Abstract
We report here a case of acute ischemic stroke exhibiting rapid recovery after intravenous rt-PA therapy without recanalization of a culprit large vessel. An 83-year-old woman who displayed drowsiness, total aphasia, and right-sided hemiparesis was transferred to our institution at 40 min after the onset. Her NIHSS score was 22 points and cranial computed tomography (CT) revealed neither a high density area nor early CT findings. Her carotid ultrasonography demonstrated patency of the left internal carotid artery. Her clinical information satisfied an indication for intravenous rt-PA therapy, and she therefore received the therapy at 130 min after the stroke onset. Her symptoms improved remarkably at 170 min after the onset during the rt-PA infusion, but her magnetic resonance angiography (MRA) performed immediately after completion of the rt-PA therapy demonstrated no recanalization of the left middle cerebral artery (MCA) which was considered as her culprit large vessel. On the second day, her neurological symptoms improved completely, but occlusion of the left MCA was again confirmed by a second MRA. Finally, patency of the left MCA was confirmed by a fourth MRA performed on the 17th day. During the hospital stay, her neurological symptoms did not reworsen and she was discharged without any sequelae on the 24th day. This case experience suggests that the rapid effect of rt-PA therapy on clinical improvement occursing immediately after the infusion is due to recanalization of not only a culprit large vessel but also other small vessels such as the branches of the anterior/middle cerebral artery or the leptomeningeal anastomosis.
