Acute Left Middle Cerebral Artery Research Articles

Thrombectomy using Zoom Reperfusion System in pediatric acute ischemic strokes: Case series and literature review.

Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in adult mechanical thrombectomies (MTs) but has not been described in pediatrics. We present two cases of a 14-year-old with acute right middle cerebral artery (MCA) syndrome and a 10-year old with acute left MCA syndrome who underwent MT using Zoom Reperfusion System safely with TICI 2B and TICI 3 recanalization, respectively. Case report and literature review. A 14-year-old healthy boy with right supraclinoid internal carotid artery (ICA) occlusion (case 1) and a 10-year-old boy with left hypoplastic heart syndrome and left ICA terminus occlusion (case 2) were taken for MT after receiving alteplase at our institution. Through femoral access, an 8-French sheath was introduced into the right femoral artery through which a Zoom 88 catheter was introduced and parked at the right petrous ICA segment in case 1 and left ophthalmic ICA segment in case 2. Angiogram demonstrated complete ICA occlusion just past the ophthalmic artery origin in case 1 and at the ICA terminus in case 2. Zoom system (88 and 71) was then navigated to the face of clot with vacuum manifold engaged with the clot. TICI 2B (with the help of Trevo stent retriever [Stryker]) and TICI 3 recanalization were achieved in cases 1 and 2, respectively. The use of Zoom reperfusion system could potentially be feasible for use in pediatric age group. Larger pediatric patient population is needed to establish its safety.

Mechanical thrombectomy for acute left middle cerebral artery occlusion in a patient with mirror- image dextrocardia

Mirror-image dextrocardia is a physiological variant in which the heart is located in a mirror position to the right of the position of the normal human heart. Mirror-image dextrocardia combined with acute large-artery occlusive stroke is extremely rare in clinical practice. We present here a 67-year- old woman with complete blockage in her left middle cerebral artery. The patient also had a mirror- image dextrocardia. In this report, we share our experience in treating the patient using mechanical thrombectomy. During her visit to the emergency department, we performed various tests to understand the patient’s anatomy. Based on the findings, we decided to approach the femoral artery. Using a combination of stent thrombectomy and intermediate catheter aspiration, we successfully restored blood flow to the patient’s left middle cerebral artery.

Abstract 198: Case Report: Thrombectomy using Zoom Reperfusion System In Pediatric Acute Ischemic Strokes

Introduction Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in mechanical thrombectomies in adults but has not been described in pediatrics to our knowledge. We present two cases of a 14‐year‐old boy with acute right middle cerebral artery (MCA) syndrome and a 10‐year‐old boy with acute left MCA syndrome who underwent mechanical thrombectomy using Zoom Reperfusion System safely with TICI 2B and 3 recanalization respectively. Methods Case report and review of literature Results Case 1: 14‐year‐old previously healthy boy presented to our facility for acute right MCA syndrome secondary to right supraclinoid internal carotid artery (ICA) occlusion. After receiving alteplase, patient was taken for mechanical thrombectomy. After femoral access was obtained, an 8‐French sheath was introduced into the right femoral artery through which a Zoom 88 catheter and 5‐French BERN catheter (Terumo) were coaxially advanced over a Terumo Glidewire into the right common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the lacerum ICA segment with BERN catheter and Glidewire then removed. Angiogram demonstrated complete occlusion of the ICA just past the origin of the ophthalmic artery. Via Zoom 88 catheter, a Zoom 71 catheter was then navigated to the face of clot over a velocity microcatheter (Penumbra) and synchro 2 wire system (Stryker) which was then removed. The vacuum manifold was then attached to Zoom 71 catheter and allowed to engage with the clot for 3 minutes prior to withdrawal into the Zoom 88 catheter. TICI 2B recanalization was achieved with sub‐occlusive thrombus within the proximal M1 segment. Retrieval of the sub‐occlusive thrombus in the M1 segment was performed with TREVO stentriever (Stryker). Procedure was complicated by vasospasm in the A1 and M2 segments which resolved with milrinone and verapamil infused through the Zoom 88 catheter. Case 2: 10‐year‐old with left hypoplastic heart syndrome presented to our facility for acute left MCA syndrome due to left ICA terminus occlusion. Mechanical thrombectomy was performed after receiving alteplase. Femoral artery access was obtained with a 8‐French sheath, through which Zoom 88 catheter and 5‐French select catheter (Penumbra) were advanced over Terumo Glidewire into the left common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the ophthalmic segment of ICA with select catheter and Glidewire then removed. Angiogram demonstrated complete occlusion at the ICA terminus. Zoom 71 catheter was introduced through Zoom 88 catheter and navigated to the face of clot at the ICA terminus over velocity microcatheter (Penumbra) and synchro wire system (Stryker) which was then removed. Zoom 71 was then attached to a vacuum manifold to engage with the clot for 90 seconds. TICI 2A recanalization after first pass was achieved with flow restoration in anterior cerebral artery but none in the MCA.TICI 3 recanalization was achieved after second pass. Conclusion The use of Zoom reperfusion system potentially proves to be safe for use in the pediatric age group with good recanalization results and no intraoperative or postoperative complications.

