Ischemic Stroke - Hennepin County Medical Center

Case Reports
and a Glasgow Coma Score (GCS) of 15.
Secondary survey was remarkable only in his
neurologic exam. He was alert and orientated
to person, place and time. He had a left facial
droop and dysarthria. There was no gaze preference.
Strength was 5/5 RUE and RLE, and
0/5 LUE and LLE. Response to light touch and
pinprick were mostly absent on left side.
Scoring on the National Institutes of Health
(NIH) stroke scale was 13 on presentation.
Chest x-ray and electrocardiogram (ECG)
obtained in the Emergency Department were
normal. The patient was packaged for head
CT with the acute stroke team present.
Given the long time period between being last
seen normal and presentation (>12 hours), the
patient was initially not considered a candidate
for intravenous (IV) thrombolytics. He was
taken for a non-contrast head CT scan to rule
out hemorrhage. This was negative for an acute
bleed. He then underwent emergent magnetic
resonance imaging (MRI) and magnetic resonance
angiography (MRA) to evaluate the
extent of the injury. His brain MRI demonstrated
an acute infarction of the middle cerebral
artery distribution involving the right insular
cortex and posterior limb of the right internal
capsule and right corona radiata, along with
chronic small vessel ischemic disease. The
MRA demonstrated occlusion of the right middle
cerebral artery beyond the proximal M1 segment,
without distal reconstitution. The neck
MRA demonstrated 40% stenosis of proximal
right internal carotid artery. He was felt to be
beyond the time window of intervention and
taken to the ICU for further management.
After arriving in the ICU, he developed a new
right gaze preference and hemi-neglect. It was
felt that these likely represented signs of ongoing
ischemia/infarction and he was emergently
taken for a CT perfusion study, which revealed
diminished perfusion over the entire right middle
cerebral artery (MCA) territory consistent with
ischemia and a small localized area of infarction
in the right insula similar to the infarct
seen on MRI. (See Figure One on page 8.)
Given these findings, he was felt to have a
large area of ischemic but not-yet-infarcted
brain (termed “penumbra.”) He was emergently
taken to angiography, where he received lowdose
intra-arterial tPA and angioplasty of the
M1 lesion. This resulted in TIMI 3 flow and he
was noted to have antigravity strength on the
left side and improvement in his dysarthia.
On hospital day (HD) 2, the patient was ambulating
with assistance and had 4/5 strength
proximal and distal in the LUE and LLE. A
thromboembolic work-up including a transesophageal
ECG was negative and it was felt
that his stroke was a result of atherosclerotic
vascular disease. Risk factors identified were
his gender and hypertension. His LDL was 84
and he was considered a candidate for statin
therapy. On HD 3, his NIH stroke scale score
was 3 with residual difficulties with speech and
word finding. He underwent aggressive PT/OT
and was discharged home on HD 6.
On follow-up, the patient has persistent mild
weakness in the left arm and leg along with
some coordination difficulty. He is otherwise
at baseline except for his memory and
activity tolerance.
Discussion
This case illustrates that intervention is not limited
solely to three hours after symptom onset,
which is the current standard for IV tPA.
Studies published in late 2008 may alter this
standard. Because the clock starts when the
patient was last seen normal, which includes
cases where the patient wakes up or is found
symptomatic, this patient was considered to be
symptomatic for nearly 12 hours. The patient
had some area of brain that was ischemic for
nearly 12 hours but the patient also had a
much larger area of ischemic brain for less
than 3 hours when he clinically deteriorated in
the hospital.
The patient was initially not considered a candidate
for acute stroke intervention because he
Approaches in Critical Care | December 2008 | 7