Wake-Up Stroke Due to Middle Cerebral Artery Occlusion and the Decision Between Medical Management and Stenting: A...

Intracranial arterial dissections (IAD) are rare but high-morbidity entities, especially in young adults. Optimal management remains controversial, ranging from conservative medical therapy to emergent endovascular intervention. A 27-year-old female presented with a "wake-up stroke" (National Institutes of Health Stroke Scale (NIHSS) 21). Initial angiography revealed a supraclinoid right internal carotid artery (ICA) dissection with 40% stenosis without hemodynamic compromise. Conservative management with dual antiplatelet therapy (DAPT) was initiated, given the patient's young age, leading to initial improvement (NIHSS 9), with a favorable clinical course; she was therefore discharged home five days after treatment. However, 48 hours after discharge, she suffered a neurological deterioration. Repeated angiography showed critical progression to 90% stenosis and M1 occlusion. An emergent rescue stenting with a LVIS EVO stent (4×21 mm) achieved total revascularization (Thrombolysis in Cerebral Infarction (TICI) 3). The patient experienced a remarkable recovery, with substantial improvement in motor strength (3/5 in the upper limb, 4/5 in the lower limb) and normalized speech. This case highlights the dynamic and potentially unstable nature of supraclinoid dissections. Although initial medical management is standard, close monitoring is vital, as rapid progression may require urgent endovascular reconstruction to prevent catastrophic outcomes.