Recurrent occlusion treated with secondary thrombolysis in AIS: a case report

Recurrent vascular occlusion after initial thrombolysis is a challenging complication of acute ischemic stroke (AIS), particularly in patients with atrial fibrillation. Secondary intravenous thrombolysis (IVT) for recurrent AIS remains controversial due to limited consensus on candidate selection, optimal dosing, and safety profiles. Large artery occlusion (LAO)-induced perforator artery infarction (PAI) is a distinct AIS subtype, and data on secondary IVT for this subgroup are extremely scarce globally.

A 78-year-old female with non-valvular atrial fibrillation (NVAF) presented with LAO-induced PAI in the left middle cerebral artery (LMCA) territory. Initial weight-based standard-dose alteplase IVT (0.9 mg/kg, 50 mg) achieved LMCA recanalization and neurological improvement (National Institutes of Health Stroke Scale [NIHSS] score: 13→9). Four days later, symptom exacerbation (NIHSS score: 9→12) occurred due to new PAI from recurrent cardioembolic LMCA near-occlusion. The patient was successfully treated with low-dose secondary alteplase IVT (0.45 mg/kg, 24 mg), resulting in NIHSS score improvement (12→11) and no intracranial hemorrhage. The modified Rankin Scale (mRS) score remained stable at 4 points throughout treatment.

Secondary weight-based low-dose alteplase IVT may be a feasible therapeutic option for selected patients with recurrent cardioembolic LAO-induced PAI. Multimodal imaging guidance, strict adherence to time windows, and individualized dose tailoring are critical for safe and effective outcomes. This case highlights the need for large-scale multicenter studies to validate secondary IVT strategies for this high-risk AIS subgroup.