Ischemic Stroke - Hennepin County Medical Center

Case Reports
Guidelines regarding early recognition and
treatment of CVA are well established. Intraarterial
thrombolysis (IAT) has been shown to
improve outcomes in a select group of patients
with thrombosis of the middle cerebral artery
(MCA). Class I recommendations by the
American Stroke Association include IAT for
patients who are not candidates for intravenous
thrombolysis and who present to a
stroke center with thrombus in the MCA within
6 hours of symptom onset. This case involves
a young patient who underwent delayed IAT
with a successful outcome.
Case report
A 29 year-old male with no significant past
medical history presented to a local emergency
department with sudden onset of severe leftsided
headache, profound right-sided weakness
and slurred speech about 30 minutes
after sexual intercourse. A head CT showed no
evidence of infarction or hemorrhage. The
patient’s symptoms completely resolved after
symptomatic treatment of the headache (about
1-2 hours from onset) and he was discharged
to home. The patient fell asleep around 4:00
a.m. feeling normal. He awoke at 10:00 a.m.
with aphasia and right-sided weakness and
returned to the hospital. A repeat head CT at
this time showed small hypodensities in the
region of his left MCA. He was transferred to a
stroke center with persistent right-sided facial
droop and profound weakness of the right
upper and lower extremities.
Upon arrival at the stroke center, his vital signs
were temperature 35.9° Celsius, BP 153/77,
HR 75, RR 17, and O2 saturation of 100%. An
emergent CT perfusion showed a large perfusion
deficit with a small area of infarction in the
territory of the left MCA, consistent with a large
area of at-risk but salvageable brain tissue. CT
angiogram showed a small focal thrombus in
the proximal segment of the MCA. Emergent
MRI confirmed a small amount of existing
stroke in the left MCA distribution. Cerebral
angiogram by the neurointerventionalist
revealed an occlusion of the left M1 with a
string of delayed flow around the thrombus.
Low-dose intra-arterial alteplase (2 mg) was
administered directly into the clot approximately
17 hours after his initial presentation and
just over 12 hours after he went to sleep feeling
normal again after the first transient
ischemic attack (TIA). Intra-arterial thrombolytic
treatment was chosen over mechanical
embolectomy despite the late time window
because a small clot burden was seen that
would likely respond to the thrombolytic treatment.
The angiogram showed partial resolution
of the clot and significant improvement in distal
perfusion of his left MCA. (See Figure One on
page 10.)
Intravenous Integrilin ® was administered to
prevent vessel reocclusion and facilitate further
clot lysis. A follow-up angiogram showed a
spontaneous dissection in the area of the
thrombus, which was thought to be the cause
of occlusion. At a later date, the patient underwent
stenting of his left M1 dissection and is
currently on aspirin and Plavix ® . Other workups,
including labs for hypercoaguable disease
and imaging for cardiac sources of thromboembolism,
were negative. The remainder of
the patient’s hospital course was unremarkable
and at the one-year follow-up, the patient’s
only remaining deficit was an occasional
tremor of his right hand at rest. He is back to
work and otherwise living a normal life.
Discussion
American Stroke Association class I recommendations
for IAT include patients presenting
within 6 hours of symptom onset with ischemic
CVA to the MCA, who are not candidates for
intravenous thrombolysis (IVT). Class I recommendations
also include IAT by a qualified
interventionalist at a center with access to
cerebral angiogram. Preliminary data show
significant benefit of IAT versus placebo. One
example is the PROACT II trial, which has
shown favorable results for IAT use. One
aspect of this study compared patients who
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