Abstract Number ‐ 218: Mechanical Thrombectomy in a HIV Patient with Staphylococcus Lugdunensis Bacteremia: A Case Report.

Introduction Occlusion of cerebral arteries account for 40–50% of neurological complications of infective endocarditis with the emboli most commonly lodging in the middle cerebral artery. The management of these occlusions with the use of thrombolytic therapies are associated with intracranial hemorrhage whereas outcomes with endovascular thrombectomy, while still under investigation, appear to be more favorable. In this case report, we present a HIV patient with persistent staphylococcus lugdunenesis bacteremia of unknown origin and acute left middle cerebral artery occlusion, who underwent endovascular thrombectomy. Methods Case Report Results A 66‐year‐old male past medical history of HIV on Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir, pancytopenia and treated hepatitis C who presented for malaise, back pain, and urinary symptoms for 1 week. Initial labs remarkable for pancytopenia, CD4 count 44 and positive urinalysis. Ceftriaxone was started for UTI and Trimethoprim/Sulfamethoxazole for PJP prophylaxis. Urine and multiple blood cultures were positive for staphylococcus lugdunensis. Vancomycin was added to antibiotic therapy. On day two of hospitalization, patient developed new onset aphasia, right facial droop, and right hemiparesis. Upon evaluation, NIHSS was 14. CT head was negative. CTA head and neck showed left M1 occlusion. CT perfusion showed an infarct core of 20cc and 144cc of penumbra. Due to concern for possible infective endocarditis, thrombolytics were not administered but he was taken for thrombectomy. Emboli retrieval was successful with mTICI‐2c reperfusion. During thrombectomy, clot noted to have septic emboli appearance. Post thrombectomy, patient had complete resolution of neurological deficits. MRI brain showed multiple punctate foci of restricted diffusion in the left middle cerebral artery distribution consistent with embolic process. TTE was inconclusive. Intraoperative cultures of the clot resulted positive for staphylococcus lugdunensis and pathology examination detailed clot with bacterial colonization. TEE was performed and negative for valvular vegetations, mass, thrombus, or endocarditis but there was an intrapulmonary shunt. Patient later developed a small acute left parietal lobe parenchymal hematoma and basal ganglia infarct. His neurological status remained unchanged. He completed 6 weeks of IV antibiotic therapy upon discharge. Conclusions This case illustrates the importance of timely endovascular thrombectomy in suspected cerebral septic emboli as outcomes are favorable. It supports prompt recognition of septic emboli bacterial species for targeted antibiotic therapy along with further investigation into staphylococcus lugdunensis and its relation with cerebral septic emboli. This case urges additional exploration into the relationship between HIV patients and cerebrovascular disease including cerebral septic emboli.

