Tanvee Sinha, BS
Medical Student
University of Alabama at Birmingham
Birmingham, Alabama, United States
Zachary A. Satin, MD
PM&R PGY4
MedStar National Rehabilitation Hospital
Washington, District of Columbia, United States
Aliraza Jafri, DO
Brain Injury Fellow
MedStar National Rehabilitation Hospital
Washington, District of Columbia, United States
Emma Nally, MD
Brain Injury and Stroke Rehabilitation Assistant Professor
MedStar National Rehabilitation Hospital
Washington, District of Columbia, United States
Hemorrhagic transformation of ischemic stroke is a serious complication, particularly in patients who require anticoagulation, and can obscure a rehabilitation prognosis. The decision to anticoagulate is nuanced with recent ischemic stroke, especially in polytrauma or those that involve posterior circulation infarcts.
Case Description:
A 50-year-old man who suffered multiple gunshot wounds requiring emergent thoracotomy was found to have bilateral cerebellar infarcts during work-up for seizure-like activity. His stroke etiology was thought to be cryptogenic with the source being either from a perioperative source, fat embolism, or paradoxical embolism from an incidentally found interatrial shunt. He developed a pulmonary embolism ten days later and anticoagulation was initiated. Five days later, he experienced hemorrhagic conversion of the cerebellar infarcts. Imaging showed mass effect and hydrocephalus requiring an external ventricular drain and suboccipital craniectomy. His rehabilitation readiness was complicated by subsequent left-sided hemiparesis, agitation, respiratory failure and dysphagia requiring tracheostomy and percutaneous endoscopic gastrostomy placement. Subsequently, as the patient demonstrated neurological improvement, he was transitioned to acute inpatient rehabilitation. There, he demonstrated improvements in agitation, dysphagia, and functional mobility, although he was still expected to require assistance with activities of daily living at discharge.
Discussions:
This case highlights the challenges in managing cryptogenic stroke and underscores the impact hemorrhagic transformation in ischemic stroke and rehabilitation implications. The decision to initiate anticoagulation was difficult given the patient’s ischemic stroke, polytrauma, pulmonary embolism and interatrial shunt. The timing of anticoagulation for secondary stroke prophylaxis in those with embolic sources is debated in literature, with greater uncertainty regarding posterior circulation strokes.
Conclusions:
Careful consideration is required when resuming anticoagulation in patients with recent ischemic stroke, particularly in those with trauma and potential embolic sources. This case emphasizes the need for robust guidelines to guide these critical decisions and the devastating functional impact that results from hemorrhagic conversion with ischemic stroke.
