Skip to main content
SpringerLink
Log in

Reversal of locked-in syndrome with anticoagulation, induced hypertension, and intravenous t-PA

  • Practical Pearl
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Introduction: Widespread use of intravenous tissue plasminogen activator (t-PA) for acute ischemic stroke is limited by multiple contraindications to its use.

Case report: This article describes a patient with stuttering symptoms of pontine ischemia caused by vertebrobasilar dissection who suddenly deteriorated into a locked-in state 32 hours after symptom onset. The quadriparesis was successfully reversed within 3 hours of onset with the combination of pharmacologically induced hypertension, anticoagulation, and intravenous t-PA.

Discussion: Even in the face of numerous contraindications (including hypertension, anti-coagulation, and treatment beyond 3 hours of symptom onset), intravenous t-PA can be used successfully in carefully selected cases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995). Tissue plasminogen activator in acute ischemic stroke. NEJM 1995;333:1581–1587.

    Article  Google Scholar 

  2. Gasecki AP, Graffagnino C, Hachinski V. Tissue plasminogen activator in vertebral artery dissection. Can J Neurosci 1997;24:151–154.

    CAS  Google Scholar 

  3. Derex L, Nighoghossian N, Turjman F, et al. Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection. Neurology 2000;54:2159–2161.

    PubMed  CAS  Google Scholar 

  4. Arnold M, Nedeltchev K, Sturzenegger M, et al. Thrombolysis in patients with acute stroke caused by cervical artery dissection. Arch Neurol 2002;59:549–553.

    Article  PubMed  Google Scholar 

  5. Leistner S, Hartmann A, Marx P, Koennecke HC. Successful thrombolytic treatment of intracranial carotid occlusion due to dissection. Eur Neurol 2001;45:284,285.

    Article  PubMed  CAS  Google Scholar 

  6. Rudolf J, Neveling M, Grond M, Schmulling S, Stenzel C, Heiss WD. Stroke following internal carotid artery occlusion—a contraindication for thrombolysis. Eur J Neurol 1999;6:51–55.

    Article  PubMed  CAS  Google Scholar 

  7. Rordorf G, Koroshetz WJ, Ezzeddine MA, Segal AZ, Buonanno F. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology 2001;55:1210–1213.

    Google Scholar 

  8. Wojner AW, Gerami Z, Nosser EA, Shaw S, Malkoff M, Alexandrov AV. Heads down: lower head position is better in acute ischemic stroke [abstract]. Stroke 2003;34:278.

    Google Scholar 

  9. Lewandowski CA, Frankel M, Tomsick TA, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke 1999;30:2598–2605.

    PubMed  CAS  Google Scholar 

  10. IMS Study Investigators. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 2004;35:904–911.

    Article  Google Scholar 

  11. Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Systemic Review 2000;(4):CD00025.

  12. Schevink WI. The treatment of spontaneous carotid and vertebral artery dissections. Curr Opin Cardiol 2000;15:316–321.

    Article  Google Scholar 

  13. Koch S, Romano JG, Bustillo IC, Concha M, Forteza AM. Anticoagulation and microembolus detection in a case of internal carotid artery dissection. J Neuroimag 2001;11:63–66.

    Article  CAS  Google Scholar 

  14. Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999;282:2019–2026.

    Article  PubMed  CAS  Google Scholar 

  15. Rother J, Schellinger PD, Gass A, et al. Effect of intravenous thrombolysis on MRI parameters and functional outcome in acute stroke <6 hours. Stroke 2002;33:2438–2445.

    Article  PubMed  CAS  Google Scholar 

  16. Stapf C, Marshall RS, Mohr JP, et al. Late intra-arterial thrombolysis. Eur J Med Res 2000;5:303–306.

    PubMed  CAS  Google Scholar 

  17. Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ. Intra-arterial thromblytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke 1988;19:1216–1222.

    PubMed  CAS  Google Scholar 

  18. Brandt T, von Kummer R, Muller-Kuppers M, Hacke W. Thrombolytic therapy of acute basilar artery occlusion. Variables affecting recanalization and outcome. Stroke 1996;27:875–881.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. The Neurological Intensive Care Unit, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY

    Nazli Janjua, Katja E. Wartenberg & Stephan A. Mayer

  2. Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY

    Philip M. Meyers & Stephan A. Mayer

Authors
  1. Nazli Janjua
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katja E. Wartenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Philip M. Meyers
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stephan A. Mayer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Nazli Janjua or Stephan A. Mayer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Janjua, N., Wartenberg, K.E., Meyers, P.M. et al. Reversal of locked-in syndrome with anticoagulation, induced hypertension, and intravenous t-PA. Neurocrit Care 2, 296–299 (2005). https://doi.org/10.1385/NCC:2:3:296

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1385/NCC:2:3:296

Key Words

Search

Navigation