Stroke due to typical thrombotic thrombocytopenic purpura treated successfully with intravenous thrombolysis and therapeutic plasma exchange

Matteo Boattini

Gaetano Procaccianti

^{Department of Internal Medicine, Santa Marta's Hospital, Lisbon, Portugal}

^{Stroke Unit, Ospedale Maggiore, IRCCS, Bologna, Italy}

^{Dr Matteo Boattini,}moc.liamg@inittaoboettam

Abstract

We report a case of a 39-year-old man with expressive aphasia due to occlusion of the temporal stem of the left middle cerebral artery. Laboratory tests showed microangiopathic haemolytic anaemia and thrombocytopenia. A thrombotic thrombocytopenic purpura (TTP) was diagnosed, and thrombolytic therapy (TT) with alteplase followed by therapeutic plasma exchange (TPE) were performed with complete resolution of symptoms. The gold standard TTP treatment is TPE, and its delay can be lethal. The use of TT in TTP is controversial and has potential risks. This case shows a successful TT in a patient with typical TTP presenting as a stroke due to a large cerebral artery occlusion.

Abstract

Learning points

Footnotes

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

Footnotes

References

1. Torok TJ, Holman RC, Chorba TL. Increasing mortality from thrombotic thrombocytopenic purpura in the United States-analysis of national mortality data. Am J Hematol 1995;50:84–90 [[PubMed]
2. Idowu M, Reddy P. Atypical thrombotic thrombocytopenic purpura in a middle-aged woman who presented with a recurrent stroke. Am J Hematol 2012. doi:[PubMed]
3. Downes KA, Yomtovian R, Tsai HM, et al Relapsed thrombotic thrombocytopenic purpura presenting as an acute cerebrovascular accident. J Clin Apher 2004;19:86–9 [[PubMed][Google Scholar]
4. Sevy A, Doche E, Squarcioni C, et al Stroke in a young patient treated by alteplase heralding an acquired thrombotic thrombocytopenic purpura. J Clin Apher 2011;26:152–5 [[PubMed][Google Scholar]
5. Adams HP, Jr, Del Zoppo G, Alberts MJ, et al Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and Quality Of Care Outcomes In Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655–711 [[PubMed][Google Scholar]
6. Furlan M, Robles R, Galbusera M, et al von Willebrand factor–cleaving protease in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome. N Engl J Med 1998;339:1578–84 [[PubMed][Google Scholar]
7. Ono T, Mimuro J, Madoiwa S, et al Severe secondary deficiency of von Willebrand factor-cleaving protease (ADAMTS13) in patients with sepsis-induced disseminated intravascular coagulation: its correlation with development of renal failure. Blood 2006;107:528–34 [[PubMed][Google Scholar]
8. Hovinga JA Kremer, Vesely SK, Terrel DR, et al Survival and relapse in patients with thrombotic thrombocytopenic purpura. Blood 2010;115:1500–11 [[PubMed][Google Scholar]
9. Aksay E, Kiyan S, Ersel M, et al Thrombotic thrombocytopenic purpura mimicking acute ischemic stroke. Emerg J Med 2006;23:e51 [Google Scholar]