Large Left Ventricular Pseudoaneurysm Presenting as an Embolic Stroke After a "Silent" Myocardial Infarction.

A 72-year-old woman with no history of coronary artery disease presented with an acute left middle cerebral artery stroke and was found to have a large left ventricular pseudoaneurysm measuring 8.7 × 7.6 cm and 2 large left ventricular thrombi, the source of her systemic embolization. Despite initial medical management, she developed refractory New York Heart Association functional class III heart failure, uncontrolled atrial fibrillation, and further enlargement of her pseudoaneurysm to 5.5 × 10.6 × 9.2 cm. She underwent urgent aneurysmectomy. Left ventricular pseudoaneurysms are rare and most commonly occur following an acute myocardial infarction when a ventricular free-wall rupture is contained by pericardium or thrombi. Historically, left ventricular angiography displaying a lack of an overlying coronary artery was the gold standard for diagnosis. Now, noninvasive imaging such as computed tomography, magnetic resonance imaging, and echocardiogram with ultrasound-enhancing agent, are reliable diagnostic tools. They can distinguish a pseudoaneurysm from a true left ventricular aneurysm using characteristic findings such as a narrow aneurysm neck, bidirectional doppler flow between the pseudoaneurysm and the left ventricle, and abrupt changes in the cardiac wall structures. Progressive dilation, wall thinning, and dyskinesis can result in refractory heart failure, arrhythmias, and thrombi formation from venous stasis. Pseudoaneurysms have a 30% to 45% risk of rupture and can be treated with left ventricular aneurysmectomy.

Immediate Angioscopic Investigation After Cerebral Artery Thrombectomy Revealed Aortogenic Cerebral Infarction

Background Aortogenic embolism is one of the causes of embolic stroke of undetermined source, which can be difficult to diagnose. Methods We present the case of a 74‐year‐old male patient with a history of Bentall surgery and thoracic endovascular aortic repair who was transported to our hospital with sudden‐onset right‐sided hemiplegia and total aphasia. Magnetic resonance imaging revealed an acute left middle cerebral artery occlusion. Subsequently, an emergency mechanical thrombectomy was performed, through which the left middle cerebral artery was partially reperfused. We immediately investigated the aorta using an angioscopy. Results The angioscopy revealed a thrombus attached to an artificial blood vessel of the aorta close to the origin of the left common carotid artery. Because no other source of the embolus could be identified using electrocardiography or ultrasound, we diagnosed an aortogenic cerebral infarction by combining these findings with the pathological findings of the collected thrombus. Conclusions This is the first report that aortogenic cerebral infarction could be diagnosed using an angioscopy immediately after a cerebral artery thrombectomy.

Hyperprolactinaemia in a Patient with Acute Ischaemic Stroke

This is a case report of a 47-year old man with an unknown medical illness, presented with neurological deficits typical of clinical stroke. The Magnetic Resonance Imaging (MRI) findings were an acute left middle cerebral artery (MCA) territory infarction and an incidental finding of a sellar mass likely pituitary origin. The pituitary hormones showed markedly hyperprolactinaemia with the level of 21146 ng/ml (n 4.04 – 15.2 ng/ml), low Follicle-stimulating hormone (FSH) with a level of 0.929 IU/L (n 1.5-12.4 IU/L), and low luteinizing hormone (LH) with a level of 1.11 IU/L (n 1.7-8.6 IU/L). Other investigations of serum cortisol, growth hormone (GH), thyroid-stimulating hormone (TSH), platelet count and coagulation profiles were normal. The patient was treated conservatively in the ward for acute ischaemic stroke and later was started on dopamine agonist cabergoline for hyperprolactinaemia.

