Mathews Journal of Case Reports

2474-3666

Previous Issues Volume 8, Issue 2 - 2023

Concurrent Cardio-Cerebral Infarction: Meta-Analysis

Mohammed Habib1,*, Sommaya Alhout2

1Head of Cardiology Department, Alshifa Hospital, Gaza, Palestine, Israel

2Cardiology Department, Alshifa Hospital, Gaza, Palestine, Israel

*Corresponding author: Mohammed Habib, MD, PhD, Head of Cardiology Department, Alshifa Hospital, Gaza, Palestine, Israel, Mobile: 00972599514060; E-mail: [email protected]

Received Date: January 18, 2023

Published Date: February 03, 2023

Citation: Habib M, et al. (2023). Concurrent Cardio-Cerebral Infarction: Meta-Analysis. Mathews J Case Rep. 8(2):87.

Copyrights: Habib M, et al. © (2023).

ABSTRACT

Background: The concurrent occurrence of acute ischemic stroke and acute myocardial infarction (concurrent Cardio-cerebral infarction) is an extremely rare emergency condition that can be lethal. The causes, prognosis and optimal treatment in these cases are still unclear. Methods: We conducted a comprehensive review of five databases, PubMed, Embase, Scopus, Research Gate and Google Scholar on concurrent or simulations and synchronous cardio-cerebral infarction to locate all case reports or case series done on this topic, we analyzed clinical presentations, risk factors, type of myocardial infarction, site of stroke, modified ranking scale at discharge and at 90 days after discharge and treatment options. Results: we identified 94 cases of concurrent cardio-cerebral infarction from case reports and series with mean age 62.5±12.6 years. Female 36 patients (38.3%), male 58 patients (61.7%). Median admission NIHSS 15 (range 1-30). 29 patients (30.8%) were treated using percutaneous coronary intervention (PCI) and Mechanical thrombectomy of cerebral vessels was done in 24 patients (25.5%). Only 21 (22.3%) were treated combination by both PCI and Mechanical thrombectomy of cerebral vessels. The outcome of 94 patients, the mortality rate at hospital discharge were in 24 patients from 72 patients with mortality rate (33.3%), the mortality rate at 90 days we recorded in 29 patients from 59 patients with mortality rate (49.2%). In patients with combination intervention treatment group: hospital mortality rate was 13.3% and 90-days mortality rate was: 23.5% compared with mortality rate in medical treatment (23.5% and 59.5% respectively (P value 0.038 and 0.012 respectively). Conclusion: despite its rarity, concurrent cardio-cerebral infarction prognosis is very poor, about third of patients died before discharge and half of patients died at 90 days after stroke. Only 22 % of patients treated by combination of both percutaneous coronary intervention and mechanical thrombectomy. Thus, further studies would be important to outline new possibilities in the management of this emergency condition.

Keywords: Acute Stroke, Myocardial Infarction, Percutaneous Coronary Intervention (PCI), Mechanical Thrombectomy (MTE), Modified Ranking Scale (mRS).

INTRODUCTION

Concurrent occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are very rare medical emergency conditions and leading causes of morbidity and mortality worldwide [1]. Both conditions have a narrow therapeutic time-window and have high risk of mortality. The use of intravenous thrombolytics for acute myocardial infarction (AMI) increase the risk for intracranial hemorrhagic [2-3], and the use of a thrombolytic in acute ischemic stroke (AIS) increase the risk of cardiac wall rupture in the setting of early hours of AMI [4].

The association between cerebrovascular disease and coronary artery disease were reported in the Global Registry of Acute Coronary Event (GRACE) trial suggested the incidence of intra-hospital stroke 0.9% in patients presenting with acute coronary syndrome, and the incidence was much higher in patients with ST elevation myocardial infarction than the non-ST elevation myocardial infarction [5].

The definition of concurrent cardio-cerebral infarction according to Alshifa Hospital classification [6], Concurrent cardio-cerebral infarction syndrome can be diagnosed by the presence of simultaneous onset of a focal neurological deficit, indicating acute stroke and a chest pain with evidence of elevation of cardiac enzymes and electrocardiogram changes to confirm myocardial infarction. The prevalence rates of concurrent CCI were between 0.009 to 0.29 % [7-9]. The present review examines that we analyzed clinical presentations, risk factors, type of myocardial infarction, site of stroke, modified ranking scale at discharge and at 90 days after discharge hemorrhage and treatment options.

METHODS

Study design and patient selection

In this meta-analysis, we screened retrospective a comprehensive review of five databases, PubMed, Embase, Scopus, Research Gate and Google Scholar on concurrent or simulations and synchronous Cardio-cerebral infarction to locate all case report or case series done on this topic. Based on the literature review, we analyzed all the cases of concurrent cardio cerebral infarction (Figure 1).

Figure 1. Flowchart summarizing case report selection.

Definitions of concurrent cardio-cerebral infarction

The occurrence of acute ischemic stroke (onset of a focal neurological deficit) and acute myocardial infarction (elevation of cardiac enzymes plus ischemic symptoms and/or ECG changes and/or loss of viable myocardium on noninvasive test and/or coronary artery thrombus on angiography) either at the same time or one after the other within 12 hours

Data collection

The following variables were collected: age and sex ,vascular risk factors (hypertension, diabetes mellitus, atrial fibrillation, history of coronary heart disease, dyslipidemia, smoking and previous stroke), stroke location (anterior vs posterior circulation; in anterior circulation strokes, right or left), stroke severity at admission evaluated by the National Institutes of Health Stroke Scale (NIHSS), first symptoms of cardio cerebral infarction ( chest pain: Myocardial infarction or neurological deficit: acute ischemic stroke or synchronous symptoms chest pain and neurological deficit at same time) stroke etiology, presence of large vessel occlusion, myocardial infarction electrocardiographic subtype (ST elevation myocardial infarction: STEMI vs Non ST elevation myocardial infarction: NSTEMI), in STEMI Cases localization: anterior, inferior and lateral, coronary angiography findings and infarcted related artery (culprit lesion) , AMI treatment namely percutaneous coronary intervention (PCI) and AIS treatment by mechanical thrombectomy (MTE). Antithrombotic medication, outcomes according to modified Rankin Scale (mRS) in-hospital and the 3-months were registered (Table 1).

