We report a case of a preterm infant who underwent transcatheter closure of patent ductus arteriosus (PDA) with Amplatzer Piccolo device through the left femoral vein. During the procedure, a partially occluded inferior vena cava (IVC) with significant collateralization was noted. The catheter was negotiated using a coronary guide wire and the infant tolerated the procedure well. Interestingly, the infant had a normal IVC in prior radiological films. The cause of this acquired occluded IVC remained obscure.

The incidence of acute ischemic stroke (AIS) after recent myocardial infarction (MI) during the hospital stay ranges from 0.7% to 2.2%. [1-3] AIS occurred more frequently in the first days after Acute myocardial infarction (AMI), but incidence progressively decreased over time. [3-5] Brandi Witt et al, suggested that during hospitalization for MI 11.1 the AIS occurred per 1000 MI compared with 12.2 at one month and 21.4 at one year. The most positive predictors of ischemic stroke after MI included: older age, hypertension, diabetes, history of previous stroke, history of anterior location MI, previous MI, atrial fibrillation and heart failure [6].
Case report
72 years old male patient, previously healthy with no chronic medical illnesses, presented complaining of acute burning retrosternal chest pain within two hours associated with diaphoresis and nausea. On examination, the patient was lying supine mildly anxious and sweaty. Blood Pressure: 142/90 mmHg. Oxygen saturation on room air 95 %, Pulse rate 105 beats per minute Temperature 37.6. Focused precordial exam: regular tachycardia with no added sounds. Back: normal vehicular breathing sounds with no crepitations. Electrocardiogram was done within 10 minutes and revealed ST segment elevation in inferior leads II, III, aVF with reciprocal ST depression in leads I, aVL (figure 1)

Figure 1: ECG sinus tachycardia, inferior ST elevation.

Because the patient arrived at the time window of thrombolytic strategy according to Al-Shifa Hospital protocol, thrombolytics was given rather than primary PCI. The patient was prepared before thrombolytics and was given 300 mg loading Aspirin and 300 mg loading clopidogrel, Streptokinase 1.5 million units over 60 minutes was given to the patient over 40 minutes in emergency department, then the patient was transferred to the coronary care unit with continuous ECG monitoring and defibrillator. After 90 minutes of giving streptokinase, ECG was done and showed more than 50% resolution of ST segment in inferior leads with great improvement of chest discomfort and symptoms by the patient. (Figure 2)

Figure 2: ECG 90 minutes after streptokinase, ST resolution > 50%.

The day after that, the patient was transfer to the catheterization laboratory for pharmaco-invasive PCI and while sterilization process the patient suddenly developed difficult speech, weakness in the left arm and disorientation.

Rapid coronary angiography by femoral access showed total occlusion of the mid right coronary artery and 2.75x26 mm resolute stent (drug eluting stent) was deployment. (figure 3a, 3b)

Figure 3a: Mid RCA totally occluded                                      Figure 3b: patent RCA after stent deployment

At the same time, the interventional cardiologist went to cerebral circulation and on the screen appeared haziness in the right middle cerebral artery (MCA). IA tPA 4 mg was given into right MCA with TICI flow III.

Figure 4a: haziness in the Right MCA                Figure 4b: TICI flow III in right MCA

After 5 minutes the was able to speak fluently and move his left arm with full power and good consciousness level, after 48 hours the patient discharge from hospital without any complications.

Discussion

According to the 2018 guideline of scientific statement from the American Heart Association/American Stroke Association (AHA/ASA), [7] 1. For patients presenting with AIS and a history of recent MI in the past 3 months, treating the ischemic stroke with IV alteplase is reasonable if the recent MI was non-STEMI. (Class IIa) 2. For patients presenting with AIS and a history of recent MI in the past 3 months, treating the ischemic stroke with IV alteplase is reasonable if the recent MI was a STEMI involving the right or inferior myocardium. (Class IIa) 3. For patients presenting with AIS and a history of recent MI in the past 3 months, treating the ischemic stroke with IV alteplase may reasonable if the recent MI was a STEMI involving the left anterior myocardium. (Class IIb) The main concerns about giving rt-PA to patients with AIS and history of recent MI are (Beyond the bleeding): 

1. Thrombolysis-induced myocardial hemorrhage predisposing to myocardial wall rupture 2. Possible ventricular thrombus that could be embolize because of thrombolysis. 3-post-myocardial infarction pericarditis that may become hemopericardium the safety of IV rt-PA for acute ischemic stroke (AIS) treatment after recent myocardial infarction (MI) is still controversial. In recent Retrospective review article of 102 AIS patients admitted for AIS with history of recent MI in the previous 3 months. Patients according to treated with standard IV rt-PA dose for AIS were divided into 2 groups: treated or not treated. Four patients with STEMI patients in the week preceding ischemic stroke (8.5%) and IV rt-PA treated died from confirmed cardiac rupture/ tamponade. This complication occurred in 1 (1.8%) patient in the nontreated group (P=0.178), and no non-STEMI patients receiving IV rt-PA had cardiac complications [8]. The new recommendation according to 2021 guidelines of European Stroke Organization (ESO) on intravenous thrombolysis for acute ischemic stroke suggested that [14]: Contraindication of rt-PA For patients with acute ischemic stroke of < 4> 6 h) ST elevation myocardial infarction during the last seven days. • Insufficient evidence to make a recommendation for patients with acute ischemic stroke of < 4> 3 months [9]. Despite the increasing risk of mortality, further studies are necessary to determine whether the benefit of rt-PA outweighs its risk among AIS patients with a recent history of MI in last 3 months. 

According to Alshifa hospital classification this is type II cardiocerebral infarction syndrome and diagnosis AIS (a sudden onset of focal neurological deficit caused by an cerebral vascular narrowing cause) and recent history of MI (acute elevation cardiac enzyme plus ischemic electrocardiogram changes and/or symptoms) in the previous 3 months but not in first 12 hours from MI. and the causes may be  Left ventricle thrombus formation or Increased coagulation activity or The circulatory inflammatory cytokines or Post myocardial infarction atrial fibrillation/ atrial flutter or Intervention of myocardial infarction (PCI and CABG) (10).

Conclusion

The type II cardiocerebral infarction syndrome one of the most challenging medical emergency conditions and requires timely management. therapeutic strategies and efficient team-work among neurologists and cardiologists are required for ideal management for such exceptional cases. We believe that invasive treatment using mechanical thrombectomy for cerebral arteries and PCI to culprit coronary artery must be done. Future clinical trial study, though difficult to perform due to its rarity, is required in order to develop the optimal management of this catastrophic clinical scenario.