Case Report Thrombolysis Following Central Venous Catheter Placement Kenichi Sakuta, MD, PhD,* Ryoji Nakada, MD,* Shinji Miyagawa, MD,* Izumu Hasegawa, MD,† and Hiroshi Yaguchi, MD, PhD* Thrombolytic agents are infusion formulations, and some patients cannot be cannulated by a peripheral venous route. This report describes a patient with acute ischemic stroke who was administered alteplase following central venous catheter placement. An 82-year-old man with paroxysmal atrial fibrillation presented with left unilateral spatial neglect and left hemiparesis. Magnetic resonance imaging showed acute cerebral infarction located in the right cerebrum without occlusion of the main artery. The infarction was considered appropriately indicated for thrombolysis. However, no peripheral venous access could be secured, even by trained emergency room physicians. A central venous catheter was therefore placed in the right jugular vein and thrombolysis was performed. After treatment, neurological deficits completely resolved without any clinically serious bleeding. Venous catheter placement may be a safe alternative to peripheral vein access in such a circumstance. Key Words: Thrombolysis—Central venous catheter—Ischemic stroke— Hemorrhagic complication © 2020 Elsevier Inc. All rights reserved. Introduction Since the importance of time in the treatment of hyperacute ischemic stroke became widely known, the frequency of thrombolysis has been gradually increasing.1,2 As thrombolytic agents are infusion formulations, securing a venous access route is mandatory. Here, we report the case of an acute ischemic stroke patient in whom a peripheral venous route could not be secured, and a central venous catheter was effectively utilized for alteplase administration. Case report An 82-year-old man was admitted to our hospital with numbness of the left limbs. He had a medical history of From the *Department of Neurology, Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa-shi, Chiba 277-8567 Chiba, Japan; and †Department of Emergency Medicine, Jikei University Kashiwa Hospital. Chiba, Japan. Received July 2, 2020; revision received August 18, 2020; accepted August 20, 2020. Corresponding author. E-mail: kenichisakuta@jikei.ac.jp. 1052-3057/$ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105267 hypertension, dyslipidemia, diabetes mellitus, paroxysmal atrial fibrillation, aortic valve replacement (biological valve) for aortic valve stenosis, and coronary artery bypass grafting for angina pectoris. He had been prescribed aspirin at 100 mg/day, an oral hypoglycemic drug, and a statin. On examination, consciousness was clear, body temperature was 35.2 °C, blood pressure was 126/55 mmHg, and heart rate was 64 beats/min. Neurological examination revealed left hemiparesis and left unilateral spatial neglect. National Institutes of Health Stroke Scale score was 2. Blood tests on admission showed results largely within normal limits, except for mild elevations of brain natriuretic peptide (95.3 pg/mL) and D-dimer (1.3 mg/mL). We immediately performed brain magnetic resonance (MR) imaging and MR angiography and confirmed an acute right cerebral hemispheric infarct without main artery occlusion (Fig. 1A C). The brain infarction was considered to meet the indications for thrombolysis (recombinant tissue plasminogen activator [rt-PA]), and the decision was made to administer this agent. However, securing peripheral venous access proved extremely difficult, with failure of more than 10 attempts performed by trained emergency room physicians and neurologists. Peripheral venous access Journal of Stroke and Cerebrovascular Diseases, Vol. 29, No. 11 (November), 2020: 105267 1 K. SAKUTA ET AL. 2 Fig. 1. (A, B) Magnetic resonance imaging on admission. Diffusion-weighted imaging shows acute infarction in the right cerebrum (arrow). (C) Magnetic resonance angiography. The right middle cerebral artery and internal carotid artery are patent. was abandoned, and central venous access was selected to administer rt-PA. A central venous catheter was inserted in the right internal jugular vein under ultrasound guidance, to reduce the risk of penetration of the posterior vessel wall or accidental arterial puncture. The rt-PA was then initiated with mild compression of the puncture point using rolled gauze. The time from onset to first door was 46 min, from first door to imaging (brain MRI) was 90 min, from imaging to puncture of the internal jugular vein was 34 min, and from puncture to initiation of rt-PA administration was 16 min. In total, the time from onset to rt-PA initiation was 186 min. Fifteen minutes after rtPA initiation, the neurological deficits completely resolved. No clinically serious hemorrhagic events were encountered during or after rt-PA administration, including at the puncture point under careful observation. Subcutaneous bleeding and hematoma in the extremities had been observed where the physicians had tried to secure peripheral venous access. Apixaban was prescribed at 10 mg/day from hospital day 4 as secondary prevention, and he was discharged on hospital day 8 without sequelae. Conclusion Thrombolysis following central venous catheter placement was safe and effective in this case. Declarations Ethical approval and consent to participate The authors declare that ethical approval was not required for this case report. Consent to publish Written informed consent was obtained from the patient for publication of this case report and the accompanying data. Availability of data and materials All data containing relevant information to support the study findings are included in the manuscript. Funding Discussion The unique point of the present case is that urgent central venous catheter placement was performed prior to rtPA, and no serious hemorrhagic complications arose. Since the currently available thrombolytic agents are infusion formulations, securing a venous access route is mandatory.3 However, some patients cannot be cannulated using a peripheral venous route, as in the present case. There is presently insufficient evidence regarding cannulation of central veins in patients for thrombolytic therapy. However, hemostasis of venous bleeding can be obtained by soft manual compression, so the bleeding risk would be acceptable if the catheter is inserted under ultrasound guidance and monitored carefully during and after thrombolysis.4 The internal jugular vein was selected in the present case, but from a safety perspective, the femoral vein may be preferable. The authors received no financial support for the research, authorship, or publication of this article. Authors' Contributions KS drafted the manuscript and prepared the figures. RN, SM, and IH treated the patient and collected the clinical data. HY helped write and revise the manuscript. All authors have read and approved the final manuscript. Acknowledgments None. Declaration of Competing interest The authors declare that they have no competing interests. THROMBOLYSIS FOLLOWING CENTRAL VENOUS CATHETER PLACEMENT References 1. Marko M, Posekany A, Szabo S, Scharer S, Kiechl S, Knoflach M, et al. Trends of r-tPA (Recombinant Tissue-Type Plasminogen Activator) treatment and treatment-influencing factors in acute ischemic stroke. Stroke 2020;51: 1240-1247. 2. Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis 3 of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010;375:1695-1703. 3. Toyoda K, Koga M, Iguchi Y, Itabashi R, Inoue M, Okada Y, et al. Guidelines for Intravenous thrombolysis (Recombinant Tissue-type Plasminogen Activator), the third edition, March 2019: a guideline from the Japan Stroke Society. Neurologia Medico-Chirurgica 2019;59:449-491. 4. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care 2017;21:225.