Table 1. Concurrent CCI cases (age, sex, culprit lesion, treatment options, mRS in hospital and at 90 days) Results.

No.

Name/REF

age

Sex

Culprit

heart

Culprit

Brain

Treatment

tPA PCI MTE

MRS

discharge

MRS

90 d

1st event

1

Bao C-h[10]

75

M

LCX

NS

Y

DES

N

0

6

MI

2

Bao C-h[10]

84

M

RCA

NS

Y

A,DES

N

4

NR

CVA

3

Habib M[11]

61

M

LAD

LMCA

Y

B,DES

Y

1

0

MI

4

Nakajima H[12]

86

F

RCA

LMCA

N

A

Y

4

NR

SYN

5

Chong CZ[13]

45

M

LAD

RICA

N

DES

Y

NR

3

SYN

6

Chong CZ[13]

53

M

LAD

LMCA

N

DES

Y

NR

5

SYN

7

Chong CZ[13]

71

F

LAD

PCA

N

DES

Y

NR

6

SYN

8

Chong CZ[13]

55

M

NR

LMCA

Y

NO

N

NR

1

SYN

9

Chong CZ[13]

57

M

NR

LMCA

Y

NO

N

NR

1

SYN

10

Chong CZ[13]

51

M

LAD

LMCA

Y

DES

N

0

0

SYN

11

Chong CZ[13]

70

M

NR

PCA

N

NO

N

NR

6

SYN

12

Chong CZ[13]

45

M

LAD

LMCA

Y

DES

N

NR

1

SYN

13

Chong CZ[13]

67

M

LAD

NS

N

DES

N

NR

1

SYN

14

Chong CZ[13]

76

M

NR

RMCA

N

NO

N

NR

6

SYN

15

Ibekwe E[14]

43

M

LAD

LMCA

N

NO

N

6

6

CVA

16

Ibekwe E[14]

80

F

NR

LMCA

Y

NO

N

5

6

CVA

17

Ibekwe E[14]

72

M

NR

LMCA

N

NO

N

6

6

CVA

18

Eskandarani R[15]

62

M

NR

LCCA

N

NO

N

6

6

CVA

19

Eskandarani R[15]

50

M

NR

NR

N

NO

N

5

NR

CVA

20

Eskandarani R[15]

50

M

NR

LMCA

N

NO

N

2

NR

CVA

21

Eskandarani R[15]

67

F

NR

RICA

NR

NO

N

6

6

SYN

22

Eskandarani R[15]

56

M

NR

RICA

N

NO

N

5

NR

MI

23

Iqbal P[16]

65

M

NR

LMCA

Y

NO

N

NR

NR

CVA

24

Abe S[17]

73

F

RCA

LMCA

Y

NO

Y

2

2

CVA

25

Katsuki M[18]

72

M

RCA

PCA

N

NO

N

5

NR

MI

26

Gungoren F[19]

69

M

LAD

LMCA

Y

DES

N

2

NR

SYN

27

Obaid O[12]

41

F

LAD

LMCA

Y

A,DES

N

5

NR

CVA

28

Sakuta K[21]

55

F

RCA

LMCA

N

B

Y

3

3

CVA

29

Wan Asyraf WZ[22]

33

M

NR

LMCA

Y

NO

N

1

NR

CVA

30

Chen KW[23]

76

M

LAD

RICA

Y

A

Y

1

NR

CVA

31

Nardai S[24]

67

F

LAD

LMCA

N

DES

Y

1

NR

CVA

32

Seiya Nagao[25]

86

F

LCX

LMCA

Y

DES

Y

3

NR

CVA

33

Cabral M[26]

46

F

RCA

LICA

N

B,A,DES

N

NR

NR

MI

34

Plata-Corona JC[27]

46

M

LAD

RMCA

Y

DES

Y

2

0

CVA

35

Yeo LL[28]

45

M

LAD

RICA

N

DES

Y

NR

3

MI

36

Yeo LL[28]

53

M

LAD

LMCA

N

BMS

Y

NR

5

CVA

37

Yeo LL[28]

71

F

LAD

PCA

N

DES

Y

6

6

CVA

38

Yeo LL[28]

55

M

NR

LMCA

Y

NO

N

1

1

CVA

39

Yeo LL[28]

57

M

NR

LMCA

Y

NO

N

1

1

CVA

40

Kijpaisalratana N[29]

65

M

LCX

RMCA

Y

DES

N

NR

NR

CVA

41

Kijpaisalratana N[29]

64

M

LAD

RMCA

N

B

N

6

6

SYN

42

Hosoya H[30]

50

M

NR

NR

N

NO

N

NR

NR

MI

43

Maciel R[31]

44

M

NR

RMCA

Y

NO

N

3

2

MI

44

Wee CK[32]

49

M

RCA

PCA

N

A

N

5

2

CVA

45

Tokuda K[33]

87

F

RCA

RMCA

N

A

Y

NR

3

CVA

46

González- H[34]

66

F

RCA

NR

Y

B

N

NR

NR

SYN

47

Hashimoto O[35]

84

M

LAD

NR

N

A

N

2

NR

SYN

48

Kim HL[36]

58

M

LAD

LMCA

N

A,DES

N

NR

NR

CVA

49

Kleczyński P[37]

62

M

LAD

NR

N

A,B

N

NR

NR

MI

50

Omar HR[38]

48

M

NR

PCA

N

NO

N

6

6

SYN

51

Khairy M[39]

70

F

NR

NR

Y

NO

N

6

6

SYN

52

Lee Kijeong[40]

54

M

RCA

RMCA

Y

DES

Y

6

6

CVA

53

Yusuf M[41]

56

M

RCA

NR

N

DES

N

NR

1

MI

54

Bhandari M[42]

38

M

NR

LMCA

N

NO

N

6

6

MI

55

Mai Duy T[43]

79

M

RCA

NS

Y

A

N

2

NR

CVA

56

Bersano A[44]

70

F

NR

RMCA

N

NO

N

4

1

SYN

57

T. NISHIMURA[45]

50

F

RCA

RMCA

N

NO

N

2

NR

MI

58

Grogono J[46]

