the introduction of intravenous alteplase , which is a recombinant tissue plasminogen activator ( rtpa ) for reperfusion therapy , has led to a dramatic change in approach to patients with ischemic stroke . the intravenous route of this medication should be used in acute phase of ischemic stroke , notably within 4.5 hours of initiation of ictus . the typical method for administration of intravenous alteplase is the total dosage of 0.9 mg per kilogram of body weight ( maximum 90 mg ) that one tenth of total dosage is administered as a bolus dose and the remaining 90% of total dosage is infused over the next hour . there are some risks of major bleeding , particularly in the brain ; therefor , patients need to be carefully selected based on eligible criteria . hypersensitivity reaction including angioedema , reocclusion and secondary embolization and brain edema due to reperfusion injury are the other reported complications of rtpa administration in ischemic stroke . cardiac complications following acute cerebrovascular accidents are common , but fortunately many of them had minimal cardiac adverse effects . up to 12% of acute cerebrovascular accidents ( cvas ) . there may be an underlying cardiac embolic source for both ischemic stroke and acute myocardial infarction such as a left ventricular thrombus . embolic stroke to insula can cause autonomic dysfunction and cardiac arrhythmia which can cause ischemia of myocardium due to increasing demand of premorbid coronary arteries . several conditions such as aortic dissection , large vessel arteritis and endocarditis can induce myocardial infarction and ischemic stroke , simultaneously . in addition , some drugs like amphetamines and cocaine may lead to concurrent occurrence of myocardial infarction and ischemic stroke . an indication of acute myocardial infarction after administration of rtpa for ischemic stroke is increasingly reported . in this study , we described a patient with previous cardiovascular risk factors who was complicated with acute myocardial infarction following prescription of rtpa for an acute ischemic stroke . a 78-year - old right - handed lady was referred to elective cardiac surgery department for coronary artery bypass graft ( cabg ) surgery . she was hospitalized for conducting the pre - operation investigations . on the second day of admission , she developed sudden onset weakness of left upper and lower limbs and dropping of left side of the face . she has had a past history of hypertension , which was controlled by taking 50 mg atenolol twice a day . she has had angina pectoris but not any history of myocardial infarction . according to her coronary angiography the vital signs at the onset of left side hemiparesis included pulse rate of 74/min with regular rhythm , respiratory rate of 16/min , blood pressure of 160/100 mm hg and normal body temperature . her baseline electrocardiogram showed evidences of left ventricular hypertrophy ( lvh ) and there was no evidence of acute cardiac ischemia . axial brain computed tomography ( ct ) scan without contrast , which has been done after 30 minutes of hemiparesis , showed no evidence of hemorrhage , no new parenchymal hypodensity and no dense clot sign . although , the brain ct scan showed an old stroke in left hemisphere which was not compatible with the symptoms of the patient . due to acute left hemiparesis and no evidence of hemorrhage on brain ct scan , the national institutes of health stroke scale ( nihss ) was 10 out of 42 , composed of 2 score for partial paralysis of lower face , 3 score for left arm motor weakness , 3 score for left leg motor weakness , 1 score for sensory disturbances and 1 score for language problem . the bolus dosage of rtpa was 8 mg , followed by infusion of 58 mg in the next 60 minutes . the immediate electrocardiogram ( ecg ) showed st - segment elevations in the inferior leads ( ii , iii , avf ) , and st - segment depressions in the anterolateral leads ( i , avl ) ( figure 1 ) . the patient was emergently transferred to the cardiac catheterization laboratory for rescue percutaneous coronary intervention ( pci ) . on angiography , the occlusion of right coronary artery was detected . thrombectomy via an aspiration catheter was performed and normal coronary blood flow was restored . then pci was conducted on right coronary artery and posterior descending artery bifurcation with two bare metal stents . after revascularization , the patient s heart rhythm returned to normal sinus and hypotension was resolved . the brain ct scan was repeated and showed a new hypodensity in right parietal lobe . brain mri with diffusion - weighted sequence ( dw ) revealed a watershed ischemic infarction between anterior cerebral artery ( aca)-multiple correspondence analysis ( mca ) and mca - principal component analysis ( pca ) territories in right side , which was hyposignal in equivalent apparent diffusion coefficient ( adc ) sequence that means an acute stroke occurred ( figure 2 ) . the echocardiography revealed a left - ventricular ejection fraction of 50% with inferior hypokinesia and without evidence of intracardiac thrombus or intracardiac right - to - left shunt . in this case , the development of mi related to the use of iv rtpa within 24 hours after receiving of iv rtpa was presented . despite having previous major involvement of coronary arteries , the patient had not any symptoms of acute myocardial infarction before admission and during the first day of admission . sudden occurrence of acute left hemiparesis in our patient may have some possible mechanisms ; first , the coronary artery disease may be associated with diffuse atherosclerosis , which involved carotid artery simultaneously . the other possible explanation is an embolus originating from the morbid heart or a plaque of aorta . in fact , the both of thrombotic or embolic mechanism for ischemic stroke may be the presumed mechanism , but the evidence of an old stroke in left hemisphere and now incidence of another stroke in left hemisphere signifies the embolic mechanism compared to thrombotic mechanism . one can suppose that there was a cardiac clot , which was the mechanism of ischemic stroke and itself introduced an extra embolus to right coronary artery after the injection of rtpa . the presence of cardiac clot during ischemic stroke can be 10 to 15% based on the used modality including transesophageal echocardiography . in fact rtpa can degrade the clot to small fragments with subsequent embolization to coronary arteries leading to mi . the presented patient afflicted with an inferior mi after administration of rtpa . in the cases that presented with stewa et al . and wallace et al . , it is not clear if there is any direct correlation between rtpa injection and occurrence of inferior mi , or maybe there is an identical etiology for both of ischemic stroke and inferior mi , as we encounter in aortic dissection . contraries , there are some evidences for development of ischemic stroke as a consequence of inferior mi . in addition to common cause of ischemic stroke after any types of mi , the inferior mi has some special characteristics which are risk factors for ischemic stroke . inferior mi can lead to infarction of right ventricle in about half of the cases , which is associated with severe hemodynamic compromise and diminished cardiac output . it is also shown that inferior mi can be complicated with transient atrial fibrillation and future risk of ischemic stroke in preserve of ejection fraction will increased . nowadays rtpa is widely used for the treatment of acute stoke . the occurrence of mi especially inferior mi had been reported following administration of rtpa but current data can not clarify the underlying reason . it is a hazardous complication that needs to be carefully considered after administration of rtpa and should be treated quickly .
recombinant tissue plasminogen activator ( rtpa ) is one of the main portions of acute ischemic stroke management , but unfortunately has some complications . 
 myocardial infarction ( mi ) is a hazardous complication of administration of intravenous rtpa that has been reported recently . 
 a 78-year - old lady was admitted for elective coronary artery bypass graft surgery . on the second day of admission 
 , she developed acute left hemiparesis and intravenous rtpa was administered within 120 minutes . 
 three hours later , she has had chest pain . 
 rescue percutaneous coronary intervention was performed on right coronary artery due to diagnosis of inferior mi , and the symptoms were resolved .