Thrombotic storm presenting with synchronous myocardial infarction, stroke and bowel ischaemia: A case report

Abstract

BACKGROUND

We present the first known case of simultaneous myocardial infarction, stroke, and bowel infarction, likely triggered by a thrombotic crisis.

CASE SUMMARY

A 72-year-old man was found unresponsive in his car and was diagnosed with acute inferoposterior ST-elevation myocardial infarction (STEMI) and slow atrial fibrillation (AF). A computed tomography (CT) brain scan initially ruled out stroke, and the preliminary diagnosis was cardiogenic shock, slow AF, and Killip 4 acute STEMI, complicated by lactic acidosis and delirium. The patient underwent catheterization, revealing a complete occlusion of the right coronary artery. Afterward, he suffered two episodes of pulseless electrical activity but regained spontaneous circulation. However, a repeat CT brain scan revealed an acute left insula and M2 ischemic stroke, with subtle findings already present on the initial scan. Blood tests showed increasing lactate levels, prompting a CT mesenteric angiogram that identified multiple infarcts in the spleen, kidney, and intestines, suggesting bowel infarction had already occurred. The patient passed away two days later.

CONCLUSION

This case underscores the diagnostic challenges and complexities of managing thrombotic storms, particularly when multiple ischemic events occur simultaneously. It highlights the importance of timely diagnosis and multidisciplinary coordination in such cases. We recommend a time-sensitive management approach and further research to establish evidence-based strategies for treating thrombotic storm.

Keywords: Thrombosis; Stroke; Acute myocardial infarct; Ischaemic bowel; Case report

Core Tip: This case describes the first known instance of simultaneous myocardial infarction, stroke, and bowel infarction, likely due to a thrombotic crisis. Synchronous cardiocerebral infarcts are rare (0.009%–0.29%) and typically affect older males. Etiology remains unclear but may involve cardiogenic shock reducing cerebral perfusion. Management requires a multidisciplinary approach. If within the thrombolysis window (4.5 hours), IV recombinant tissue plasminogen activator (0.9 mg/kg) should be given first, followed by coronary intervention. Outside this window, treatment prioritization depends on hemodynamic stability—cardiac intervention for shock, stroke management otherwise. Post-acute care involves high-dose statins if atherosclerosis is suspected and close monitoring in a high-acuity setting.