Treatment of ChAdOx1 nCoV-19 Vaccine-Induced Immune Thrombotic Thrombocytopenia Related Acute Ischemic Stroke

Recently cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) and thrombosis following the adenoviral vector vaccine against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported. A mechanism similar to heparin-induced thrombocytopenia was proposed with antibodies to platelet factor 4 (PF4). Vaccine related arterial thrombosis in the brain is rare but life-threatening and optimal treatment is not established. We report clinical, laboratory, imaging findings and treatment in a 51-year-old female presenting with acute left middle cerebral artery (MCA) occlusion 7 days after the first dose of ChAdOx1 nCoV-19 vaccine. Due to low platelet count and suspicion of VITT she was not eligible for intravenous thrombolysis (IVT) and proceeded to mechanical thrombectomy (MER) with successful recanalization four hours after onset of symptoms. Treatment with intravenous immunoglobulin (IVIG) and heparin pentasaccharide fondaparinux was initiated. Presence of anti-PF4 antibodies was confirmed. The patient improved clinically with normalization of platelet count. Clinicians should be alert of VITT in patients with acute ischemic stroke after ChAdOx1 nCov-19 vaccination and low platelet counts. MER showed to be feasible and effective. We propose considering MER in patients with VITT and large vessel occlusion despite thrombocytopenia. High-dose IVIG should be started immediately. Alternative anticoagulation to heparin should be started 24 hours after stroke onset unless significant hemorrhagic transformation occurred. Platelet transfusion is contraindicated and should be considered only in severe hemorrhagic complications. Restenosis or reocclusion of the revascularized artery is possible due to the hypercoagulable state in VITT and angiographic surveillance after the procedure is reasonable.

Dilated cardiomyopathy-related stroke mimicking large-artery atherosclerosis-related stroke: report of two cases

The clinical characteristics and treatment of stroke caused by dilated cardiomyopathy (DCM) are not clear, especially in patients with large-artery atherosclerosis (LAA)-related stenosis, which commonly causes acute ischemic stroke (AIS); therefore, the diagnosis and treatment of such patients are challenging. Herein, we summarize the clinical characteristics and suggest clues to guide the diagnosis and treatment of two cases. Case 1: A 67-year-old woman with a history of DCM presented with sudden-onset slurred speech and left limb weakness (>2 hours duration), which worsened after intravenous thrombolysis. Repeated brain computed tomography showed no hemorrhage; thus, cerebral artery occlusion or embolism was suspected. Emergency magnetic resonance imaging (MRI) and angiography (MRA) revealed acute multiple bilateral cerebral infarctions and severe left middle cerebral artery stenosis, respectively. We considered a DCM-related stroke and administered anticoagulation therapy. Subsequently, the patient’s symptoms improved significantly, and she was discharged on day 9, after showing no abnormal neurological signs. Case 2: A 49-year-old man with a history of DCM presented with acute headache and blurred vision for 4 days. MRI and MRA revealed multiple acute cerebral infarctions and left vertebral artery stenosis, respectively. We considered an LAA-related stroke and administered antiplatelet and cholesterol-lowering drugs. Eventually, the patient was discharged on day 13, after his right-sided hemianopia improved significantly. Both patients had LAA, which can be easily misdiagnosed as a stroke. LAA-related and DCM-related stroke need to be differentiated. DCM-related AIS lesions are often distributed in the areas supplied by the different cerebral arteries. It is necessary to carefully analyze the shape, location, and scope of the lesions, and identify the main causes of stroke. Anticoagulant therapy is preferred for DCM-related AIS.

S72. Case of acute stroke after high-risk carotid surgery: Visual and quantitative EEG analysis

