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Tissue-Based Thrombolysis for Wake-Up Stroke With Basilar Artery Occlusion: A Case Report
Nicholas J Janocko1, Alison Seitz1, A J Tsiouris2
1Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
The Neurohospitalist
|December 19, 2022
Summary
Basilar artery occlusion stroke has poor outcomes. A wake-up stroke case successfully used MRI to guide thrombolysis beyond 4.5 hours, improving neurological recovery.
Area of Science:
- Neurology
- Neuroradiology
- Emergency Medicine
Background:
- Basilar artery occlusion (BAO) stroke carries a high mortality and disability rate.
- Intravenous thrombolysis (IVT) within 4.5 hours improves outcomes in ischemic stroke, but BAO treatment remains challenging.
- Mechanical thrombectomy for BAO has yielded variable results.
Observation:
- A patient presented with a wake-up acute ischemic stroke due to BAO, experiencing vertigo and progressive brainstem dysfunction.
- The patient received IVT beyond the standard 4.5-hour window, guided by hyperacute MRI findings.
- MRI revealed restricted diffusion without T2 FLAIR changes, indicating salvageable brain tissue.
Findings:
- Successful reperfusion of the basilar artery was achieved with IVT.
- The patient experienced significant neurological recovery to a near-normal state.
- This treatment occurred outside the conventional time criteria for thrombolysis.
Implications:
- Hyperacute MRI can function as a "tissue clock" to identify select wake-up stroke patients for reperfusion therapy.
- This approach may extend treatment eligibility to patients not meeting standard trial criteria, including those with BAO.
- Individualized, MRI-guided reperfusion strategies can improve outcomes in complex stroke presentations.
