A 42-year-old man with a history of type 2 diabetes mellitus and amputation of the first toe of the right foot.
He came to the emergency service of San Juan de Dios Hospital (HSJD) due to a two-day history of sudden onset occipital headache, 8/10 intensity associated with blurred-photophobia, vision.
Physical examination revealed conscious, spatially oriented, hemodynamically stable, isochoric pupils, preserved direct and consensual photomotor reflex, oculomotility without alterations, highlighting a right hemianopsia.
Non-contrast-enhanced computed tomography (CT) of the brain showed hypodense parietal-occipital lesions and right occipital lesions, the latter compatible with arachnoid cyst.
An electrocardiogram showed signs of old infarction.
He was hospitalized for study with diagnosis of left parieto-occipital ischemic stroke.
On the fifth day of the onset of symptoms, a transthoracic echocardiogram showed systolic-diastolic dysfunction with an ejection fraction of 40%, mild left atrial dilatation and a left intraventricular pediculate mass of 7 x 4 cm suggestive.
Anticoagulation was initiated with continuous infusion pump (CIB) of heparin not administered (NFH) and it was decided to perform a thrombectomy due to the high risk of thrombus detachment and aortic valve obstruction.
Preoperatively, coronary angiography showed coronary arteries with moderate, non-stenotic atheromatosis and dissection of the right coronary artery at the distal mid-level.
On the same fifth day, coronary artery bypass grafting plus thrombectomy was performed in the infero-apical region of the left ventricle with extracorporeal circulation (ECC), under intravenous heparinization at 3 mg/kg.
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The patient had a favorable evolution and no signs of hemorrhagic transformation on control cerebral CT.
She was discharged on the fourth postoperative day with oral anticoagulation, with no evidence of neurological deterioration in subsequent outpatient controls.
A 38-year-old male computer professor with a history of acute myocardial infarction in 2011 underwent angioplasty with non-medicated vascular endoprosthesis in left anterior descending coronary artery outpatient follow-up.
She also had a history of active smoking 10 cigarettes/day.
He came to the emergency service of the SJDH due to sudden presentation of left labial commissure deviation and loss of strength of the left hemibody.
The patient was admitted to the emergency room one hour after the onset of symptoms.
Neurological examination at admission revealed temporal-spatial disorientation, Glasgow 14 scale, severe motor aphasia, left hemiplegia-brachio-crural and left hemiparesis.
The National Institute of Health Stroke Scale (NIHSS) scored 19.
Brain CT without contrast showed neither acute nor old lesions.
An ongoing acute ischemic cerebrovascular accident (CVA) was diagnosed and a thrombolysis protocol was activated with human fibrinogen activator (rt-PA).
Since the patient met the inclusion criteria for the procedure, thrombolysis was initiated one hour and ten and seven minutes after the onset of symptoms.
A weight of 70 kg was estimated, with 6.73 mg bolus and 56.7 mg infusion in one hour.
During the procedure, there was a tendency to hypotension up to a mean arterial pressure (MAP) of 78 mmHg, which was maintained with intravenous saline, achieving MAPs at 100 mmHg, with no major complications.
A decrease was observed from 19 at the beginning of thrombolysis to 15 at 60 minutes and 3 at 90 minutes.
The following day, GCS 15 showed minimal paresis in left lower quadrant but no other focalities or neurological abnormalities.
A CT scan showed cerebral hypodense right frontoparietal areas with signs of edema without signs of hemorrhagic transformation.
Transthoracic echocardiography detected an intracardiac thrombus of 1.6 cm x 2.3 cm, which was considered a source of the embolus causing ischemic stroke.
Five days after the stroke, intravenous low molecular weight heparin was started with subsequent switch to oral anticoagulants.
She was discharged on the tenth day with acenocoumarol.
Hereditary hypercoagulability study showed normal values of protein S, protein C, homocysteinemia, antithrombin III and absence of factor V Leiden (mutation R50620Q) and prothrombin G10A mutation
In control with transthoracic echocardiography, one month later, no thrombus was observed in the left ventricle.
Rankin patient with minimal facial paresis as a sequel of the ischemic event (modified Rankin scale of 1).
