Combined therapy in acute ischemic cerebral stroke - case report

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BACKGROUND AND PURPOSE: Stroke remains the third most common cause of death in industrialized nations, and the single most common reason for permanent disability. Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA, Alteplase) for the treatment of acute ischemic stroke within 3 hours of onset become, a worldwide conventional standard of care. Thrombolytic stroke therapy is based on the hypothesis, that reopening of occluded vessels improves clinical outcome in acute ischemic stroke through regional reperfusion and salvage of threatened tissues. However, intravenous thrombolysis is successful in approximately one third of patients. Thromboaspiration through either a microcatheter, or a guiding catheter may be an option for a fresh nonadhesive clot. The use of mechanical thrombectomy devices in patients experiencing ischemic stroke and reoclusion after intravenous thrombolysis can now gain approval on the basis of recanalization. CASE DESCRIPTION: We describe a case of a 51-year-old man who presented with ischemic stroke (right-sided hemiparesis and sensomotor aphasia) and sudden onset on 06.50h. He was hospitalised in Neuro intensive Care Unit on 08.10h with NIHSS 8 points. The CT of the head was normal and on 8.40h. began an intravenous rtPa by protocol: body weight 70 kg x 0,9 mg rtPA- 63 mg ACTILYSE with 10% bolus and i.v. infusion for 60 min. After beginning it was a significant improvement with neurological deficite NIHSS 5 points. After the end of the fibrinolysis the patient was with severe deterioration of the symtoms (right-sided hemiplegia and aphasia) - NIHSS 15 points. The patient underwent control CT of the head to exclude intracerebral haemorrhage - was normal. On the digital subtraction angiography there was total thrombosis of the left internal carotid artery. Through a guiding catheter was done thrombo aspiration with effective reperfusion with reversal of neurological deficits - NIHSS 3 points. CONCLUSIONS: This case represents a valuable example of two recanalization therapies in acute ischemic stroke to improve clinical outcome by restoring anterograde perfusion and salvaging ischemic brain.