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Open Access 01-07-2015 | Heart Beat

Acute pontine infarction after percutaneous coronary intervention: a very rare but devastating complication

Auteurs: F. Arslan, J. Mair, W.-M. Franz, M. Otten, L. van Lelyveld

Gepubliceerd in: Netherlands Heart Journal | Uitgave 7-8/2015

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Abstract

A 64-year-old man suffering from an acute posterior wall myocardial infarction underwent primary percutaneous coronary intervention. After several aspiration attempts, tirofiban infusion and pre- and post-dilatation, a bare-metal stent was successfully implanted in the culprit right coronary artery. While the patient did not show any neurological symptoms before or during the procedure, he exhibited hemiplegia and loss of spontaneous speech. Additional magnetic resonance imaging showed an extensive brain stem infarction. This is the first report of a brain stem infarction as a complication of percutaneous coronary intervention.
Here we present a case of a 64-year-old man, without any history of cardiovascular risk factors or other comorbidities, who underwent acute percutaneous coronary intervention (PCI) for an acute posterior wall myocardial infarction. Coronary angiography revealed an occluded right coronary artery (Fig. 1a, Online Video 1). In addition, the left circumflex coronary artery showed a non-occlusive thrombus, and the left anterior descending coronary artery revealed a Thrombolysis in Myocardial Infarction grade II flow (Fig. 1b, Online Video 2). After several aspiration attempts and intracoronary administration of tirofiban, the right coronary artery could be reopened with several pre-dilatations and implantation of a Driver Sprint bare-metal 4.5 15-mm stent (Medtronic Inc, Minnesota, USA) with subsequent 5.0 NC balloon post-dilatation. Because of the high thrombus load, successful reperfusion of the posterolateral branch was not possible (Fig. 1c, Online Video 3). A temporary pacemaker was placed before the PCI due to bradycardia. After the procedure, the patient became hemiplegic and exhibited loss of spontaneous speech. Cerebral magnetic resonance imaging revealed an extensive left-sided infarction in the brain stem expanding into the cerebral and cerebellar peduncle (Fig. 2). Thrombolysis was not possible, as dual anti-platelet therapy, heparinisation and continuous intravenous tirofiban had already been initiated. Subsequently, he was mechanically ventilated and treated with antibiotics for 6 days after which he developed aspiration pneumonia caused by neural dysphagia. Although he was extubated after 9 days, he received a tracheostoma due to persistent dysphagia and high risk for aspiration. He was transferred to the stroke unit for further rehabilitation. Coronary angiography and/or percutaneous coronary interventions have been associated with cerebral ischaemic complications. The complication rate varies between 0.07 and 0.4 % of the procedures [14]. However, a brain stem infarction is highly unusual compared with cerebral stroke considering the difficult anatomical path for an embolus originating from the aortic arch. Before the embolus reaches the basilar artery, it needs to pass through the subclavian (or the brachiocephalic trunk for right-sided lesions) and the vertebral artery. To our knowledge, this is the first report of an acute pontine infarction as a complication of percutaneous coronary intervention.

Funding

None.

Conflict of interest

Dr. F. Arslan is an associate editor of the Netherlands Heart Journal.
Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
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Netherlands Heart Journal

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Metagegevens
Titel
Acute pontine infarction after percutaneous coronary intervention: a very rare but devastating complication
Auteurs
F. Arslan
J. Mair
W.-M. Franz
M. Otten
L. van Lelyveld
Publicatiedatum
01-07-2015
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 7-8/2015
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-015-0717-2