10.1.1 Clinical Presentation

A 68-year-old man presented with a reduced conscious state associated with focal neurology on examination. His wife reported acute onset of left facial droop and altered conscious state at home. An ambulance was called and he was intubated in the community. He arrived at the emergency department 1 hour after onset of symptoms.

The patient had a known history of chronic atrial fibrillation (AF), and was on aspirin due to nonadherence with recommended warfarin therapy. He also had a history of congestive cardiac failure, and essential hypertension. Prior to intubation, the Glasgow Coma Score (GCS) was 4; the patient had no verbal response or eye opening, and had an extensor response to pain. Examination revealed left facial droop, extensor posturing, and positive left Babinski reflex.

10.1.2 Imaging Workup and Investigations

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  Noncontrast computed tomography (NCCT) performed 2 hours after symptom onset demonstrates no acute ischemic changes (Fig. 10.1).

  
  
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  Subsequent CT angiography (CTA) demonstrated a filling defect in the tip of the basilar artery extending into the left and right P1 segments.

  

10.3.1 Initial Management

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  Patient received intravenous thrombolysis 4.5 hours after the onset of symptoms.

10.3.2 Endovascular Management

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  Endovascular clot retrieval was conducted at 5.5 hours with Trevo device.

  
  
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  1-cm clot was removed from basilar artery with Trevo device. Some residual clot was seen in the right superior cerebellar artery (SCA) (Fig. 10.2).

  

10.3.3 Outcome

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  The patient had an excellent response to therapy. He was able to follow commands after sedation was weaned on the same day.

  
  
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  He was extubated on day 2 of admission, and discharged from intensive care on day 3.

  
  
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  He was discharged from the hospital 2 weeks later; on discharge he was able to ambulate independently, with some residual deficits in dynamic balance.

  
  
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  MRI performed 3 months later showed a large infarct involving the pons, as well as multiple small cerebellar infarcts (Fig. 10.3). Multiple cerebral microbleeds (CMBs) were also identified in a lobar distribution (Fig. 10.4).

  

  

10.4.1 Background

Thrombolysis and mechanical thrombectomy are therapies proven to improve clinical outcomes following acute ischemic stroke. ^{1 ,​ 2 ,​ 3 ,​ 4 ,​ 5 ,​ 6} However, tissue plasminogen activator (tPA) increases the risk of intracerebral hemorrhage (ICH). ⁷ The risk of ICH may also be increased in people with multiple lobar CMBs. ⁸ Identification of CMBs on MRI therefore invites the question, is thrombolysis indicated in patients with CMBs who present with acute ischemic stroke?

CMBs are small hypointense lesions, visible on susceptibility weight imaging and gradient echo (GRE) MRI sequences that represent hemosiderin-laden macrophage deposits in areas of angiopathy. ⁹ Risk of CMBs increases with age, with prevalence of CMBs reported to be around 25% in a general older population of mean age 68 years. ^{10 ,​ 11} They are a marker of frailty, have been shown to correlate with severity of white matter lesions (WML), and found to be an independent predictor of cognitive dysfunction. ^{12 ,​ 13}

CMBs that occur in the lobar regions have been associated with cerebral amyloid angiopathy, carriage of the apolipoprotein e4 allele, and raised diastolic blood pressure (BP), while those that are infratentorial or deep are associated with cardiovascular risk factors such as hypertension, as well as subcortical infarcts, and WML on MRI. ^{11 ,​ 14 ,​ 15}

In observational studies, CMBs have been associated with an increased risk of ICH, and an increased risk of hematoma expansion in patients with ICH. ^{8 ,​ 16 ,​ 17 ,​ 18} CMBs may also increase the risk of ICH in patients taking antiplatelet drugs. ^{18 ,​ 19}

In a recent meta-analysis of five observational studies by Shoamanesh et al, there was a nonsignificant trend toward an increased risk of symptomatic and asymptomatic ICH after thrombolysis, in patients with CMBs compared to those without. ²⁰ These studies were limited by small sample size and inconsistent methodology; thus, further studies are required.

10.4.2 Workup and Diagnosis

10.4.3 Decision-Making Process

The decision to perform thrombolysis requires a diagnosis of ischemic stroke causing a measurable neurological deficit, with onset of symptoms no longer than 4.5 hours prior to beginning treatment in patients 18 years or older. ¹ See Table 10.1 for a list of absolute and relative exclusion criteria. Endovascular clot retrieval has been shown to be superior to thrombolysis alone. ²