39

F

LAD

NR

N

NO

N

1

NR

SYN

59

Almasi M[47]

78

F

RCA

ACA

Y

A,BMS

N

NR

NR

CVA

60

Karunathilake P[48]

59

F

NR

NR

N

NO

N

3

3

MI

61

Polo Taborda[49]

64

F

NR

RMCA

Y

NO

N

NR

NR

CVA

62

Nguyen TL[50]

60

M

RCA

LCCA

N

NO

N

NR

NR

SYN

63

Loffi M[51]

69

F

LCX

LICA

Y

A

N

6

6

CVA

64

Yong TH[52]

53

M

RCA

RMCA

N

DES

N

1

1

SYN

65

Yong TH[52]

61

M

LCX

LICA

N

DES

N

5

4

CVA

66

Yong TH[52]

80

M

RCA

NR

N

DES

N

2

1

CVA

67

Kawano H[53]

49

M

NS

RMCA

N

NO

N

6

6

SYN

68

Wang X[54]

72

F

NR

RICA

N

NO

N

6

6

CVA

69

Chlapoutakis GN[55]

50

F

NS

NS

N

NO

N

1

1

CVA

70

Koneru S[56]

50

M

NR

LICA

N

NO

N

1

1

CVA

71

Wallace EL[57]

70

M

RCA

LICA

Y

A,BMS

N

NR

NR

CVA

72

Meissner W[58]

62

F

LAD

RMCA

Y

B

N

6

6

CVA

73

Sweta A[59]

78

M

NR

RMCA

Y

NO

N

6

6

CVA

74

Sweta A[59]

58

F

NR

LMCA

Y

NO

N

6

6

CVA

75

Yang CJ[60]

79

M

RCA

LMCA

Y

B,DES

N

2

NR

CVA

76

Brz˛eczekM[61]

62

M

RCA

LMCA

NR

A,DES

N

1

NR

MI

77

Manea MM[62]

87

F

RCA

RMCA

Y

A,DES

N

6

6

CVA

78

Cai X-Q[63]

59

M

LAD

RICA

Y

DES

Y

1

1

MI

79

Fitzek S[64]

88

F

NR

RMCA

Y

NO

N

6

6

CVA

80

Mehdiratta M[65]

65

F

NR

RMCA

Y

NO

N

6

6

CVA

81

Mehdiratta M[65]

81

F

LAD

LMCA

Y

B,DES

N

6

6

CVA

82

Mehdiratta M[65]

75

F

NS

RMCA

Y

NO

N

NR

NR

CVA

83

Y-Hassan S[66]

67

F

NS

PCA

N

NO

Y

2

2

SYN

84

Wang B[67]

84

M

LAD

PCA

Y

DES

N

1

NR

CVA

85

Stafford P J[68]

69

F

NR

NR

Y

NO

N

6

6

MI

86

Stafford P J[68]

57

M

NR

NR

Y

NO

N

6

6

MI

87

Peng H[69]

60

M

RCA

NR

Y

DES

N

1

1

SYN

88

Chang GY[70]

56

M

NR

LMCA

Y

NO

N

NR

NR

MI

89

O. Kawarada[71]

64

F

LAD

RMCA

N

A,DES

Y

1

1

MI

90

Sihite T A[72]

69

M

LAD

NR

N

DES

N

1

NR

MI

91

ABUHEIT E[73]

49

M

RCA

RMCA

N

DES

Y

4

1

MI

92

Abdi IA[74]

51

M

NR

RMCA

Y

NO

N

2

1

MI

93

de Castillo LLC[75]

56

M

NR

PCA

Y

DES

y

2

1

CVA

94

de Castillo LLC[75]

56

M

NR

PCA

N

NO

N

2

2

CVA

95

de Castillo LLC[75]

56

M

NR

PCA

N

NO

N

6

6

CVA

96

de Castillo LLC[75]

56

M

NR

NR

N

NO

N

6

6

CVA

97

de Castillo LLC[75]

56

F

NR

NR

N

NO

N

6

6

CVA

98

de Castillo LLC[75]

56

F

NR

NR

N

NO

N

4

2

CVA

99

de Castillo LLC[75]

56

F

NR

NR

N

NO

N

4

NR

CVA

100

de Castillo LLC[75]

56

F

NR

NR

N

NO

N

4

NR

CVA

101

de Castillo LLC[75]

56

F

NR

NR

N

NO

N

4

NR

MI

102

M. Habib[76]

72

M

RCA

RMCA

Y

DES

Y

1

6

MI

N: not done, NR: not reported, NS: non-significant lesion, Y: yes- done, M: male, F: female, LAD: left anterior descending artery, RCA: right coronary artery, LCX: left circumflex, RMCA: right middle cerebral artery, LMCA: left middle cerebral artery, PCA: posterior cerebral artery, ACA: anterior cerebral artery, RICA: right internal carotid artery, LICA: left internal carotid artery, LCCA: left common carotid artery, RVA; right vertebral artery. A: thrombus aspiration, B: balloon angioplasty, DES: drug eluting stent, BMS: bare-metal stent, SYN: synchronized.

Intervention treatment

Combination of treatment by: AMI treatment namely percutaneous coronary intervention (PCI) and AIS treatment by mechanical thrombectomy (MTE) from cerebral arteries.

Statistical analysis

Baseline variables Continuous data are reported as means ± SD. Categorical data are presented as absolute values and percentages. NIHSS, hospitalization time, and time between acute ischemic stroke and acute myocardial infarction calculated as median (lower-upper value). Using the x2, Fisher for calculation mortality rate between female and male, and between patients treated with combination treatment with PCI plus MTE and medical treatment. Significance level was set at P value < 0.05. Statistical analysis was performed with SPSS Statistics, Version 23.0.

