Reversal of Progressive In-Hospital Posterior Artery-to-Artery Embolic Stroke With Argatroban: A Case Report

In-hospital progressive stroke in patients with pre-existing large artery occlusion presents a therapeutic dilemma, particularly when standard reperfusion strategies are unsuitable. This case report aims to illustrate a mechanism-guided medical approach in this complex scenario.

We report the case of a 65-year-old male patient with chronic left vertebral artery occlusion, hospitalised for dizziness, who experienced acute neurological deterioration with a National Institutes of Health Stroke Scale (NIHSS) score ranging from 2 to 14. Magnetic resonance imaging confirmed a new pontine infarction. Endovascular therapy was deferred due to suspected artery-to-artery embolism from an unstable plaque. Instead, argatroban infusion combined with antiplatelet therapy was initiated within 5 h.

The patient showed gradual improvement, and follow-up imaging demonstrated complete thrombus resolution. The NIHSS score was reduced to 4 at discharge.

This case highlights the successful use of a mechanism-guided approach with argatroban for thrombolysis-naïve posterior circulation stroke, effectively balancing the thrombotic and haemorrhagic risks. This suggests that personalised anticoagulation may optimise outcomes in similar complex scenarios in which standard reperfusion is unsuitable.