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Discussion

The patient was treated 8 hours after the time of onset which is technically outside the 6 hour "window" that is dogmatically emphasized. I believe that the time of onset is pretty much irrelevant to outcome, especially in the posterior fossa. Although, it is true that most of the time strokes shouldn't be treated intra-arterially after 6 hours, (some not after 30 minutes for that matter) but if the collaterals are sufficient, the window for anterior circulation strokes can be extended depending on MRI findings. I have successfully treated MCA/ICA strokes up to 12 hours after onset, and basilar thrombosis after 4 days of symptoms. Since this patient's MCA territory cortex was still viable, I decided it was worth the risk of a hemorrhage into the infarcted basal ganglia since even if he ended up hemiplegic, he would still be able to talk. While some may question the wisdom of adding even more time by doing an an MRI instead of a CT, I believe the additional physiologic information added far outweighs the risk of extra time. I don't have CT perfusion and I haven't really found MR perfusion to add much to the combination of FLAIR/DWI.

The patient made a dramatic recovery, was extubated 2 days later, and discharged to rehab today 5 days after admission. As expected he is very weak in his right arm and leg, but does have movement against gravity and intact sensation. I expect significant improvement after a few weeks of rehab. His wife is very happy.

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Your Comments

It is the outcome that matters. Don't know if I would have waited for MRI - depends on how quickly it could be obtained. If I had to wait an hour, or call in a tech from home, I wouldn't do it. If the scanner were available within a few minutes, that would be different.

I agree that the basal ganglion infarct was already completed. Obviously the clot started occluding the M1, picking off the lenticulostriates, and then migrated distally into the superior division. Given that, a reperfusion hemorrhage in the basal ganglia was likely no matter what you did. Since there was no sign of cortical infarct, direct infusion into this territory was relatively safe as long as the dose was kept low. Anecdotally, this would probably have been a great case for the MERCI device or some other clot retrieval device; avoiding the need for lytic agents altogether. Then no one could have said you caused the hemorrhage - the lenticulostriates were already re-opened when you started and you would have done nothing that would have altered the fate of the basal ganglia. I might not have tried lytics here, but would have considered a mechanical device for sure.

I don't routinely get MR because of the time involved. One thing I find very useful are the late phase arterial and parenchymal angiographic images. If I see good pia circulation, in my experience, the patient will probably do well after thrombolysis, whether pharmacologic or mechanical. I'm using the delayed angiogram like a perfusion study. I don't know if there are any good papers on this. This is just anecdotal from my experience. BTW, could you post the delayed images of this patient?

1100 h T2-weighted and Flair are a waste when the patient needs immediate treatment. Their findings are no more than those from CT which could only have taken seconds for acquisition. DWI shows infarcted/infarcting zones that are confirmed later at 1600. Treatment at 1100 was indicated, either IV or IA. MRAs look like TOF, which are not anatomic but flow "enhanced". CTA and CE MRA are more accurate and only need about 20 s for acquisition compared with 2 - 3 m or more TOF.Angio seems done hours later. Diagnostic information would have been available with CTA at 1100h after a 20s acquisition. The superior main branch of M1 seems proportionately to be a continuation of the trunk rather than a smaller M2 branch. This is a case where mechanical clot removal, as mostly done, without tPa, might be better. Best yet would be to have 1) worked with dispatch in the beginning (CT-CTA-CTP or DWI-EPI/Gradient-CE MRA); 2) IV tPa be applied urgently (it works even for M1 clots if done quickly); 3) considering IA revascularization, IV tPa dose might be only half usual. The learning from a case like this might be better applied to get patients treated earlier. Yet your patient and you have done well enough. Is he mute?