Abstract 386: Rapid Left Ventricular Thrombus Formation After Thrombolysis For Acute Cardioembolic Stroke

Introduction/purpose Thrombolysis with tissue plasminogen activator (tPA) has been utilized as a treatment for acute ischemic stroke in select patients. However, the effects of tPA on the coagulation cascade and its dissolution capabilities are not entirely understood. Cardiac thrombus is often implicated as a cause of cardioembolic strokes, and limited data has suggested that thrombolysis is capable of dissolution of the thrombus (1). Materials and methods We present a 39‐year‐old female with multiple vascular risk factors who suffered a cardioembolic stroke for which she received Tenecteplase (TNK) followed by thrombectomy with complete reperfusion. Results/discussion She underwent a transthoracic echocardiogram (TTE) with ultrasound contrast the following day which revealed apical hypokinesis demonstrating heart failure with reduced ejection fraction (HFrEF) but no thrombus to the surprise of the cardiology team. Two days later, she had a repeat TTE that showed a new large 1.7times0.8cm LV thrombus, confirmed by the same cardiology team. This finding was unexpected given a thrombus of such size would not be expected to appear in just two days, and raised the possibility that TNK may have dissolved the thrombus and hence why it wasn't visualized on the initial TTE post‐thrombolysis. Another possibility is that the LV thrombus completely embolized to cause the stroke; however, the formation/reformation of a thrombus of that size so quickly was unexpected (5). Literature has suggested that thrombolysis induces a pro‐thrombotic state up to 72 hours afterward (4), with a predilection for cardiac thrombus formation. This may explain why the patient had such a rapid formation/reformation of such a large LV thrombus. Conclusion This case presents a potential dual benefit for patients receiving thrombolysis with TNK for cardioembolic stroke, and suggests a potential benefit in undergoing serial echocardiograms in this patient population group. References 1) Davutoglu, V., Soydinc, S. & Sezen, Y. Complete Lysis of Left Ventricular Giant Thrombus with Fibrinolytic Therapy in Clopidogrel Resistant Patient. J Thromb Thrombolysis 15, 59‐63 (2003). https://doi.org/10.1023/A:10261965027562 )Biso S, Wongrakpanich S, Agrawal A, Yadlapati S, Kishlyansky M, Figueredo V. A Review of Neurogenic Stunned Myocardium. Cardiovasc Psychiatry Neurol. 2017;2017:5842182. doi: 10.1155/2017/5842182. Epub 2017 Aug 10. PMID: 28875040; PMCID: PMC5569748. 3)Farah Yusuf Mohamud M, Mukhtar MS, Hassan MO. Successfully thrombolysis using tenecteplase in a case of massive pulmonary embolism with multiple free‐floating thromboses in the right atrium and right ventricle. Ann Med Surg (Lond). 2022 Apr 26;77:103629. doi: 10.1016/j.amsu.2022.103629. PMID: 35638082; PMCID: PMC9142651. 4)Doepp F, Sanad W, Schreiber SJ, Baumann G, Borges AC. Left ventricular apical thrombus after systemic thrombolysis with recombinant tissue plasminogen activator in a patient with acute ischemic stroke. Cardiovasc Ultrasound. 2005 May 26;3:14. doi: 10.1186/1476‐7120‐3‐14. PMID: 15918893; PMCID: PMC1156922. 5) Cosentino, Nicola, Lucci, Claudia, Marenzi, Giancarlo. Inflammation and left ventricular thrombosis after STEMI: Risk marker or risk factor? International Journal of Cardiology. 2022/10/01. doi: 10.1016/j.ijcard.2022.06.008