Intravenous thrombolysis within 4.5 hours from symptom onset improves functional outcome in acute ischemic stroke patients. Repeated intravenous tissue plasminogen activator (IVtPA) is contraindicated in patients presenting with early recurrent stroke (ERS) within 3 months from the initial stroke because of a greater risk of intracranial hemorrhage.
A 59-year-old man presented with ERS, National Institute of Health Stroke Scale of 16, 10 days after a previous stroke. Brain computed tomography (CT) showed a previous hypodensity with 4 cm3 volume. Angio-CT highlighted the left middle cerebral artery and left internal carotid occlusion. Perfusion CT showed small deep core and large penumbra. The patient underwent IVtPA. After 24 hours, the National Institute of Health Stroke Scale was 7, and CT scan showed an acute ischemic lesion in the left basal ganglia area and frontal lobe without hemorrhagic transformation.
This case report suggests that further randomized studies may evaluate whether repeated IVtPA may be safe and effective in ERS occurring shortly after a previous stroke when patients experience a period of complete neurological regression, minor disability, and a small infarct volume. Should the hypothesis be confirmed, small volume core and wide volume penumbra at perfusion CT may support the decision of adopting IVtPA repetition.
*Department of Medicine, Surgery and Health Sciences, Clinical Unit of Neurology, University Hospital and Health Services of Trieste, University of Trieste, Trieste
†NEUROFARBA Department, Neuroscience Section, University of Florence, Florence, Italy
M.A. is supported by AIRAlzh Onlus—(ANCC-COOP). The remaining authors declare no conflict of interest.
Correspondence to: Paola Caruso, MD, Department of Medicine, Surgery and Health Sciences, Clinical Unit of Neurology, University Hospital and Health Services of Trieste, Strada di fiume, 447-34149 Trieste, Italy. E-mail: email@example.com.