APCU25MPB6 When the heart and brain collide: navigating the complexities of cardiocerebral infarction

Introduction Cardiocerebral infarction (CCI) is a life-threatening condition with dual cardiac and cerebral injury, involving simultaneous or sequential occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI). It has a narrow therapeutic window, complex management, poor prognosis, and significantly higher mortality than isolated events.Case Presentation A 66-year-old male smoker with no prior medical history presented with sudden left-sided weakness, slurred speech and facial asymmetry for one day. On admission, his Glasgow Coma Scale (GCS) was E4V5M6. Neurological exam showed left facial droop and muscle strength graded 3/5 in the left upper and lower limbs. Vital signs revealed blood pressure of 141/101 mmHg and an irregular pulse. ECG revealed atrial fibrillation and ST elevation in inferior leads, although he reported no chest pain. Troponin I was elevated at 38.57 ng/mL. CT brain showed hyperacute right middle cerebral artery infarction (MCA) with ASPECT score of 5. Thrombolysis was deferred due to high risk of hemorrhagic transformation, despite presentation within the therapeutic window. He was treated with subcutaneous fondaparinux and dual antiplatelet therapy. On day 5 of admission, he became less responsive, with a GCS of E2V1M4. CT brain showed enlargement of the right MCA territory infarct without haemorrhagic transformation and a new acute infarct in the right temporal lobe. Despite intensive medical management, the patient succumbed.Discussion The cornerstone of CCI management is rapid reperfusion of both cardiac and cerebral tissue. A consensus statement from the American Heart Association and American Stroke Association recommends intravenous thrombolysis for acute ischemic stroke, followed by percutaneous coronary intervention if indicated, without specific guidance on post-procedure dual antiplatelet therapy. However, this approach does not address the heterogeneity of AMI presentations. Key challenges include differing thrombolytic doses for AMI and AIS, stroke severity at presentation, availability of specialized expertise, recent events precluding thrombolysis, and risk of hemorrhagic transformation. Management of antiplatelet and anticoagulant therapy is also complex due to conflicting treatment needs, bleeding risks, and limited standardized protocols.Conclusion CCI demands a multidisciplinary, individualized approach. Atrial fibrillation often underlies these events. Urgent research is needed to develop evidence-based strategies to improve patient outcomes.