RESULTS

Patient Characteristics

Total 102 cases were collected from literature; 8 cases were excluded due to the time between stroke and myocardial infarctions were more than 12 hours. Total 94 cases were analyzed, the mean age 62.5±12.6 years. Female 36 patients (38.3%), male 58 patients (61.7%). Median hospital duration 24 hours (0-792 hours). Time between stroke and myocardial infarction 0.5 hour (0-12 hours). The most common risk factors of concurrent CCI was hypertension (46.8%) followed by diabetes mellitus and atrial fibrillation. The median NIHSS was 15 (range: 1-30) and the most type of myocardial infarction type was anterior ST segment elevation myocardial infarction (38.3%), the most culprit lesion in coronary arteries was left anterior descending artery (28.7%), the most common culprit artery in brain was left middle cerebral artery (30.9%). Cardiac and neurological investigations were performed on 94 patients by both ECG and computed tomography (CT) or magnetic resonance imaging (Table 2).

Table 2. Patient Characteristics.

Risk factors

Hypertension

44 (46.8%)

Diabetes mellitus

26 (27.7%)

Atrial fibrillation

19 (20.2%)

Previous stroke

11 (11.7%)

Smoker

16 (17%)

History of Coronary artery disease

11(11.7)

Dyslipidemia

19 (20.2%)

Stroke severity NIHSS (median)

15(1-30)

The type of myocardial infarction

Anterior ST segment elevation

36 (38.3%)

Inferior wall St segment elevation

26 (27.7%)

Non-ST elevation myocardial infarction

20 (21.3%)

Inferior ST elevation and Right ventricle infarction

5 (5.3%)

High Lateral ST elevation Myocardial infarction

2 (2.1%)

Non-Reported

5 (5.3%)

Infarcted related artery (IRA)

Left anterior descending artery

27 (28.7%)

Right coronary artery

22 (23.4%)

Left circumflex artery

4 (4.3%)

No significant stenosis

3 (3.2)

Non reported

38 (40.4%)

Culprit stenosis in cranial arteries

Middle cerebral artery

Right 18 (19.1%), Left 29 (30.9%)

Basilar artery

10 (10.6%)

Internal carotid artery

Right 7(7.4%), Left 5 (5.3%)

Non reported

17 (18.1%)

No stenosis

4 (4.3%)

Anterior cerebral artery

1 (1.1%)

Left common carotid artery

2(2.1%)

Right vertebral artery

1(1.1%)

Treatments in concurrent Cardio-cerebral Infarction Patients

Medication: Alteplase forty-one patients were treated with intravenous t-PA (43.6%), for antiplatelet and anticoagulation 69 (73%) patients were reported and 25 (27%) patients not reported, Dual antiplatelet 27 (39 %) patients, single antiplatelet 7 (10%) patients, combination of dual antiplatelet and anticoagulation 26 (37.7%) patients (5 NOAC and 21 warfarin), combination of single antiplatelet and anticoagulation 5 (7%) patients (3 warfarin and 2 NOAC), anticoagulation alone 4 (6%) patients ( 1 NOAC and 3 warfarin).

Interventions procedures: percutaneous coronary intervention (PCI) was used to treat 29 patients (30.8%): PCI with balloon only 9 (9.6%), PCI with aspiration only 1 (3.2%), PCI with Bare metal stent 3 (3.2%), PCI with Drug eluting stent 16 (17%). Treated via Mechanical thrombectomy of cerebral vessels in 24 patients (25.5%). Only 21 (22.3%) were treated combination by both PCI and Mechanical thrombectomy of cerebral vessels.

Causes of cardio cerebral infarction

The most common cause of cardio cerebral infarction was cardiogenic shock. Hypotension (37.2%), and heart failure (37.2%), then by atrial fibrillation (25.5%) and left ventricle thrombus (21.3%) (Table 3).

Table 3. Causes of cardio cerebral infarction.

Cardiogenic shock/hypotension

35 (37.2%)

Atrial fibrillation

24 (25.5%)

Left ventricle thrombus

20 (21.3%)

Atherosclerosis

32 (34%)

COVID-19 infection

6(6.4%)

Heart failure

35 (37.2%)

Aortic dissection

 4 (4.3%)

Malignancy

2(2.1%)

Patent foramen ovale

1 (1.1)

Causes of death

We identified confirm causes of death in only 23 patients. The most causes of patient were cardiac causes 18 (78%) such as ventricle tachyarrhythmias, cardiac Tamponade, aortic dissection, ventricle septal rupture or sudden death. Noncardiac causes 5 (22%): sepsis, infections and multi organ failure.

Outcomes

We calculated outcome according to modified ranking scale which 0-2: mild disability, 3-5: moderate to severe disability and 6: death. The modified Rankin Score (mRS) was measured in 72 patients at hospital and in 59 patients at 90 days.

The mortality rate was 33.3% at hospital discharge measured from 72 (76.6%) patients and at 90 days the mortality rate was (49.2%) measured from 59 (62.8%) patients (Table 4)

Table 4. Modified ranking scale (mRS) outcomes at hospital discharge and at 90 days after cardio-cerebral infarction.

Modified ranking scale at hospital discharge (number: 72 patients)

mRS 0-2 (mild disability)

32 (44.4%)

mRS 3-5 (moderate to severe disability)

16 (22.3%)

mRS 6 (death)

24 (33.3%)

Modified ranking scale at 90 days (number 59 patients)

mRS 0-2 (mild disability)

22 (37.3%)

mRS 3-5 (moderate to severe disability)

8 (13.5%)

mRS 6 (death)

29 (49.2%)

Sex and in-hospital mortality

The hospital mortality rate in male was 11 from 58 patients (18.9%) and in female 13 from 36 patients (35%) the p value is 0.063.

Hospital and 90 days outcomes according to combination of intervention (PCI plus MTE)

We identified 21 cases of concurrent cardio-cerebral infarction. Female 8 patients (38.1%), male 13 patients (61.9%). Interventions procedures: percutaneous coronary intervention (PCI) was used to treat 21 patients: PCI with balloon only 3 (14%), PCI with aspiration only 1 (5%), PCI with Bare metal stent 1 (5%), PCI with Drug eluting stent 16 (76%). treated via Mechanical thrombectomy of cerebral vessels in 21 patients (100%). The outcome of 21 patients, we can calculate modified ranking scale (mRS) at discharge from 15 patients: mRS 0-2: 8 (53.3%) patients, mRS 3-5: 7 (46.7%) patients, mRS 6: 2 (13.3%), the mRS at 90 days we reached from 17 patients, the mRS was 0-2: 7 (41% %) patients, 3-5: 6 (35 %) patients and 6: 4 (23.5%) Patients.

