Abstract 319: IV Thrombolysis Administration for Acute Ischemic Stroke After Cervical Epidural Injection: A Case Report

Introduction Intravenous (IV) thrombolysis with recent lumbar puncture is a relative contraindication due to the potential for development of epidural hematoma. While there have been case reports of uncomplicated IV thrombolysis after lumbar puncture or epidural anesthesia, there is limited data overall regarding the safety of IV thrombolysis for acute ischemic stroke (AIS) in patients who have undergone a neuraxial procedure. To our knowledge, there are no reported cases of successful IV thrombolysis after cervical epidural injection (CEI). Methods This is a case report. Results An 83‐year‐old male with past medical history of hyperlipidemia and prior stroke with residual right arm weakness presented for worsening right arm weakness and new symptoms of right leg weakness. Neurological exam also revealed aphasia and right facial droop. Patient presented within the time window for IV thrombolysis. However, the patient received a CEI earlier that day, which was confirmed to be around C7 level and considered uncomplicated with additional clinical observation that the dura was not punctured. Non‐contrast CT head showed no evidence of intracranial hemorrhage. CT angiogram of the head and neck showed an occlusion of the proximal aspect of the left internal carotid artery. Neurointerventional radiology was consulted to discuss the safety of IV thrombolysis given the recent epidural steroid injection. After extensive discussion regarding indication, risks, and benefits of IV thrombolysis with the patient and his son, informed consent was obtained, and IV Tenecteplase (TNK) was administered. The patient was then transferred to a thrombectomy capable center, where he received a balloon angioplasty and stenting to the left ICA with TICI 2b revascularization. MRI confirmed acute left frontal infarct. The patient remained stable without complications from the TNK and was discharged home on optimal medical management with antiplatelet therapy. Conclusion We present a case report of safe and successful administration of IV thrombolysis for AIS after recent CEI with resulting favorable recovery. The decision for IV thrombolysis was made after confirmation that the dura was not punctured. Further studies are necessary to establish the safety for IV thrombolysis after neuraxial procedures, such as epidural injections or epidural anesthesia.