Long-Term Follow-Up of Actilyse-Thrombolysis for a Disabling Acute Ischemic Pontine Stroke

Abstract

Background : The current thrombolysis guidelines allow only a small number of acute ischemic stroke (AIS) patients to be treated with Recombinant Tissue Plasminogen Activator (rtPA) known as Alteplase under the kind of conditions prevailing in clinical trials (imaging, timing, experience and hesitancy). The Case: A 58-year-old male doctor, with mild diabetes mellitus, presented with sudden left-sided hemiplegia as well as right trigeminal, abducens, facial and vestibular palsy indicating an acute pontine infarct at 12 based on the National Institute of Health Stroke Scale (NIHSS) and +4 by modified Rankin score (mRs). Since he presented within 3 hours of the onset of symptoms and the initial brain CT did not show an intracranial bleed, he was treated with rtPA followed by unfractionated heparin for 24 hours then Acetylsalicylic acid and Clopidogrel for 1 year then Acetylsalicylic acid alone. By 12 hours, he had resumed his motor power fully (mRs +2) and by 72 hours; he had only left-sided numbness (mRs +1). At that time, CT confirmed right posterolateral non-hemorrhagic pontine infarct. MRI angiogram by day 7; showed 0.6 × 1 cm subacute non-hemorrhagic pontine infarct and normal extra- and intracranial vascular disease. Moreover, tests for hypercoagulable and autoimmune disorders were negative. The patient was able to resume his active work, 1-week post-AIS, and remained stable for 13 years later. On follow up MRI, the infarct size regressed to 0.5 × 0.4 × 0.4 cm, by 3 months, and remained quiescent at 1 and 13 years later. Conclusion: In selected patients, with AIS, thrombolysis improves morbidity and quality of life.