When thrombus meets intracranial dissection: a tricky decision for intravenous thrombolysis

Intravenous thrombolysis (IVT) has transformed the management of acute ischemic stroke, yet uncertainties remain, especially regarding its use in intracranial arterial dissection due to the risk of bleeding complications. While guidelines advise against IVT in intracranial dissection cases, previous studies have reported varying outcomes.

We present the case of a 34-year-old male with sudden onset neurological symptoms. Initial imaging (NCCT) revealed a spontaneous hyperdense enlargement along the left V4 vertebral artery. CT Angiography (CTA) suggested a focal dissection with an associated thrombus. IVT was administered despite guideline recommendations, leading to a rapid clinical improvement and normalization of neurological function within 24 h. Subsequent MRI confirmed the diagnosis of left V4 artery dissection and monitored changes over time, showing the evolution of the mural hematoma.

The case underscores the importance of considering unusual causes of stroke and the value of advanced imaging techniques for diagnosis. The initial NCCT raised suspicion for dissection, which was further validated by MRI. The treatment choice in this hyperacute phase was guided by clinical deterioration and imaging findings, despite the lack of extensive data supporting IVT in similar cases. The favorable outcome raises questions about the rigid application of current guidelines.

This case highlights the need for individualized treatment approaches in patients with intracranial dissections presenting as ischemic stroke. The integration of various imaging modalities can aid in accurate diagnosis and management, suggesting that IVT may be beneficial in select cases despite existing guidelines. Further studies are warranted to investigate the efficacy and safety of IVT in this population.