Off-label Use of Intravenous Thrombolysis in an Acute Ischemic Stroke Patient With Multiple Contraindications

Intravenous thrombolysis (IVT) is a powerful treatment for acute ischemic stroke, yet its use remains limited due to numerous absolute and relative contraindications.

We present the case of a 54-year-old man who received intravenous thrombolysis (IVT) for an early recurrent wake-up ischemic stroke caused by a tandem left internal carotid artery and M2 middle cerebral artery occlusion, occurring <48 hours after the initial ischemic event, which had been misdiagnosed as a peripheral-type facial nerve palsy. Moreover, in the context of the initial work-up, the patient had undergone a diagnostic lumbar puncture <24 hours before IVT. Despite the history of a very recent acute ischemic stroke, which is listed as a contraindication for IVT, as well as the recent lumbar puncture, the patient demonstrated marked clinical improvement without any complications.

IVT may be considered even in the presence of multiple relative contraindications, provided the risks and benefits are carefully weighed for each patient.