CASE REPORT

The patient is a 69 year old female who presented to Clínica Las Condes within 2 hours of experiencing complete Wernicke´s aphasia. The patient has a history of atrial fibrillation and was not taking her anticoagulation medications at the time of presentation. An early brain computed tomography (CT) scan did not show any evidence of hemorrhage or early ischemic changes. At that moment, it was decided that the patient was a good candidate for thrombolysis and an IV tPA infusion (10% dose in bolus and 50% of total dose given over 45 minutes) was begun. She was also injected with Tc99mHMPAO radioisotope and subsequently acquired the images after the endovascular procedure. An immediate cerebral angiogram demonstrated an occlusion of the angular branch of the left middle cerebral artery, probably cardioembolic in origin (Figure Ia). Approximately 30 minutes after having begun the IV tPA, a microcatheter was advanced to the point of occlusion (Figure 1b) and local IA thrombolysis begun, terminating the IV tPA after having delivered a dose of 24mg. After one hour, a complete recanalization of the occluded vessel was achieved (Figure 1c and 1d), delivering an additional 20mg of IA tPA. Immediately after having recanalized the occluded vessel, the patient recovered completely from her aphasia. The pre-thrombolysis NeuroSPECT demonstrated an extensive area of hypoperfusion in the territory of the angular artery (Figures 2a and 2b). A 24 hour control with brain SPECT showed complete recovery of the extensive area of hypoperfusion.(Figures 2c and 2d) The patient was admitted to the Cerebral Vascular Unit of our hospital for specialized medical management including hemodynamic control, anticoagulation after the first 24 hours, and control of her arrhythmia. A control brain magnetic resonance imaging scan was also normal (Figure 3). The patient was discharged 7 days later without any difficulties.

Figure 2d (click=zoom)

Figure 1 (click=zoom)

Figure 2a (click=zoom)

Figure 2b (click=zoom)

Figure 2c (click=zoom)

Figura 3 (click=zoom)

DISCUSSION

We present the first case of combined IV and IA trombolysis in Chile for the treatment of acute cerebral infarct. This procedure was performed without difficulties, demonstrating that it is technically feasible and achieved excellent angiographic and clinical results. This procedure required good coordination between the members of the Cerebral Vascular Unit of our Institution, in particular between the stroke neurologist and the interventional neuroradiologist.

It is also important to analyze other factors which influenced in the excellent clinical results of this case. First, a rapid arrival of the patient to the hospital was pivotal. The patient arrived in less than two hours, principally because her family members were able to immediately recognize the symptoms related to a brain infarct and arranged for emergency transportation (4). Once in the hospital, the patient had a rapid and precise diagnosis and medical management. It was possible to optimize the thrombolysis procedure by first utilizing the more rapid IV access and then, when a microcatheter was in place, convert to the IA procedure.

Review of this case is also particularly helpful because it demonstrates well the phenomena of the "ischemic penumbra". The "penumbra" is a term which refers to the loss of neuronal cell function related to cerebral hypoperfusion. This loss of function can be reversible if the cerebral hypoperfusion is rapidly normalized. In this patient, the initial brain SPECT showed an extensive area of hypoperfusion in the distribution of the occluded vessel, the angular branch of the middle cerebral artery. Furthermore, the initial brain CT was normal, which indicated that there was no apparent irreversible brain injury, consistent with ischemic penumbra. The control brain SPECT post-thrombolysis, confirmed the restoration of normal perfusion without showing areas of cerebral infarct. That is, during the first hours, the symptoms related to a cerebral infarct can be potentially reversible if the occluded vessel can be recanalized utilizing new techniques like thrombolysis.

We present the excellent results of the first combined IV and IA brain thrombolysis case in Chile in the management of an acute cerebral infarct. Furthermore, we analyze the evaluation of the ischemic penumbra utilizing NeuroSPECT.