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Issue: Issue 4 (2017) – Supplement 1


Debate

Early recurrent stroke: reset clock and give RT-PA or directly to thrombectomy?

Author(s):
Fernando Rocha Correia, Margarida Viana, Cristina Correia, Luís Flores, João Coimbra, Cláudia Matos, Teresa Mendonça, Goreti Moreira, Guilherme Gama, and Jorge Almeida
Abstract:
Introduction: It is established that patients who are eligible for intravenous rt-PA therapy should be treated even if endovascular therapy is considered. However, there are situations in which thrombectomy could be directly performed. 
Case: 69-year-old male patient with hypertension and pernicious anemia. He had sudden right arm paresis. Four hours later, at the hospital, the neurological examination was unremarkable. At admission, he was hypertensive (191/94 mmHg) but, otherwise, had normal vital signs.  Analytical study, electrocardiogram and brain CT were normal and he was admitted for transient ischemic attack(TIA) study. The next day, after being asymptomatic for 22 hours, he developed right central facial and limb paresis, scoring 10 in NIHSS. Repeated brain CT and CT-angiography (CTA) showed no early ischemic signs, a left internal cervical carotid (ICA) occlusion and tandem thrombus at the terminal intracranial carotid. Intravenous rtPA was given and he was selected tomechanical thrombectomy. Before the procedure, 2h30 after symptom onset, NIHSS was 5 and a new CT and CTA were performed, showing resolution of the terminal ICA occlusion, left parietal subarachnoid blood and a deep hemorrhagic focus. Thrombectomy was held-up and he returned to stroke unit. He had progression of deficits scoring 20 over the following 72 hours. Ultrasound showed the same left ICA occlusion with patent intracranial main vessels. No other etiology was advanced after study. 
Conclusion: The authors question the need of CTA in TIA’s with presumable cortical symptoms and if, in this particular case, thrombolysis was not beneficial but even detrimental to patient evolution, making impossible to perform thrombectomy.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D7
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