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Issue: Issue 4 (2017) – Supplement 1


Debate

48th hour dilemma

Author(s):
Rita Prayce, Patrícia Ferreira, Sofia Galego, Isabel Fragata, João Reis, Ana Paiva Nunes, and João Reis
Abstract:
A 58-year-old woman with history of non-treated hypertension presented sudden-onset right side hemiparesis, dysarthria and facial asymmetry. The Stroke Code was activated. Upon admission at the emergency department she was alert, oriented, with a left gaze palsy, normal eye field, subtle horizontal rotatory nystagmus to the left, right hemiplegia and ipsilateral hypoesthesia (NIHSS: 12). The Brain computed tomography (CT) revealed no acute lesions. CT angiography showed basilar artery megadolichoectasia. Treatment with alteplase was promptly initiated, and she was admitted in the Stroke Unit. Close clinical monitoring showed stable neurological deficits in the first 24 hours and the control brain magnetic resonance imaging scan (MRI) exhibited acute left paramedial pons ischemic infarct. Antiplatelet treatment was started. On the second day, neurological deterioration was noted: ophthalmoparesis with right side one-and-a-half syndrome and left limb dysmetria. A new MRI brain scan showed expansion of the ischemic lesion, encompassing the pons and the mesencephalon bilaterally. CT angiography revealed the presence of a nonocclusive endoluminal thrombus. The patient was started on non-fractioned heparin infusion for 48 hours, and then switched to fractioned heparin after CT scan with no bleeding. A control CT angiography revealed reduction of thrombus size. The neurologic deficits stabilized. Slight improvement of the ophthalmoparesis was noted. Conclusion: Would a complementary endovascular approach have an additional benefit 48 hours after symptom onset?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D5
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