EEG monitoring in the intensive care unit (ICU) has multiple potential uses outside of seizure detection by providing a continuous noninvasive assessment of neurologic function. Since the early 1990s, EEG has been widely employed intraoperatively during carotid endarterectomy to evaluate for cerebral ischemia. Its utility in the ICU, however, is contingent on access to frequent review by an expert neurophysiologist. Several studies found that quantitative EEG (QEEG), particularly a decrease in the alpha/delta ratio (ADR), can be sensitive in screening for delayed cerebral ischemia after subarachnoid hemorrhage. QEEG monitoring may be useful in other situations during which monitoring for ischemia is critical. The EEG for this case was reviewed by three neurophysiologists. QEEG analysis was performed retrospectively with Persyst InsightII software. A 56-year-old right-handed man presented with acute expressive aphasia. Imaging revealed a left frontal stroke and >70% left internal carotid artery stenosis. Six weeks later, he underwent left carotid endarterectomy, complicated by a diseased vessel wall necessitating complete ligation of the artery. Post-operative neurologic exam was non-focal. He was sedated and placed on normothermia protocol in the ICU to prevent cerebral infarction. Visual EEG review initially showed gradually increasing intermittent left temporal slowing. Approximately 90 min later, acute persistent left hemispheric attenuation was seen, most prominent over the centro-posterior region, followed by a gradual increase in left hemispheric delta slowing. Subsequent neurologic exam off sedation revealed a new right hemiparesis; brain MRI showed an acute left middle cerebral artery infarct. QEEG showed immediate prominent and persistent decreases in delta, theta, and alpha power, as well as large reductions in the amplitude-integrated EEG (aEEG) over the left hemisphere. There was also a slight decline in beta power over the left. A delayed decrease in the ADR over the left side was seen approximately 20 min later. Visual EEG inspection in this case revealed acute lasting focal left hemispheric attenuation, with subsequent increased slowing after the time of presumed infarct. Interestingly, QEEG analysis showed simultaneous decreases in absolute power values and aEEG prior to change in the ADR. An automatic alarm system monitoring multiple QEEG parameters could therefore be helpful in monitoring for cerebral ischemia in the ICU, particularly when a trained neurophysiologist is not available.

Catastrophic antiphospholipid syndrome (CAPS): A rare and fatal encounter.

Sir, Antiphospholipid syndrome (APS) is a rare, multisystem, autoimmune, hypercoagulable disorder caused by production of antibodies against cell membrane made up of phospholipids, which will cause venous and/or arterial thromboembolism that can become disastrous if multi organ failure develops. We report a case of catastrophic variant of APS with good outcome. Patient developed pulmonary and peripheral vessels thrombosis in spite of anticoagulant and antiplatelet agents that was treated by surgical intervention which is reported in very few cases. A 35-year-old female obese (102 kg) patient, without any bad obstetric history or other co-morbidities except 1st time detected diabetes mellitus, admitted for acute left middle cerebral artery infarct at peripheral hospital. She was not thrombolysed there because of late presentation. She was discharged after 2 days with improved limb weakness and was on subcutaneous low-molecular-weight heparin at home for 3 more days [Figure 1]. Figure 1 CT Angiography showing Bilateral pulmonary thrombosis She developed breathlessness on exertion 2 days after discharge. She was diagnosed to have bilateral massive pulmonary embolism with respiratory failure, so referred to our hospital for further management. She was not thrombolysed for pulmonary embolism because of recent cerebral vascular stroke. She was put on Bipap ventilator support and given heparin and supportive treatments. She also diagnosed to have right popliteal vein thrombosis on Doppler examination after admission to our hospital. Subsequently ventilator requirement increased and she was not maintaining oxygen saturation with 100% FiO2 and 15 positive end-expiratory pressure. So decided for surgical embolectomy by thoracovascular surgeon. When surgical preparation was going on, she developed right lower limb femoral arterial thrombosis also. Hence, it was operated first followed by pulmonary embolectomy (thrombectomy). Postoperatively oxygen requirement decreased to minimal on ventilator with good femoral arterial flow also. However, she developed severe sepsis, septic shock and acute renal failure postoperatively, which was treated accordingly. After stabilization, she was weaned from ventilator support and shifted to the ward. She was discharged on day-22. Considering multiple arterial/venous thromboembolic events, APS work up was done, which came positive. And according to criteria that was a catastrophic variant.[1] After 3 months of follow-up, again antiphospolipid antibodies sent, which came positive. So diagnosis was confirmed.[2] Our patient developed multiple thrombotic events within a span of 1-week. We suspect APS initially and taken prompt actions particularly for pulmonary and femoral arterial thrombosis. We succeeded in tackling both the life threatening events of thrombosis with the help of vascular surgeon. In selected/resistant cases, immunosuppresion with corticosteroids, immunoglobulines, plasma exchange, cyclophosphamide can be added.[3]

Intracerebral hemorrhage after intravenous thrombolysis in patients with cerebral microbleeds and cardiac myxoma.

