Prompt administration of thrombolysis reduces morbidity in patients with acute ischemic stroke. In the absence of specific large randomized controlled trials, current AHA/ASA guidelines recommend administration of intravenous thrombolysis in patients with acute ischemic stroke in sickle cell crisis. Blood pressure greater than 185/110 mmHg is an absolute contraindication to initiating intravenous thrombolysis in acute ischemic stroke. In this respect, blood pressure elevation is a common finding in sickle cell pain crisis, through activation of the sympathetic nervous system.
We review the case of a 36-year-old male with history of sickle cell disease, protein C deficiency, and prior stroke who presented with acute-onset right-sided hemiparesis and hypoesthesia. Apart from acutely uncontrolled blood pressure, he had no other exclusions to thrombolytic therapy. His blood pressure could not be lowered to less than 185/110 mmHg with intravenous labetalol and continuous infusion of nicardipine. His presenting hypertension was thought to be related, in part, to concurrent vaso-occlusive pain crisis. When pain was ameliorated upon administration of intravenous opioid analgesia, blood pressure goals were reached. He subsequently was administered intravenous thrombolysis followed by exchange transfusion. Post-treatment examination and neuroimaging revealed no evidence of new residual deficit or acute infarct.