Difference of mortality rate between combination intervention treatment and medical treatment

The mortality rate was significantly lower in patient with combination intervention group than medical treatment). In medical group patients: 8 patients were treated with PCI plus medications and 3 treated with MTE plus medications and other patients treated with medication alone) (Table 5).

Table 5. Mortality rate between combination intervention treatment and medical treatment.

 

Intervention (PCI and MTE)

Medical treatment

P value

Hospital mortality

13.3% (2/15)

38.6% (22/57)

0.038

90 days mortality

23.5% (4/17)

59.5% (25/42)

0.012

Outcome according to first presentation symptoms

First presentation myocardial infarction symptoms followed by acute ischemic stroke symptoms were reported in 18 (19.1%) patients. In those patients the most common stroke type (total: 18 cases, 14 cases were reported and 4 cases none reported) anterior circulation (86%) with right middle cerebral artery and right internal carotid artery occlusion (RMCA: 4 patients, LMCA: 2 patients, Basilar artery 2 patients, RICA: 2), and this group had the highest mortality rate 33.3%.

The first acute ischemic stroke symptoms followed by acute myocardial infarction symptoms 50 (53.2%) patients. The type of MI: inferior STEMI 19 patients, anterior STEMI 17 patients, Non-STEMI 13 patients and 1 patient high lateral STEMI. Coronary angiography to confirm culprit lesion were reported in 28 patients (13 patients RCA and 2 Patients LCX, 11 patients LAD and 2 patients' non-significant stenosis), the mortality rate in this patient was reported in 13 patients 26%.

The same time presentation of myocardial infarction and acute ischemic stroke symptoms in 26(27.7%) patients. the mortality rate in this patient was reported in 5 (19%).

DISCUSSION

We present a total of 94 patients with concurrent cardio-cerebral infarction and we reported multiple causes which can be categorized into five types:

  1. Embolic (left ventricle thrombus in patients with previous myocardial infarction or dilated cardiomyopathy, left atrial appendage thrombus in patients with atrial fibrillation).
  2. Hypotensive (patients with cardiogenic shock and heart failure).
  3. Atherosclerotic (patient with hypertension, smoking, diabetes mellitus and previous coronary artery disease).
  4. Hyper coagulant states (COVID 19 infection, Polycythemia, malignancy and patent foramen ovale).
  5. Mechanical complication (aortic dissection).

The left ventricle systolic dysfunction and atrial fibrillation are increasing the likelihood of embolic stroke due to thrombus formation in the left ventricle and left atrial appendage. These two phenomena have been commonly reported in this analysis.

About half of the patients were presented with acute ischemic stroke symptoms followed by acute myocardial infarction symptoms 50 (53.2%). In this patient the most common MI type was inferior MI. First presentation myocardial infarction symptoms followed by acute ischemic stroke symptoms were reported in 18 (19.1%) patients. In this patient the most common stroke type anterior circulation with right middle cerebral artery or right internal carotid artery occlusion. The same time presentation of myocardial infarction and acute ischemic stroke symptoms in 26(27.7%) patients.

For alteplase medication forty-one patients were treated with intravenous alteplase (43.6%), percutaneous coronary intervention (PCI) was used to treat 29 patients (30.8%). Mechanical thrombectomy of cerebral vessels in 24 patients (25.5%). only 21 (22.3%) were treated combination by both PCI and Mechanical thrombectomy of cerebral vessels. The main concerns about giving alteplase 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. According to the 2018 scientific statement guideline from the American Heart Association/American Stroke Association (AHA/ASA), For patients presenting with synchronous AIS and AMI, treatment with intravenous alteplase at the dose appropriate for acute ischemic stroke, followed by percutaneous coronary intervention (PCI) and stenting if indicated, is reasonable [77]. The new recommendation according to 2021 guidelines of European Stroke Organization (ESO) on intravenous thrombolysis for acute ischemic stroke suggested that [78]: Contraindication of alteplase for patients with acute ischemic stroke of < 4.5 h duration and with history of sub-acute (> 6 h) ST segment elevation myocardial infarction during the last seven days. The intravenous alteplase also contraindications in patients with acute STEMI with recent acute ischemic stroke if stroke duration more than 4.5 hours from onset symptoms [79]. So that if AIS after 6 hours from STEMI onset, or STEMI after 4.5 hours from AIS intravenous alteplase is contraindication. In these conditions we recommended intervention treatment with PCI and/or MTE.

Our meta-analysis showed that concurrent CCI had high in-hospital mortality rate 33.3%, and 3-month mortality rate 49.2%. In-hospital mortality rate was higher in male (35%) than female (18.9%) and 78% of death related to cardiovascular causes. Lennie Lynn C. de Castillo et al [75], in case series involved 9 patients with concurrent CCI reported mortality rate 45% and cardiovascular death was 69% (8), In another metanalysis of 44 patients, ten patients died (23%), and nine (90%) of those were due to cardiac causes [80]. The uses of combination of intervention reduce hospital mortality to 13.3% and 90-days mortality to 25.3%. (P value: 0.038 and 0.012 respectively)

The most common co-morbidities that patients presented with included hypertension, smoking, atrial fibrillation and diabetes mellitus. A greater number of male patients were noted but the mortality rate was higher in female patient. The combination intervention (PCI and MTE) treatment was significantly reduce mortality.

