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March 2009

Thrombolysis in Patients With Stroke and Marked Clinical Fluctuations

Arch Neurol. 2009;66(3):416-421. doi:10.1001/archneurol.2008.595

We were greatly interested in the article by Ozdemir et al1 and also in the editorial comment by Caplan.2 To add some arguments to the discussion, we describe a patient with fluctuating deficits successfully treated with recombinant tissue plasminogen activator (rtPA). A 26-year-old woman with a history of antiphospholipid syndrome was admitted to our hospital 1 hour after the onset of a left-sided hemiplegia and dysarthria. From the beginning she experienced uncountable (no less than 10) fluctuations, with a National Institutes of Health Stroke Scale score ranging from 0 to 10. The computed tomographic scan results were normal, whereas transcranial Doppler and computed tomographic angiography demonstrated a right middle cerebral artery (MCA) occlusion (Figure, A and B). When stroke workup was complete (150 minutes from stroke onset), the transcranial Doppler signal had not changed and fluctuations continued; thus, we decided to give her an out-of-protocol rtPA treatment. From that moment, fluctuations stopped and the patient remained asymptomatic. However, transcranial Doppler continued to show an MCA occlusion. An angiogram performed 24 hours later confirmed the persistence of the occlusion, demonstrating a rich collateral flow (Figure, C). Magnetic resonance imaging showed a small right basal ganglia lesion (Figure, D). One year later, the patient remains asymptomatic.

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