Abstract
Background An 83-year-old woman with a history of hypertension and dyslipidemia developed acute onset of impaired speech and comprehension, and right-sided weakness. Her previous medical history was notable for hyperthyroidism and a curative remote mastectomy for breast cancer. The patient was on two antihypertensive medications and a statin, and she was not receiving any antiplatelet medication. She was taken by ambulance to a primary stroke center. Initial examination showed global aphasia, right homonymous hemianopia, right hemiplegia, and hemisensory loss.
Investigations Physical examination, laboratory tests, noncontrast head CT scan, multimodal brain MRI scan, catheter cerebral angiogram, echocardiogram, continuous cardiac monitoring.
Diagnosis Acute ischemic stroke caused by distal left internal carotid artery occlusion, with salvageable penumbral tissue and a persistent large-vessel occlusion.
Management Neuroprotective study agent (total dose of 20 g intravenous MgSO4 or matched placebo), intravenous tissue plasminogen activator, rescue mechanical thrombectomy using the Merci® clot retrieval device.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
References
Kidwell CS et al. (2000) Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke 31: 71–76
Saver JL et al. (2004) Prehospital neuroprotective therapy for acute stroke: results of the Field Administration of Stroke Therapy–Magnesium (FAST–MAG) pilot trial. Stroke 35: e106–e108
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333: 1581–1588
Adams HP Jr et al. (1993) Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. TOAST: Trial of Org 10172 in Acute Stroke Treatment. Stroke 24: 35–41
Schlaug G et al. (1999) The ischemic penumbra: operationally defined by diffusion and perfusion MRI. Neurology 53: 1528–1537
Kidwell CS et al. (2000) Thrombolytic reversal of acute human cerebral ischemic injury shown by diffusion/perfusion magnetic resonance imaging. Ann Neurol 47: 462–469
Parsons MW et al. (2001) Perfusion magnetic resonance imaging maps in hyperacute stroke: relative cerebral blood flow most accurately identifies tissue destined to infarct. Stroke 32: 1581–1587
Kidwell CS et al. (2003) Beyond mismatch: evolving paradigms in imaging the ischemic penumbra with multimodal magnetic resonance imaging. Stroke 34: 2729–2735
Molina CA and Saver JL (2005) Extending reperfusion therapy for acute ischemic stroke: emerging pharmacological, mechanical, and imaging strategies. Stroke 36: 2311–2320
Saqqur M et al. (2007) Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 38: 948–954
Smith WS et al. (2005) Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 36: 1432–1438
Smith WS (2006) Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke: results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol 27: 1177–1182
Smith WS (2007) Technology Insight: recanalization with drugs and devices during acute ischemic stroke. Nat Clin Pract Neurol 3: 45–53
Albers GW et al. (2006) Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol 60: 508–517
Vahedi K et al. (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6: 215–222
Acknowledgements
BH Buck is supported by a fellowship award from the Heart and Stroke Foundation of Canada.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
JL Saver is Principal Investigator of the NIH FAST–MAG Trial, is an investigator in the NIH MR RESCUE, IMS 3 and CLEAR trials, is on the Scientific Advisory Board and Speaker's Bureau for Boehringer Ingelheim (secondary prevention) and has received speaking honoraria from Concentric Medical. BH Buck declared no competing interests.
Rights and permissions
About this article
Cite this article
Buck, B., Saver, J. A case of acute ischemic stroke: optimizing management with penumbra and vessel imaging. Nat Rev Neurol 3, 465–469 (2007). https://doi.org/10.1038/ncpneuro0553
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1038/ncpneuro0553