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A 77-year-old woman, who had a history of rheumatic mitral stenosis with atrial fibrillation (AF), was referred and admitted to our hospital because of a transient ischemic attack at 4: 55 p.m.. She had taken warfarin for over 10 years, but her condition was not well controlled on admission. At 8: 30 p.m., she had acute ischemic stroke with right facial palsy, right hemiparesis and slurred speech. At 10: 35 p.m., she was treated with intravenous tissue plasminogen activator (t-PA) and her neurological deficits almost fully recovered by 0: 05 a.m. (90 min after t-PA started). At 0: 08 a.m., she collapsed due to sudden pulseless arrest. Using advanced life support, she soon recovered with no complications. After mitral valve replacement and left atrial appendectomy, she was discharged with a modified Rankin scale 0 at day 40. To the best of our knowledge, this is the first case report showing pulseless arrest immediately after treatment with t-PA in an elderly patient with ischemic stroke. Left insular injury seemed to be a crucial mechanism of pulseless arrest in this case.

Pulseless arrest in an elderly patient treated with intravenous tissue plasminogen activator for cardioembolic ischemic stroke