CONCLUSION

The occurrence of concurrent cardio cerebral infarction is to the best of our knowledge, this is the largest meta-analysis on the concurrent cardio cerebral infarctions, encompassing of 94 patients. Rare with high risk of mortality rate especially in female patients. The intervention with PCI and MTE was significantly reduces the mortality rate. Further studies will need to examine the optimum treatment strategies

DECLARATION OF COMPETING INTERESTS

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

REFERENCES

  1. White H, Boden-Albala B, Wang C, et al. (2005). Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. 111(10):1327-1331.
  2. Zinkstok SM, Roos YB. (2012). Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: A randomised controlled trial. Lancet. 380(9843):731-737.
  3. Sandercock PA, Counsell C, Kane EJ. (2015). Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev. 10(10):CD000024.
  4. Patel MR, Meine TJ, Lindblad L, et al. (2006). Cardiac tamponade in the fibrinolytic era: analysis of >100,000 patients with ST-segment elevation myocardial infarction. Am Heart J. 151(2):316-322.
  5. Budaj A, Flasinska K, Gore JM, et al. (2005). Magnitude of and risk factors for in-hospital and postdischarge stroke in patients with acute coronary syndromes: Findings from a global registry of acute coronary events. Circulation. 111(24):3242-3247.
  6. Habib M. (2021). Cardio-Cerebral Infarction Syndrome (CCIS): Definition, Diagnosis, Pathophysiology and Treatment. Cardiology and Cardiovascular Research. 5(2):84-93.
  7. Chong CZ, Tan BY, Sia CH, Khaing T, Litt Yeo LL. (2022). Simultaneous cardiocerebral infarctions: a five-year retrospective case series reviewing natural history. Singapore Med J. 63(11):686-690.
  8. de Castillo LLC, Diestro JDB, Tuazon CAM, Sy MCC, Añonuevo JC, San Jose MCZ. (2021). Cardiocerebral Infarction: A Single Institutional Series. J Stroke Cerebrovasc Dis. 30(7):105831.
  9. Yeo LLL, Andersson T, Yee KW, Tan BYQ, Paliwal P, et al. (2017). Synchronous cardiocerebral infarction in the era of endovascular therapy: which to treat first? J Thromb Thrombolysis 44(1):104-111.
  10. Bao C-h, Zhang C, Wang X-m, Pan Y-b. (2022). Concurrent acute myocardial infarction and acute ischemic stroke: Case reports and literature review. Front Cardiovasc Med. 9:1012345.
  11. Habib M. (2022). Synchronous Cardio-Cerebral Infarction Syndrome with Cardiogenic Shock. Is it Safe to Perform Rescue Percutaneous Coronary Intervention and Mechanical Thrombectomy for Middle Cerebral Artery? EC Neurology. 14:12.
  12. Nakajima H, Tsuchiya T, Shimizu S, Watanabe K, Kitamura T, Suzuki H. (2022). Endovascular therapy for cardiocerebral infarction associated with atrial fibrillation: A case report and literature review. Surg Neurol Int. 13:479.
  13. Chong CZ, Tan BY, Sia CH, Khaing T, Yeo LL. (2021). Simultaneous cardiocerebral infarctions: a five-year retrospective case series reviewing natural history. Singapore Med J. 63(11):686-690.
  14. Ibekwe E, Kamdar HA, Strohm T. (2022). Cardio-cerebral infarction in left MCA strokes: a case series and literature review. Neurol Sci. 43(4):2413-2422.
  15. Eskandarani R, Sahli S, Sawan S, Alsaeed A. (2021). Simultaneous cardio-cerebral infarction in the coronavirus disease pandemic era: a case series. Medicine (Baltimore). 100(4):e24496.
  16. Iqbal P. (2021). The role of anticoagulation in post-COVID-19 concomitant stroke, myocardial infarction, and left ventricular thrombus: a case report. Am J Case Rep. 22(1):1-6.
  17. Abe S, Tanaka K, Yamagami H, Sonoda K, Hayashi H, Yoneda S, et al. (2019). Simultaneous cardio-cerebral embolization associated with atrial fibrillation: a case report. BMC Neurol. 19(1):152.
  18. Katsuki M, Katsuki S. (2019). A case of cardiac tamponade during the treatment of simultaneous cardio-cerebral infarction associated with atrial fibrillation-case report. Surg Neurol Int. 10:241.
  19. Gungoren F, Besli F, Tanriverdi Z, Kocaturk O. (2019). Optimal treatment modality for coexisting acute myocardial infarction and ischemic stroke. Am J Emerg Med. 37(4):795.e1-795.e4.
  20. Obaid O, Smith HR, Brancheau D. (2019). Simultaneous Acute Anterior ST-Elevation Myocardial Infarction and Acute Ischemic Stroke of Left Middle Cerebral Artery: A Case Report. Am J Case Rep. 20:776-779.
  21. Sakuta K, Mukai T, Fujii A, Makita K, Yaguchi H. (2019). Endovascular Therapy for Concurrent Cardio-Cerebral Infarction in a Patient With Trousseau Syndrome. Front Neurol. 10:965.
  22. Wan Asyraf WZ, Elengoe S, Che Hassan HH, Abu Bakar A, Remli R. (2020). Concurrent stroke and ST-elevation myocardial infarction: is it a contraindication for intravenous tenecteplase? Med J Malaysia 75(2):169-170.
  23. Chen KW, Tsai KC, Hsu JY, Fan TS, Yang TF, Hsieh MY. (2022). One-step endovascular salvage revascularization for concurrent coronary and cerebral embolism. Acta Cardiol Sin. 38(2):217-220.
  24. Nardai S, Vorobcsuk A, Nagy F, Vajda Z. (2021). Successful endovascular treatment of simultaneous acute ischaemic stroke and hyperacute ST-elevation myocardial infarction: The first case report of a single-operator cardio-cerebral intervention. Eur Heart J Case Rep. 5(11):ytab419.
  25. Nagao S, Tsuda Y, Narikiyo M, Nagayama G, Nagasaki H, Tsuboi Y, Itou N, et al. (2019). A case of a patient with endovascular treatment after intravenous t-PA therapy for the acute cerebral infarction and acute myocardial infarction. Japanese Journal of Stroke. 41(1):7-12.
