Effective Treatment with Abciximab for Consecutive Bilateral Middle Cerebral Artery Occlusion

Departments of a Neurology, b Internal Medicine, and c Institute of Neuroradiology, Technical University Dresden, Dresden , Germany Case Report A 62-year-old woman was admitted to our hospital with acute onset of left-sided hemiparesis. On admission, she had left-sided hemiplegia and facial palsy with minor dysarthria – National Institutes of Health Stroke Scale (NIHSS) 11. Cerebral computed tomography (CCT) and CT angiography demonstrated right MCA mainstem occlusion but no early ischemic changes. We initiated thrombolysis with rt-PA (0.9 mg/kg) 165 min after symptom onset. With this therapy, the patient improved to NIHSS 5. However, 1 h after termination of thrombolysis, she developed a sudden decline of consciousness. Since a repeat CCT ruled out intracranial hemorrhage (ICH), we suspected non-convulsive status epilepticus and gave intravenous lorazepam (6 mg) and valproic acid (bolus administration 900 mg, followed by 6-hour infusion 100 mg h –1 ). Electroencephalographic (EEG) monitoring was technically not feasible. The patient remained stuporous requiring intubation and mechanical ventilation the next morning. MRI demonstrated a new occlusion of the left MCA and the left internal carotid artery (ICA), as confi rmed by duplex ultrasound. The right MCA appeared recanalized ( fi g. 1 ). In the presence of only small DWI lesions, PI showed a perfusion defi cit of the complete left MCA territory resulting in a large PI/DWI mismatch. Therefore, we initiated treatment with intravenous abciximab (bolus administration 0.25 mg/kg, followed by 12-hour infusion therapy 0.125 g kg –1 min –1 ) 17.5 h after onset of new symptoms. Duplex sonography performed after the abciximab infusion demonstrated persistent occlusion of the left ICA but recanalization of the left MCA. The patient initially remained comatous. Repeated CCTs on days 1, 3 and 5 after thrombolysis ruled out ICH or major ischemia. EEG ruled out seizure activity, and there was no evidence for metabolic coma. She subsequently regained consciousness and was extubated after 11 days. Further workup revealed a stalked thrombus in the left atrial ear (transesophageal echocardiography) and intermittent atrial fi Introduction Intravenous thrombolysis with alteplase (rt-PA) is the treatment of choice for ischemic stroke within 3 h of symptom onset [1] . Metaanalysis of the major thrombolytic stroke trials suggest a small, but still signifi cant, benefi t if given within 3–6 h [2–4] . Based on the results of a recent trial, the glycoprotein IIb/IIIa receptor antagonist abciximab may be a treatment option for this time window [5] . Potentially viable penumbral tissue may be present well beyond 6 h, in isolated cases even up to 48 h [6] . Modern imaging techniques like magnetic resonance imaging (MRI) using diffusionweighted (DWI) and perfusion imaging (PI) may identify the penumbra and permit improved patient selection [7, 8] . Nevertheless, the best treatment for these patients has not yet been defi ned. This particularly applies to patients with recurrent or new symptoms after an initially successful thrombolysis where an early second thrombolytic therapy is debatable. We report on a patient with acute left middle cerebral artery (MCA) occlusion occurring after thrombolysis with rt-PA for right MCA occlusion, whom we successfully treated with intravenous abciximab 17.5 h after onset of new symptoms.