Introduction: The use of plasminogen activators (PAs) in acute stroke patients has dual effects. PAs are beneficial by dissolving thrombi occluding an artery, but may be harmful by their proteolytic and excitotoxic actions.
Methods and results: We report two patients with a fatal brain herniation who rapidly deteriorated despite the successful recanalization and the sustained arterial patency or blood flow. Imaging studies taken after the thrombolytic treatment suggested early occurrence of cellular damage and profound breakdown of the blood-brain barrier.
Conclusion: Fatal brain edema occurred after persistent reperfusion by the thrombolytic therapy. Paradoxical thrombolytic-induced injury, which has been suggested in experimental studies, might play a role.