Faculty Bibliography

BACKGROUND:Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. CASE REPORT/METHODS:We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.

BACKGROUND AND PURPOSE/OBJECTIVE:Our knowledge of the safety of thrombolytic therapy in pregnancy stems from individual case reports and series. We report the successful use of intravenous alteplase (tissue plasminogen activator; tPA) thrombolysis in a pregnant woman with acute cardioembolic stroke presumed to be paradoxical embolism through a patent foramen ovale. METHODS:A literature review found several case reports and case series of pregnant patients treated with either intravenous or intra-arterial tPA for acute ischemic stroke. RESULTS:A literature review yielded 10 cases of intravenous tPA administration and 5 cases of intra-arterial tPA. In total, there were 3 cases of asymptomatic intracerebral hemorrhage and 1 case of maternal and fetal death. CONCLUSIONS:Our patient improved clinically with no residual deficits. There was no evidence of placental or fetal injury following administration of tPA on follow-up obstetrical evaluations.

Infective endocarditis is associated with unstable infective vegetations, which have a propensity to embolize and cause embolic events, such as stroke. Many cases present with an embolic event as the first sign of infective endocarditis. We present a patient who had a history of recent and persistent fever, an acute ischemic stroke treated with intravenous tissue plasminogen activator (IV tPA), and severe, multifocal intracerebral hemorrhage as a complication of tPA treatment. Suspected infective endocarditis in a stroke patient should most likely be considered a contraindication to IV tPA.