Background and purpose: Cardiac myxoma is a rare etiology of stroke. Both cerebral microbleeds and cardiac myxoma may increase the risk of intracerebral hemorrhage after intravenous (IV) thrombolysis. However, data are still limited. We report a case of multiple cerebral microbleeds treated with IV thrombolysis with later findings of cardiac myxoma.Summary of case: A 58-year-old-man presented with right-sided hemiplegia and global aphasia. The presumptive diagnosis of acute left middle cerebral artery (MCA) infarction was made. Previous magnetic resonance imaging showed multiple cerebral microbleeds. The patient received IV thrombolysis. Bilateral cerebellar hemorrhage occurred after thrombolysis, and a median suboccipital craniectomy and hematoma removal was performed. Transthoracic echocardiogram found a left atrial myxoma. The tumor was then surgically removed. Six months later, neurological deficit improved.Conclusion: Cerebral microbleeds may be associated with atrial myxoma. IV thrombolysis could benefit acute ischemic stroke patients with both baseline cerebral microbleeds and atrial myxoma.

Acute venous thromboembolic disease and paradoxical embolism

Background:We report two cases of paradoxical cerebral embolism associated with acute venous thromboembolic disease.Case report:The first case corresponds to a 49-year-old woman with sudden onset of dyspnea and syncope, followed by right upper extremity paresis, aphasia and dysarthria.The admission brain computed tomography (CT) was unremarkable, but lung CT showed multilobar and multisegmentary pulmonary embolism.Echocardiography showed dilated right ventricle with impaired systolic function, moderate tricuspid regurgitation, moderate pulmonary hypertension and positive bubble test, suggestive of a patent foramen ovale (PFO) which was successfully closed by endovascular Amplatzer device placement. The patient was discharged with anticoagulation therapy and permanent antiplatelet aggregation therapy.The second case is a 60-year-old woman found unconscious. Neurological examination revealed expressive aphasia, right hemianopsia, right central facial paralysis and right-sided paresis with a National institute of Health Stroke Scale of 19. Brain CT showed signs of acute left middle cerebral artery infarction.Later, she developed greater impairment of consciousness.A new brain CT showed significant edema with mass effect requiring a decompressive craniotomy.Echocardiography showed PFO and lower extremities’ Doppler ultrasound showed a left infrapopliteal posterior tibial right deep venous thrombosis. An inferior vena cava filter was placed and two days after surgery, anticoagulation was started.

Last resort: case of clot translocation in intra-arterial stroke therapy

A patient was taken for emergent intra-arterial stroke therapy for an acute left middle cerebral artery stroke syndrome, with CT angiography showing a left internal carotid artery (ICA) occlusion. Through...

Adverse Outcome of Early Recurrent Ischemic Stroke Secondary to Atrial Fibrillation after Repeated Systemic Thrombolysis

Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tomographic scans. The patient did not recover from the second cerebrovascular event and died 25 days after admission. Conclusion. To the best of our knowledge, this is the second case reporting the adverse neurological outcome of a patient with diagnosis of atrial fibrillation undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Our report represents a contribution to the scarce available evidence suggesting that repeated systemic thrombolysis for recurrent ischemic stroke should be avoided.

