Pro: Intravenous Tissue Plasminogen Activator in Stroke Patients With Rapid, Complete Recovery During Evaluation (Transient Ischemic Attack) and Evidence of Middle Cerebral Artery Occlusion

Abstract

Carlos A. Molina MD, PhD Magdy H. Selim MD, PhD Section Editors: The Case: A patient presents within 3 hours of acute onset of left-sided weakness. Symptoms rapidly resolve spontaneously. Vascular imaging reveals evidence of right middle cerebral artery (MCA) occlusion. The Questions: (1) Should treatment decision be based on clinical or vascular status? (2) Would treatment with t-PA prevent clinical worsening or early stroke recurrence in this patient? (3) Is increased collateral flow good enough to maintain perfusion? The Controversy: Role of Thrombolysis in Patients with Rapid Recovery during Evaluation and Evidence of Arterial Occlusion on Vascular Imaging. There are some points on which to agree at the beginning of this controversy. The middle cerebral artery (MCA) supplies a large and important proportion of the brain, which is not meant to be perfused through small collaterals. Acute occlusion of the MCA in most cases leads to devastating strokes. Thus, a patent MCA is probably better than an occluded one. Would we really consider a spontaneously recovering stroke patient with a proven, persistent occlusion of the MCA to have a “transient ischemic attack” (TIA) not necessitating thrombolysis? The …