(698) Concurrent Acute STEMI and Acute Ischemic Stroke due to Right Middle Cerebral Artery (M2) Dissection

Introduction: Acute ischemic stroke (AIS) and ST elevation myocardial infarction (STEMI) are critical emergencies that require prompt and coordinated management. The concurrence of these events can complicate the clinical course and necessitates careful monitoring and treatment strategies.

Description: A 49-year-old male presented to the ED with sudden left-sided weakness, facial droop, and slurred speech. He denied any other symptoms. An initial CT Head showed no acute bleeding, while a CT Angiography showed a distal right M2 occlusion. The patient received tenecteplase in the ED and transferred to Memorial Hermann-Texas Medical Center for evaluation for mechanical thrombectomy. Initial labs showed glucose levels in the 400s, creatinine of 1.6 mg/dL, and troponin I of 20 pg/mL. A repeat CTH on arrival at MH-TMC showed no intracerebral hemorrhage but noted a right pontine infarct. An initial EKG at the outside hospital was non-ischemic, but a repeat EKG upon transfer revealed an anterior STEMI.

A cerebral angiogram revealed a dissection of the right middle cerebral artery (M2 segment) with a string-like sign. No intervention was performed. Afterwards, troponin I levels increased to 93,000 pg/mL. An echocardiography showed an ejection fraction of 35% and akinesis of the septum and apex. Cardiology performed cardiac catheterization with PCI of the proximal LAD using drug-eluting stent.

An MRI brain on HD #1 revealed multifocal acute infarcts in the right cerebral hemisphere and an acute infarct in the left ventral pons. A repeat MRI brain on HD #5 showed a new infarct in the right inferior cerebellum.

The hospital course was complicated by worsening neurological status, requiring intubation on HD #4, followed by tracheostomy and PEG placement on HD #7. On HD #8, a right common femoral DVT was found, anticoagulation started and later transitioned to Plavix and Apixaban. The patient was discharged to a long-term acute care hospital on HD #13.

Discussion: The concurrence of middle cerebral artery (MCA) dissection and ST-elevation myocardial infarction (STEMI) is an exceptionally uncommon and intricate medical scenario that requires swift and coordinated intervention. Our case highlights the effective management of both conditions through a multidisciplinary team approach.