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Thrombolysis in the Presence of an Intracranial Meningioma
be fore and after lung transplantation and that prevention of bone loss should be considered early and routinely in patients with respirato1y fai lure. With regard to repmting the BMD data as Z scores (rather than T scores), we chose thi s approach to allow analys is o f association s of pertin e nt va riables (eg, vitamin D levels, steroid use, etc) with BMD without confounding the analysis by age. T scores may allow a better assess ment of fracture risk, hut confound regression analyses. Dr. Fe rrari also correctly noted that our posttransplant data we re heterogeneous with respect to time of collection. \Ve have also noted th e phenom enon of early posttransplantation bone loss with subsequ ent increases in BMD 1 to 2 years after transplan tation as Dr. Ferrari reports . Longitudinal data obtained by Ferrari et a!are likely to shed further light on lung transplantassociated osteoporosis. \Ve look forward to reading th eir manuscript.
from 0.26 to 2.17%. 3 Hisk factors for bleeding include age, body weight less than 70 kg, hypertension on hospital admission, and alteplase th erapy.'3 Intracranial meningiomas are common, but rarely cause he morrhagic stroke 4 and are not considered an absolute contraindication to anticoagulation. A comp uterized MEDLI:'I!E search from 1966 to 1996 revealed no reports of thrombolytic th erapy in patients with an intracranial meningioma. Because of logistic considerations, timely direct coronary angioplasty is not a re alistic a lternative to thrombolytic therapy lor most patie nts presenting with AMP A physician must decide for eat:h individual patient whether th e potential bene fi ts of thrombolyt ic th erapy outweigh th e risks. We suggest that if a patient with an intracranial meningioma presents with an extensive anterior \vall AMI , and direct coronary angioplasty is not availab le, th ro mbolytic therapy may be co nsidered and could prove lifesaving.
Robert Aris, MD Assistant Professor of Medicine Unit;ersity of North Carolina Chapel Hill, NC
Ronen Jaffe, MD James M. Reichman, !l1D A. Teddy Weiss, MD Duron Zahger, MD Hadassah University Hospital, Mt. Scopus De]Jartment of Internal Medicine Jerusalem, Israel
Thrombolysis in the Presence of an Intracranial Meningioma To the Editor: The p resence of an intracranial space-occupyi ng lesion (SOL) is considered an absolute contraindication to thrombolytic th erapy during acute myocardial infarc tion (A MI) 1 because such lesions are potential sites for intracranial hemorrhage. Patients with an SOL we re therefore excluded from thrombolytic trials. We repmt a case of inadve rtent thrombolysis in a patient with an intracranial meningioma. A 62-year-old woman was admitted to our hospital complaining of left-sided chest pain of 1-h duration. The patie nt claim ed to be healthy. On hospital admission , th e BP was 120/80 mm Hg and th e pu lse rate was 100 beats/min and regular. Results of the physical examination we re oth erwi se normal. An ECG revealed normal sinus rhythm with 5-mm ST segment elevation in leads V1 through Vr;· The patient received 1.5 million units of IV streptokinase, as well as aspirin, propranolol, IV heparin, and nitroglyce rin . The chest pain resolved within minutes of streptokinase administration and the ECG evolution was compatible vvith successful reperfusion. The following day, th e patient disclosed that 4 years previously, after having developed ve rtigo , an MRJ of the brain had de monstrated a dura-based el ft ce rebellopontine angle lesion 1 em in diameter consistent with a meningiom a. Dming follow-up , no neurologic defects had appeared an d the lesion had not enlarged. Despite the presence of an SOL, anti coagulant therapy was continued without neurologic sequela and the patient was discharged from the hospital in good health. Thrombolytic therapy reduces early mortality in patients with exte nsive acute anterior wall myocard ial infarction hy 25 to 50%.2 Among patients recruited to th e major th rombolytic t1ials, the ove rall risk of intracranial hemorrhage was 0.7.5%, but ranged
258
REFERENCES 1 Habib GB. Current status of thrombolysis in acute myocardial infarction: II. Optimal utilization of thrombolysis in cli nical subsets. Chest 1995; 107:528-34 2 Fibrinolytic Therapy Trialists' (F TT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative ove1view of early mortality and major morbidity res ults from all randomized trials of more than 1,000 patients. Lancet 1994; 343:311-22 3 Simoons ML, Maggioni AP, Knatterud G, eta!. Individual risk assessme nt for intracranial haemorrh age during thrombolytic therapy. Lancet 1993; 342:1523-28 4 Kohli C M, Crouch RL. Meningioma with intracerebral hematoma. Neurosurgery 1984; 1.5:237-40 5 Lange RA, Hi ll is LD . Immediate angioplasty for acute myocardial infarction [editorial]. N Eng! J Med 1993; 328:726-28
Erratum To the Editor: In th e article "Ventilation-Perfusion Response Afte r Fenoterol in Hypoxe mic Patients With Stable COPD" by Viegas et al (CHEST 1996; 110:71-7), a sentence in the abstract section "Conclusions" was incorrect. The se ntence shou ld have read, "In this population of COPD patients, high-dose fenoterol therapy significantly increased heart rate and cardiac output resulting in minor adverse consequences on arterial oxygenation and VA/Q relationships."
