Hemorrhagic stroke during the acute phase of myocardial infarction: a rare and difficult situation to manage

Given the ischemic risk due to the hypercoagulability associated with acute coronary syndromes, the administration of antiplatelet and antithrombotic agents is necessary to prevent intracoronary and postprocedural thrombosis during percutaneous coronary interventions. However, the risk of bleeding, hemorrhagic stroke included, is real, although it has a lower prevalence, and it complicates the management of the coronary event if it happens. We report the case of a 66 years old patient with no prior pathological history who was initially admitted for acute coronary syndromes, complicated by paroxysmal atrial fibrillation that was successfully thrombolysed. Subsequently, the patient benefited from a drug-eluting stent angioplasty of the proximal circumflex artery, performed within 24 hours after the symptomatology onset. Following angioplasty, the patient presented with a left parietal intraparenchymal hematoma not indicating surgery. The double antiplatelet therapy was consequently withdrawn. Two days later, the patient presented with an ST-segment elevation infarction recurrence, inciting the resumption of the dual antiplatelet aggregation therapy. On evolution, the neurological state was still stable with a stationary aspect of the hematoma on cerebral imagery but without angina recurrence or electrocardiographic modifications. Hemorrhagic complications' occurrence following thrombolysis or angioplasty for ST-segment elevation infarction challenges the short and long-term management of the disease and must push practitioners to better weigh the risks and benefits before any medication administration decision.