Neuroscience · Year 2 · from Neuroscience
Case 1: Acute Ischemic Stroke - Thrombolysis and Thrombectomy
Patient Presentation
Demographics: 64-year-old male
Chief Complaint: Sudden right arm and leg weakness with slurred speech; last known well 75 minutes ago
History of Present Illness: The patient was watching television with his wife when she noticed his speech suddenly became slurred and his right arm dropped. She called 911 immediately. EMS noted right hemiparesis and activated the stroke code en route. The patient has a history of hypertension (on lisinopril), type 2 diabetes, hyperlipidemia, and former smoking (quit 5 years ago).
Pre-Hospital:
- EMS Cincinnati Stroke Scale: Positive (facial droop, arm drift, speech abnormality)
- Glucose: 156 mg/dL
- Blood pressure: 182/98
Emergency Department Evaluation:
- Time from last known well: 75 minutes
- Vital signs: BP 178/96, HR 88, T 36.9C
NIH Stroke Scale Assessment:
- Level of consciousness: 0
- LOC questions (month, age): 0
- LOC commands (close eyes, make fist): 0
- Best gaze: 1 (partial gaze palsy - eyes deviate left)
- Visual fields: 2 (complete hemianopia - right visual field cut)
- Facial palsy: 2 (partial paralysis - right lower face)
- Motor arm (left): 0
- Motor arm (right): 3 (no effort against gravity)
- Motor leg (left): 0
- Motor leg (right): 2 (some effort against gravity)
- Limb ataxia: 0 (cannot assess weak limbs)
- Sensory: 1 (mild-moderate loss on right)
- Best language: 1 (mild-moderate aphasia)
- Dysarthria: 2 (severe)
- Extinction: 1 (visual extinction)
- Total NIHSS: 15
Imaging:
- CT head without contrast: No hemorrhage; hyperdense MCA sign on left (clot in artery); early loss of insular ribbon on left
- CT angiography: Complete occlusion of left M1 segment of MCA
- CT perfusion: Core infarct volume 12 mL; penumbra 110 mL; large mismatch favorable for intervention
Laboratory:
- Glucose: 164 mg/dL
- INR: 1.0
- Creatinine: 1.1 mg/dL
- Platelet count: 245,000
Diagnosis: Acute left MCA territory ischemic stroke due to large vessel occlusion (M1 occlusion)
Treatment:
IV Thrombolysis:
- Blood pressure lowered to 178/94 (below 185/110)
- Alteplase 0.9 mg/kg (79.2 mg total for 88 kg patient)
- 10% (7.9 mg) IV bolus
- Remainder (71.3 mg) infused over 60 minutes
- Door-to-needle time: 42 minutes
Mechanical Thrombectomy:
- Patient transferred immediately to angiography suite
- Right femoral artery access
- Catheter advanced to left MCA
- Stent retriever deployed and clot retrieved
- TICI 2c reperfusion achieved (near-complete)
- Door-to-groin puncture: 78 minutes
Post-Intervention:
- Blood pressure maintained <180/105 for 24 hours
- CT at 24 hours: Small infarct in left basal ganglia; no hemorrhagic transformation
- Aspirin 81 mg started at 24 hours
- DVT prophylaxis
- Swallowing evaluation
Clinical Course:
- 2 hours post-thrombectomy: NIHSS improved to 8; patient lifting right arm against gravity
- 24 hours: NIHSS 5; mild residual weakness and word-finding difficulties
- Discharge day 5: NIHSS 3; walking with assistance; mild dysarthria
- 90-day follow-up: Modified Rankin Scale 1 (no significant disability); returned to work
Clinical Pearl: The combination of IV thrombolysis and mechanical thrombectomy for large vessel occlusion represents the modern standard of care. The "time is brain" principle is demonstrated by the favorable outcome with rapid treatment (door-to-needle 42 minutes, door-to-puncture 78 minutes). The penumbra (salvageable tissue) is the therapeutic target; CT perfusion identifies patients likely to benefit even in cases outside traditional time windows. The number needed to treat for thrombectomy is remarkably low (2-4).