presentation
A 75-year-old-Dmale
16X X
patient was admitted to an emergency department for acute onset of dysarthria and left
brachiofacial hemiparesis (National Institute of Health
Stroke ScaleD17X X score, 7). Emergency computed tomography
(CT) imaging showed no infarct demarcation or intracerebral hemorrhage (ICH), and contrast-enhanced CT
From the *Department of Neurology, University Hospital Bonn,
Bonn, Germany; †Department of Neuroradiology, University Hospital Frankfurt, Frankfurt, Germany; and ‡German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.
Received August 22, 2018; revision received September 21, 2018;
accepted September 27, 2018.
Grant support: none.
Address correspondence to Johannes Michael Weller, MD, Department of Neurology, University Hospital Bonn, 53105 Bonn, Germany.
E-mails: johannes.weller@ukbonn.de, elke.hattingen@kgu.de,
gabor.petzold@ukbonn.de, felix.bode@ukbonn.de.
1052-3057/$ - see front matter
© 2018 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.09.045

angiography revealed occlusion of the M1 segment of the
right middle cerebral artery (MCA). After exclusion of
contraindications, intravenous thrombolysis with 70 mg
of recombinant tissue plasminogen activator was initiated. The patient was transferred to our center for
mechanical thrombectomy (MT). While repeat CT imaging upon arrival showed no infarct demarcation, asymptomatic ICHD
D18X X
19X X of left parietal, temporal and frontal lobe
measuring 18 £D20X X 10 mm, 5 £D21X X 4 mm, and 7 £D2X X 5 mm, respectively, was diagnosed (Fig 1). Persistent occlusion of the
right MCA and neurological deficit (National Institute of
Health Stroke ScaleD23X X score, 7) still indicated necessity for
MT, and the patient was transferred to the angiography
suite. The procedure was performed under general
anesthesia. AD24X X 8-F sheath was placed in the right common
femoral artery. A 5-F Sofia catheter was placed in the right
internal carotid artery, and MT was performed with a Solitaire stent retriever (Medtronic, Ireland). MCA perfusion
was completely reestablished (thrombolysis in cerebral
infarction scale grading of 3). Further work-up revealed
intermittent atrial fibrillation, arterial hypertension, and

Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2018: && &&

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ARTICLE IN PRESS
J.M. WELLER ET AL.

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Figure 1. (A) Initial CT scan of the patient with acute onset left side hemiparesis. (B) Repeat CT scan after intravenous thrombolysis and transfer to our center;
1 of 3 left hemispheric intracerebral hemorrhages is shown. (C) Contrast-enhanced CT angiogram shows persistent occlusion of right middle cerebral artery, M1
segment, and thrombectomy was performed. (D) MRI 5 weeks later with T2*-weighted gradient echo sequence reveals microbleeds and residual hemorrhage.

hypercholesterinaemia. The patient was released from our
hospital without any neurological deficits (modified Rankin Scale score, 0). Follow-up magnetic resonance imaging
revealed cortical microbleeds consistent with probable
cerebral amyloid angiopathy defined by the modified Boston criteria (Fig 1).1

Discussion
Recent randomized clinical trials and current guidelines
suggest that stroke patients with anterior circulation occlusion should be treated with intravenous thrombolysis and
MT.2,3 Most hospitals do not have on-site MT facilities and
patients need to be transferred secondarily after thrombolysis, known as the drip-and-ship paradigm.4 Upon arrival,

repeat imaging is often performed to detect infarct progression or ICH before MT. ICH is a main complication of
thrombolysis and occurs in 10.6%, both inside and outside
the territory of the occluded artery.5-7 Increasing incidence
of patients treated under the drip-and-ship paradigm will
inevitably lead to an increasing number of ICH detected
after secondary referral for MT. However, ICH was an
exclusion criterion in randomized MT trials and no data
are available on the efficacy and safety of MT in patients
with ICH.3 Our case provides the first report of successful
MT in a patient with acute ischemic stroke with IV thrombolysis-associated ICH in a different vascular territory.
However, despite this encouraging case report, further
studies are needed to evaluate safety and efficacy of MT in
patients with stroke and thrombolysis-associated ICH.

ARTICLE IN PRESS
THROMBECTOMY IN STROKE WITH HEMORRHAGE AFTER LYSIS

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