A 56-year-old male presented to the emergency department of a tertiary care neurology centre with acute onset of severe global aphasia and complete paralysis of right lower face, arm and leg. National Institutes of Health Stroke Scale (NIHSS) score was 14. Initial computed tomography (CT) revealed hyperdense left middle cerebral artery (MCA) (Figure 1A) and computed tomography angiography (CTA) confirmed MCA – M1 segment occlusion (Figure 1B) with minimal pial collaterals (Figure 1C). Patient fulfilled criteria for intravenous thrombolysis and alteplase was initiated within 90 minutes of symptom onset.

No clinical improvement was observed after 40 minutes. Consent was obtained to attempt intra-arterial intervention. Mechanical thrombectomy was performed 130 minutes from symptom onset using the TREVO© microcatheter (Stryker Neurovascular, CA, USA) (Figure 1E). A long clot was retrieved (Figure 1D). Clinically, the patient experienced immediate improvement in language and strength. Angiography also revealed a 53% left ICA stenosis for which he underwent endarterectomy four days later. Follow-up brain magnetic resonance imaging (MRI) showed multiple ischemic infarcts in left MCA territory with slight hemorrhagic transformation (Figure 1F). Patient was discharged home 11 days after admission with a NIHSS score of 3.

In patients with proximal MCA occlusion (such as ours), the rate of recanalization with intravenous thrombolytic therapy alone has been reported to be less than 30%. [1] Recent efforts have provided strong evidence for a benefit of thrombectomy on functional outcome. [2] Our patient is a 56-year-old individual who would have likely remained with severe deficits following IV thrombolysis alone. This case shows the highly promising impact of intra-arterial therapy and the relevance of early vessel imaging to identify patients who could benefit from such therapy.

It is expected that this procedure will become, in addition to IV thrombolysis, the standard of care for patients with acute ischemic stroke and a proximal occlusion.

Keywords: Aphasia, Intra-arterial treatment, Stroke, Thrombectomy

1. Appireddy RM, Demchuk AM, Goyal M, et al. Endovascular therapy for ischemic stroke. J Clin Neurol 2015 Jan;11(1):1–8.   [CrossRef]   [Pubmed]    
2. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015 Jan 1;372(1):11–20.   [CrossRef]   [Pubmed]