  26. Cabral M, Ponciano A, Santos B, Morais J. (2022). Cardiocerebral Infarction: A Combination to Prevent. Int J Cardiovasc Sci. 36:e20210276.
  27. Plata-Corona JC, Cerón-Morales JA, Lara-Solís B. (2019). Nonhyperacute synchronous cardio-cerebral infarction treated by double intervensionist therapy. Cardiovasc Metab Sci. 30(2):66-75.
  28. Yeo LL, Andersson T, Yee KW, et al. (2017). Synchronous cardiocerebral infarction in the era of endovascular therapy: which to treat first? J Thromb Thrombolysis. 44:104-111.
  29. Kijpaisalratana N, Chutinet A, Suwanwela NC. (2017). Hyperacute simultaneous cardiocerebral infarction: rescuing the brain or the heart first? Front Neurol 8:664.
  30. Hosoya H, Levine JJ, Henry DH, Goldberg S. (2017). Double the trouble: acute coronary syndrome and ischemic stroke in polycythemia vera. Am J Med. 130(6):e237-e240.
  31. Maciel R, Palma R, Sousa P, et al. (2015). Acute stroke with concomitant acute myocardial infarction: Will you thrombolyse? J Stroke. 17(1):84-86.
  32. Wee CK, Divakar Gosavi T, Huang W. (2015). The clot strikes thrice: case report of a patient with 3 concurrent embolic events. Acta Neurol Taiwan. 24(3):92-96.
  33. Tokuda K, Shindo S, Yamada K, Shirakawa M, Uchida K, Horimatsu T, et al. (2016). Acute Embolic Cerebral Infarction and Coronary Artery Embolism in a Patient with Atrial Fibrillation Caused by Similar Thrombi. J Stroke Cerebrovasc Dis. 25(7):1797-1799.
  34. González-Pacheco H, Méndez-Domínguez A, Vieyra-Herrera G, Azar-Manzur F, Meave-González A, Rodríguez-Zanella H, et al. (2014). Reperfusion strategy for simultaneous ST-segment elevation myocardial infarction and acute ischemic stroke within a time window. Am J Emerg Med. 32(9):1157.e1-1157.e4.
  35. Hashimoto O, Sato K, Numasawa Y, Hosokawa J, Endo M. (2014). Simultaneous onset of myocardial infarction and ischemic stroke in a patient with atrial fibrillation: multiple territory injury revealed on angiography and magnetic resonance. Int J Cardiol. 172(2):e338-e340.
  36. Kim HL, Seo JB, Chung WY, Zo JH, Kim MA, Kim SH. (2013). Simultaneously presented acute ischemic stroke and non-st elevation myocardial infarction in a patient with paroxysmal atrial fibrillation. Korean Circ J. 43(11):766-769.
  37. Kleczyński P, Dziewierz A, Rakowski T, Rzeszutko L, Sorysz D, Legutko J, et al. (2012). Cardioembolic acute myocardial infarction and stroke in a patient with persistent atrial fibrillation. Int J Cardiol. 161(3):e46-e47.
  38. Omar HR, Fathy A, Rashad R, et al. (2010). Concomitant acute right ventricular infarction and ischemic cerebrovascular stroke; possible explanations. Int Arch Med. 3:25.
  39. Khairy M, Lu V, Ranasinghe N, Ranasinghe L. (2021). A Case Report on Concurrent Stroke and Myocardial Infarction. Asp Biomed Clin Case Rep. 4(1):42-49.
  40. Kijeong L, Woohyun P, Kwon-Duk S, Hyeongsoo K. (2021). Which one to do first? a case report of simultaneous acute ischemic stroke and myocardial infarction. Journal of Neurocritical Care. 14(2):109-112.
  41. Yusuf M, Pratama IS, Gunadi R, Sani AF. (2021). Hemodynamic Stroke in Simultaneous Cardio Cerebral Infarction: A New Term for Cardiologist. Open Access Maced J Med Sci. 9(C):114-117.
  42. Bhandari M, Pradhan AK, Vishwakarma P, Sethi R. (2022). Concurrent Coronary, Left Ventricle, and Cerebral Thrombosis-A Trilogy. Int J Appl Basic Med Res. 12(2):130-133.
  43. Mai Duy T, DaoViet P, Nguyen Tien D, Nguyen QA, Nguyen Tat T, Hoang VA, et al. (2019). Coronary aspiration thrombectomy after using intravenous recombinant tissue plasminogen activator in a patient with acute ischemic stroke: a case report. J Int Med Res. 47(9):4551-4556.
  44. Bersano A, Melchiorre P, Moschwitis G, Tavarini F, Cereda C, Micieli G, et al. (2014). Tako-tsubo syndrome as a consequence and cause of stroke. Funct Neurol. 29(2):135-137.
  45. Nishimura T, Kobashi D, Nakamura M, Takahashi Y, Maruyama J, Sasaki T. (2022). Cardio-cerebral infarction with splenic infarction. Journal of Japanese Society for Emergency Medicine. 25(1):84-88.
  46. Grogono J, Fitzsimmons SJ, Shah BN, Rakhit DJ, Gray HH. (2012). Simultaneous myocardial infarction and ischaemic stroke secondary to paradoxical emboli through a patent foramen ovale. Clin Med (Lond). 12(4):391-392.
  47. Almasi M, Razmeh S, Habibi AH, Rezaee AH. (2016). Does Intravenous Administration of Recombinant Tissue Plasminogen Activator for Ischemic Stroke can Cause Inferior Myocardial Infarction? Neurol Int. 8(2):6617.
  48. Karunathilake P, Rajaratnam A, Kularatne WKS, et al. (2022). Lessons learned from the management of a case of acute synchronous cardio cerebral infarction in a resource-poor setting, 09 June 2022, PREPRINT (Version 1).
  49. Nelson PT, Guillermo B, Flavia P. Acute cardio-cerebral simultaneous infarction: a purpose of a case. Rev. average Clin. Counts. 31(5/6):487-490.
  50. Nguyen TL, Rajaratnam R. (2011). Dissecting out the cause: a case of concurrent acute myocardial infarction and stroke. BMJ Case Rep. 2011:bcr0220113824.
  51. Loffi M, Besana M, Regazzoni V, Enrico P, Giuli VD, et al. (2021). A masked ST-elevation myocardial infarction. J Clin Images Med Case Rep. 2(4):1249-1251.
  52. Yong TH, See JHJ, Liew BW. (2022). STEMI during Cardiocerebral Infarction (CCI): Is it Safe to Perform Primary Percutaneous Coronary Intervention? Int J Clin Cardiol. 9:251.