Communications to the Editor
from 0.26 to 2.17%. 3 Hisk factors for bleeding include age, body weight less than 70 kg, hypertension on hospital admission, and alteplase th erapy.'3 Intracranial meningiomas are common, but rarely cause he morrhagic stroke 4 and are not considered an absolute contraindication to anticoagulation. A comp uterized MEDLI:'I!E search from 1966 to 1996 revealed no reports of thrombolytic th erapy in patients with an intracranial meningioma. Because of logistic considerations, timely direct coronary angioplasty is not a re alistic a lternative to thrombolytic therapy lor most patie nts presenting with AMP A physician must decide for eat:h individual patient whether th e potential bene fi ts of thrombolyt ic th erapy outweigh th e risks. We suggest that if a patient with an intracranial meningioma presents with an extensive anterior \vall AMI , and direct coronary angioplasty is not availab le, th ro mbolytic therapy may be co nsidered and could prove lifesaving.
Robert Aris, MD Assistant Professor of Medicine Unit;ersity of North Carolina Chapel Hill, NC
Ronen Jaffe, MD James M. Reichman, !l1D A. Teddy Weiss, MD Duron Zahger, MD Hadassah University Hospital, Mt. Scopus De]Jartment of Internal Medicine Jerusalem, Israel
Thrombolysis in the Presence of an Intracranial Meningioma To the Editor: The p resence of an intracranial space-occupyi ng lesion (SOL) is considered an absolute contraindication to thrombolytic th erapy during acute myocardial infarc tion (A MI) 1 because such lesions are potential sites for intracranial hemorrhage. Patients with an SOL we re therefore excluded from thrombolytic trials. We repmt a case of inadve rtent thrombolysis in a patient with an intracranial meningioma. A 62-year-old woman was admitted to our hospital complaining of left-sided chest pain of 1-h duration. The patie nt claim ed to be healthy. On hospital admission , th e BP was 120/80 mm Hg and th e pu lse rate was 100 beats/min and regular. Results of the physical examination we re oth erwi se normal. An ECG revealed normal sinus rhythm with 5-mm ST segment elevation in leads V1 through Vr;· The patient received 1.5 million units of IV streptokinase, as well as aspirin, propranolol, IV heparin, and nitroglyce rin . The chest pain resolved within minutes of streptokinase administration and the ECG evolution was compatible vvith successful reperfusion. The following day, th e patient disclosed that 4 years previously, after having developed ve rtigo , an MRJ of the brain had de monstrated a dura-based el ft ce rebellopontine angle lesion 1 em in diameter consistent with a meningiom a. Dming follow-up , no neurologic defects had appeared an d the lesion had not enlarged. Despite the presence of an SOL, anti coagulant therapy was continued without neurologic sequela and the patient was discharged from the hospital in good health. Thrombolytic therapy reduces early mortality in patients with exte nsive acute anterior wall myocard ial infarction hy 25 to 50%.2 Among patients recruited to th e major th rombolytic t1ials, the ove rall risk of intracranial hemorrhage was 0.7.5%, but ranged
258
REFERENCES 1 Habib GB. Current status of thrombolysis in acute myocardial infarction: II. Optimal utilization of thrombolysis in cli nical subsets. Chest 1995; 107:528-34 2 Fibrinolytic Therapy Trialists' (F TT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative ove1view of early mortality and major morbidity res ults from all randomized trials of more than 1,000 patients. Lancet 1994; 343:311-22 3 Simoons ML, Maggioni AP, Knatterud G, eta!. Individual risk assessme nt for intracranial haemorrh age during thrombolytic therapy. Lancet 1993; 342:1523-28 4 Kohli C M, Crouch RL. Meningioma with intracerebral hematoma. Neurosurgery 1984; 1.5:237-40 5 Lange RA, Hi ll is LD . Immediate angioplasty for acute myocardial infarction [editorial]. N Eng! J Med 1993; 328:726-28
Erratum To the Editor: In th e article "Ventilation-Perfusion Response Afte r Fenoterol in Hypoxe mic Patients With Stable COPD" by Viegas et al (CHEST 1996; 110:71-7), a sentence in the abstract section "Conclusions" was incorrect. The se ntence shou ld have read, "In this population of COPD patients, high-dose fenoterol therapy significantly increased heart rate and cardiac output resulting in minor adverse consequences on arterial oxygenation and VA/Q relationships."
Communications to the Editor