A case of acute ischemic stroke: optimizing management with penumbra and vessel imaging

Background An 83-year-old woman with a history of hypertension and dyslipidemia developed acute onset of impaired speech and comprehension, and right-sided weakness. Her previous medical history was notable for hyperthyroidism and a curative remote mastectomy for breast cancer. The patient was on two antihypertensive medications and a statin, and she was not receiving any antiplatelet medication. She was taken by ambulance to a primary stroke center. Initial examination showed global aphasia, right homonymous hemianopia, right hemiplegia, and hemisensory loss. Investigations Physical examination, laboratory tests, noncontrast head CT scan, multimodal brain MRI scan, catheter cerebral angiogram, echocardiogram, continuous cardiac monitoring. Diagnosis Acute ischemic stroke caused by distal left internal carotid artery occlusion, with salvageable penumbral tissue and a persistent large-vessel occlusion. Management Neuroprotective study agent (total dose of 20 g intravenous MgSO4 or matched placebo), intravenous tissue plasminogen activator, rescue mechanical thrombectomy using the Merci (R) clot retrieval device.