Background: In patients who are candidates for IV recombinant tissue plasminogen activator (rtPA) thrombolysis for the treatment of acute ischemic stroke, blood pressure (BP)-lowering therapy is sometimes needed for systolic BP >185 mm Hg or diastolic BP >110 mm Hg. However, there is vast uncertainty regarding the appropriate choice of an antihypertensive agent.
Case summary: A 68-year-old Algerian woman (height, 161 cm; weight, 68 kg; body mass index, 26 kg/m2) was admitted to the Cardiology Unit of Amiens University Hospital, Amiens, France, for the assessment of nonvalvular atrial fibrillation. She was prescribed furosemide 40 mg/d to treat a slight left cardiac insufficiency. On day 10 of admission, the patient developed left-sided weakness. Neurologic examination revealed left hemiparesis. A computed tomography scan of the head showed no abnormality. Approximately 90 minutes after onset of the neurologic deficit, the patient had a BP of 180/100 mm Hg in both arms, an irregular pulse >75 bpm, and normal heart sounds. The patient was transferred to the Neurovascular Unit. There were no cervical or femoral bruits in this patient. During neurologic examination, the patient was alert and showed no signs of major cognitive deficit. The neurologic examination did reveal, however, minor hemisphere syndrome with left spatial neglect. There was a left lower-facial paresis. Motor examination revealed normal bulk with diminished tone in the patient's left arm and leg. Although there were no physical signs of dehydration, laboratory results revealed moderate signs of dehydration (total protein, 91 g/L [indicating proteinemia]; sodium, 147 mmol [indicating hypernatremia]; and elevated hematocrit, 42.0%). Considering the diagnosis of ischemic stroke and the duration of the symptoms (<3 hours), IV rtPA was administered. Approximately 10 minutes after intravenous rtPA administration, the patient's BP was 210/110 mm Hg, and an IV bolus of urapidil (20 mg) was administered. Approximately 2 minutes following urapidil administration, the patient developed neurologic worsening indicated by left-sided hemiplegia. Her BP was 105/60 mm Hg. The IV rtPA was immediately discontinued and volume replacement was started for 20 minutes. IV rtPA was restarted after the patient remained hemodynamically stable (15 minutes after rtPA was restarted). Following intensive physiotherapy, the patient was discharged on anticoagulation with a favorable outcome. At her 6-month follow-up, the patient had fully recovered.
Conclusion: We report a probable case of hypotension associated with IV bolus of urapidil administration during rtPA thrombolysis for acute ischemic stroke in an elderly patient also treated with diuretics.