Deterioration following improvement with tPA therapy: Carotid thrombosis and reocclusion

Abstract

Clinical improvement of ≥4 points on the NIH Stroke Scale (NIHSS) was seen in 47% of patients 24 hours after treatment with IV tissue plasminogen activator (tPA) for acute ischemic stroke.1 Arterial recanalization can be associated with early recovery;2 following improvement, however, 15% of patients experience clinical deterioration.3 Transcranial Doppler (TCD) ultrasonography has been used to detect arterial occlusion and monitor recanalization during thrombolysis.4 The authors report the clinical and TCD findings in a patient who improved, then subsequently deteriorated, while receiving tPA therapy. A 42-year-old, right-handed woman was seen 80 minutes after the acute onset of right hemiplegia, global aphasia, eye deviation to the left, and a right homonymous hemianopsia (NIHSS score 24). Her medial history included smoking, non–insulin-dependent diabetes mellitus, and peripheral vascular disease requiring bilateral femoral–popliteal bypasses. She had no history of cardiac or cerebral ischemia, and was not taking any antiplatelet treatment. A head CT scan showed a hyperdense left middle cerebral artery (MCA) and no hemorrhage. At 90 minutes from symptom onset, a TCD was performed according to a published protocol,4 using a single-channel, 2-MHz portable unit (Multigon 500M, Yonkers, NY), and head-frame fixation (Marc 500, Spencer Technologies, Seattle, WA). The TCD was consistent with a proximal M1 MCA and A1 anterior cerebral artery (ACA) occlusion ( figure, frame 1) followed by rapid progression to a terminal internal carotid artery (ICA) occlusion (see the figure, frame 2). Within 5 minutes, the …