  53. Kawano H, Tomichi Y, Fukae S, Koide Y, Toda G, Yano K. (2006). Aortic dissection associated with acute myocardial infarction and stroke found at autopsy. Intern Med. 45(16):957-962.
  54. Wang X, Li Q, Wang Y, Zhao Y, Zhou S, Luo Z, et al. (2021). A case report of acute simultaneous cardiocerebral infarction: possible pathophysiology. Ann Palliat Med. 10(5):5887-5890.
  55. Chlapoutakis GN, Kafkas NV, Katsanos SM, Kiriakou LG, Floros GV, Mpampalis DK. (2010). Acute myocardial infarction and transient ischemic attack in a patient with lone atrial fibrillation and normal coronary arteries. Int J Cardiol. 139(1):e1-e4.
  56. Koneru S, Jillella DV, Nogueira RG. (2021). Cardio-Cerebral Infarction, Free-Floating Thrombosis and Hyperperfusion in COVID-19. Neurol Int. 13(2):266-268.
  57. Wallace EL, Smyth SS. (2012). Spontaneous coronary thrombosis following thrombolytic therapy for acute cardiovascular accident and stroke: a case study. J Thromb Thrombolysis. 34(4):548-551.
  58. Meissner W, Lempert T, Saeuberlich-Knigge S, Bocksch W, Pape UF. (2006). Fatal embolic myocardial infarction after systemic thrombolysis for stroke. Cerebrovasc Dis. 22(2-3):213-214.
  59. Sweta A, Sejal S, Prakash S, Vinay C, Shirish H. (2010). Acute myocardial infarction following intravenous tissue plasminogen activator for acute ischemic stroke: An unknown danger. Ann Indian Acad Neurol. 13(1):64-66.
  60. Yang CJ, Chen PC, Lin CS, Tsai CL, Tsai SH. (2017). Thrombolytic therapy-associated acute myocardial infarction in patients with acute ischemic stroke: A treatment dilemma. Am J Emerg Med. 35(5):804.e1-804.e3.
  61. BrzeczekM, KidawaM, Ledakowicz-Polak A, et al. (2019). Myocardial infarction with simultaneous acute stroke in a patient with prior aortic graft replacement-what is the origin of the embolic incident? Folia Cardiol. 14(2):166-168.
  62. Manea MM, Dragos D, Stoica E, Bucsa A, Marinica I, Tuta S. (2018). Early ST-segment elevation acute myocardial infarction after thrombolytic therapy for acute ischemic stroke: a case report. Medicine (Baltimore). 97(50):e13347.
  63. Cai X-Q, Wen J, Zhao Y, Wu Y-L, Zhang H-P, Zhang WZ. (2017). Acute ischemic stroke following acute myocardial infarction: adding insult to injury. Chin Med J (Engl). 130(9):1129-1130.
  64. Fitzek S, Fitzek C. (2015). A myocardial infarction during intravenous recombinant tissue plasminogen activator infusion for evolving ischemic stroke. Neurologist. 20(3):46-47.
  65. Mehdiratta M, Murphy C, Al-Harthi A, Teal PA. (2007). Myocardial infarction following t-PA for acute stroke. Can J Neurol Sci. 34(4):417-420.
  66. Y-Hassan S, Winter R, Henareh L. (2015). The causality quandary in a patient with stroke, Takotsubo syndrome and severe coronary artery disease. J Cardiovasc Med (Hagerstown). 16(Suppl 2):S118-S221.
  67. Wang B, Patel H, Snow T, et al. (2011). ST-elevation myocardial infarction following thrombolysis for acute stroke: a case report. West Lond Med J. 3(1):7-13.
  68. Stafford PJ, Strachan CJ, Vincent R, Chamberlain DA. (1989). Multiple microemboli after disintegration of clot during thrombolysis for acute myocardial infarction. British Medical Journal. 299(6711):1310-1312.
  69. Peng H, Chen M, Li G, et al. (2015). Combination refusion therapy for a hemodynamically unstable patient with acute myocardial infarction complicated by acute ischemic stroke within a time window. Int J Cardiol. 201:152-153.
  70. Chang GY. (2001). An ischemic stroke during IV tPA infusion for evolving myocardial infarction. Eur J Neurol. 8(3):267-268.
  71. Kawarada O, Yokoi Y. (2010). Brain salvage for cardiac cerebral embolism following myocardial infarction. Catheter Cardiovasc Interv. 75(5):679-683.
  72. Sihite TA, Sitepu MARM, Effendi CA. (2021). Review on Acute Cardio-Cerebral Infarction: a Case Report. IJIHS. 9(2):84-88.
  73. Abuheit E, Lu F, Liu S, et al. (2022). Mechanical thrombectomy for ischemic stroke during Percutaneous Coronary Intervention for Acute Myocardial Infarction in a three-vessel disease patient: a case report and literature review. Research Square. DOI: 10.21203/rs.3.rs-2044174/v1.
  74. Abdi IA, Karataş M, Abdi AE, Hassan MS, Yusuf Mohamud MF. (2022). Simultaneous acute cardio-cerebral infarction associated with isolated left ventricle non-compaction cardiomyopathy. Ann Med Surg (Lond). 80:104172.
  75. de Castillo LLC, Diestro JDB, Tuazon CAM, Sy MCC, Añonuevo JC, San Jose MCZ. (2021). Cardiocerebral Infarction: A Single Institutional Series. J Stroke Cerebrovasc Dis. 30(7):105831.
  76. Habib M, Awadallah S. (2022). Acute Ischemic Stroke Followed by Acute Inferior Myocardial Infarction. Tech Neurosurg Neurol. 5(3):000612.
  77. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, American Heart Association Stroke Council. (2018). 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 49(3): e46-e110.
  78. Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, et al. (2021). European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. European Stroke Journal. 0(0):1-62.
  79. Borja Ibanez et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. 39(2):119-177.
  80. Ng TP, Wong C, Leong ELE, Tan BY, Chan MY, Yeo LL, et al. (2022). Simultaneous Cardio-Cerebral Infarction—A Meta-Analysis. QJM. 115(6):374-380.

Creative Commons License

© 2015 Mathews Open Access Journals. All Rights Reserved.

Open Access by Mathews Open Access Journals is licensed under a
Creative Commons Attribution 4.0 International License.
Based On a Work at Mathewsopenaccess.com