Thrombolysis in Acute Infarct Due to Tubercular Vasculitis
Primary Recommendation
Thrombolysis with alteplase should NOT be administered in acute ischemic stroke caused by tubercular vasculitis due to the substantially elevated risk of hemorrhagic complications from fragile, inflamed vessel walls and the absence of any safety data in this specific population.
Clinical Reasoning
Why Thrombolysis is Contraindicated
The fundamental problem with thrombolysis in tubercular vasculitis is the underlying pathophysiology:
- Vessel wall integrity is severely compromised in active vasculitis, with inflammatory destruction of the arterial wall architecture creating fragile vessels prone to rupture 1
- Tubercular vasculitis specifically causes necrotizing inflammation of cerebral vessels, making them structurally unstable and at high risk for hemorrhagic transformation with any fibrinolytic therapy 1
- The risk-benefit calculation that supports thrombolysis in atherosclerotic stroke (where vessels are structurally intact despite luminal narrowing) does not apply when the vessel wall itself is diseased 2
Evidence from Analogous Vasculopathies
While no direct evidence exists for tubercular vasculitis specifically, guidance from similar fragile vessel conditions supports extreme caution:
- Moyamoya angiopathy guidelines explicitly state that tissue plasminogen activator use "can be a major challenge" due to "increasing bleeding risk due to the presence of fragile moyamoya compensatory vessels" with only low-level evidence supporting its use under "careful evaluation of the risk of hemorrhagic complication" 1
- In patients with intracranial aneurysms or arteriovenous malformations, case reports document fatal intracranial hemorrhages following thrombolysis, demonstrating the catastrophic risk when vessel walls are abnormal 1
- The 2% risk of hemorrhagic stroke with standard thrombolysis in structurally normal vessels 1 would be substantially magnified in inflamed, necrotic tubercular vessels
Standard Thrombolysis Contraindications Apply
Active inflammatory vasculitis meets several established contraindication criteria:
- Active inflammatory disease of cerebral vessels represents an absolute contraindication analogous to recent intracranial hemorrhage 2
- The presence of underlying vascular pathology that increases hemorrhage risk (similar to unruptured aneurysms or AVMs) requires "careful evaluation" at minimum, and typically precludes thrombolysis 1
Alternative Management Strategy
Instead of thrombolysis, the appropriate approach includes:
- Immediate anti-tubercular therapy with four-drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) plus corticosteroids to address the underlying vasculitis
- Antiplatelet therapy may be considered cautiously once active inflammation is controlled, though evidence is limited 1
- Mechanical thrombectomy could theoretically be considered in large vessel occlusions if the vessel wall appears structurally intact on imaging, though no data supports this approach 1
- Supportive care with blood pressure management, avoiding hypotension that could worsen perfusion in inflamed vessels 2
Critical Pitfalls to Avoid
- Do not apply standard ischemic stroke protocols reflexively without considering the underlying etiology—tubercular vasculitis is fundamentally different from atherothrombotic stroke 2
- Do not delay anti-tubercular treatment while considering thrombolysis; the priority is treating the underlying infection and inflammation
- Do not assume the standard 2% hemorrhagic stroke risk applies—the actual risk in inflamed vessels is likely substantially higher 1