Anterior Communicating Artery Aneurysm Rupture After Intravenous Thrombolysis for Acute Middle Cerebral Artery Thromboembolism

The use of intravenous recombinant tissue plasminogen activator (IV rtPA) has become an integral part of modern acute ischemic stroke management; however, its use has been associated with the development of intracranial hemorrhage in 6.4% of patients. It is possible that underlying and unsuspected vascular lesions, such as cerebral aneurysms, may lead to intracranial hemorrhage after IV rtPA thrombolysis. We present a previously unreported case of a 51-year-old woman who presented with subarachnoid hemorrhage from an acutely ruptured anterior communicating artery aneurysm after IV rtPA treatment for acute left middle cerebral artery thromboembolism. The patient underwent mechanical thromboembolectomy of the left middle cerebral artery occlusion with resultant TIMI (Thrombolysis In Myocardial Infarction) grade I recanalization, followed by coil embolization of the anterior communicating artery aneurysm. The patient never improved neurologically, and she ultimately died. Screening to identify patients at risk for development of hemorrhagic complications from underlying structural vascular lesions before the use of IV rtPA with computed tomography angiography should be considered.

Successful Intravenous Thrombolysis in a 14-Year-Old Boy With Ischemic Stroke

We report a healthy 14-year-old boy with an acute left middle cerebral artery stroke, treated 2 hours after the onset of symptoms with intravenous recombinant tissue plasminogen activator (r-TPA). Recanalization of the middle cerebral artery was documented with transcranial Doppler during the first 5 minutes of intravenous r-TPA perfusion, and progressive recovery of the neurological deficits occurred. Although lack of evidence regarding safety and efficacy in children precludes the recommendation of systematic use of r-TPA in pediatric stroke, we propose that this option should be considered and discussed with the parents, especially in older children presenting within 3 hours in centers with experience in adult thrombolysis.

Acute middle cerebral artery thrombus

An 87-year-old man presented with sudden onset of right arm and leg weakness associated with difficulty in speech. His past medical history was significant for hypertension and paroxysmal atrial fibrillation. He was afebrile and hemodynamically stable. He was alert and oriented to time, place and person. Neurologic examination revealed global aphasia with right sided inattention and right sided hemiplegia with power of 1/5 in the right arm and leg. Rest of the physical examination was normal. A non-contrast Computed tomography (CT) scan of head done at presentation revealed a hyperdense left middle cerebral artery suggestive of an acute thrombus (Figure 1, arrow). Repeat non-contrast CT scan of the head performed 72 hours later revealed an acute left middle cerebral artery infarct with mild mass effect on the left lateral ventricle (Figure 2, arrow).

Successful Intra-arterial Thrombolysis in a Patient with Perioperative Stroke after Open Heart Surgery

To present the case of a 54-year-old male who suffered from sudden-onset motor aphasia and right-sided weakness on the 14th inpatient day after open-heart surgery for mitral valve replacement. Acute left middle cerebral artery (MCA) occlusion of the M1 segment was found on contrast computed tomographic angiogram of the head. A history of recent major surgery and old intracerebral hemorrhage excluded the patient from intravenous thrombolytic (IVT) therapy. Highly selective local intra-arterial thrombolytic (IAT) therapy was selected for its lower risk of systemic bleeding complication, since symptom onset had occurred 4 hours earlier in this patient. The occluded MCA was completely recanalized after administration of 1, 250, 000 units of intra-arterial urokinase. The patient•s neurological function resumed quickly without early or delayed hemorrhagic complication. The highly selective local IAT may be an alternative therapy in patients with perioperative acute ischemic stroke who are not eligible for IVT therapy.

Endovascular mechanical retrieval of a terminal internal carotid artery breast tumor embolus

The authors report the case of an acute left middle cerebral artery distribution stroke caused by a terminal internal carotid artery occlusion in a patient who underwent endovascular mechanical embolectomy. Histopathological analysis of embolic material obtained from the mechanical retriever device was diagnostic of a high-grade phyllodes breast tumor. This case represents the first instance, to our knowledge, of tumor embolus extraction via mechanical retrieval during acute ischemic stroke intervention.