Rawashdeh Sukaina I, Al-Mistarehi Abdel-Hameed, Yassin Ahmed, Rabab'ah Walaa, Skaff Hussam, Ibdah Rasheed
Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
Int Med Case Rep J. 2020 Nov 5;13:581-590. doi: 10.2147/IMCRJ.S279603. eCollection 2020.
We are presenting a case report of a previously healthy 39-year-old man who was found to have acute inferior ST-elevation myocardial infarction (STEMI) and acute large right middle cerebral artery (MCA) ischemic stroke with hemorrhagic transformation. Transesophageal echocardiogram and chest CT angiogram revealed two thrombi; one attached to the wall of the ascending aorta just above the right coronary artery sinus, and one at the origin of the brachiocephalic trunk. The occlusion of the coronary artery and right MCA most likely could be because of embolization from these thrombi. Extensive workup looking for underlying etiology and risk factors for these concurrent vascular events in this young man revealed hyperhomocysteinemia along with unfavorable lipid profile, and family history of premature coronary artery disease which increased the suspicion of familial hypercholesterolemia. Besides, the presence of vitamin B12 and folate deficiencies. The elevated serum homocysteine is likely a major risk factor for thromboembolism in this patient. The patient received antithrombotics and vitamin supplementations and gradually improved without any worsening of the stroke's hemorrhagic transformation. We suggest that hyperhomocysteinemia needs to be considered in the differential etiology of vascular events in young people or those with no significant history of major vascular risk factors. Besides, vitamin supplementation could be a cost-effective, safe, and efficient way to decrease elevated serum homocysteine levels and prevent vascular complications. As well as this case report demonstrates that antithrombotics can safely be used after stroke's hemorrhagic transformation without neurological deterioration or aggravation of hemorrhagic transformation.
我们报告一例病例，患者为一名39岁既往健康男性，被发现患有急性下壁ST段抬高型心肌梗死（STEMI）以及急性右侧大脑中动脉（MCA）大面积缺血性卒中伴出血转化。经食管超声心动图和胸部CT血管造影显示有两个血栓；一个附着于右冠状动脉窦上方的升主动脉壁，另一个位于头臂干起始处。冠状动脉和右侧大脑中动脉的闭塞很可能是由于这些血栓的栓塞所致。对该年轻男性这些并发血管事件的潜在病因和危险因素进行的广泛检查发现高同型半胱氨酸血症、不良血脂谱以及早发冠状动脉疾病家族史，这增加了对家族性高胆固醇血症的怀疑。此外，还存在维生素B12和叶酸缺乏。血清同型半胱氨酸升高可能是该患者血栓栓塞的主要危险因素。患者接受了抗栓治疗和维生素补充，病情逐渐好转，卒中出血转化未加重。我们建议，在年轻人或无重大血管危险因素显著病史的人群中，血管事件的鉴别病因应考虑高同型半胱氨酸血症。此外，补充维生素可能是降低血清同型半胱氨酸水平升高并预防血管并发症的一种经济有效、安全且高效的方法。同时，本病例报告表明，卒中出血转化后可安全使用抗栓药物，而不会导致神经功能恶化或出血转化加重。
