FIGURE 7.1 CT perfusion revealing a large mismatch between the areas of reduced cerebral blood volume (A) and decreased cerebral blood flow (B).
Our patient represents a common clinical scenario—major deficit despite IV rt-PA and opportunity of an endovascular intervention. After confirming the presence of persistent left middle cerebral artery occlusion and a large area of ischemic penumbra in the left middle cerebral artery territory (Figure 7.1), the patient was taken to the angiography suite. The intervention started 3 hours and 30 minutes after symptom onset. Large amounts of clot were suctioned and the patient also received 6 mg of intra-arterial rt-PA. Recanalization was achieved after 80 minutes (Figure 7.2). The patient evolved favorably over the following days. He was initially discharged to the inpatient rehabilitation unit and then went home 21 days after the stroke. By that time, he had regained functional independence with mild residual expressive dysphasia, a right visual field deficit, and mild to moderate right hemiparesis. He could walk with a cane and climb a flight of stairs without assistance. His NIH stroke scale sum score was 5. Three months later he had mild residual deficits (modified Rankin score of 2). His brain infarctions are shown in Figure 7.3.
As illustrated by this case, we have seen patients improving substantially after complete (Figure 7.4) or even partial endovascular recanalization. Other patients fail to get any better, and some others develop hemorrhagic conversion or a large intracerebral hematoma. Large territorial infarcts may go on to develop swelling, resulting in more complex decisions (discussed in chapter 8). In fact, the care of patients with a major ischemic stroke has become a specialized field, and there is proof that these patients do better when admitted to stroke units or neurosciences intensive care units manned by specialized teams.
