Background: Early treatment with intra-arterial thrombolysis has been shown to be effective in the treatment of acute ischemic stroke because of occlusion of the middle cerebral artery. It is unclear how to use this therapy, however, when there is also occlusion of the parent internal carotid artery.
Case Report: A 43-year-old woman presented within 15 minutes of symptom onset caused by a large right anterior circulation ischemic stroke. Computed tomography scan showed a hyperdense right middle cerebral artery sign. Carotid angiography showed occlusion of the right internal carotid artery just distal to its origin. After balloon angioplasty of the internal carotid artery, the occluded right middle cerebral artery was successfully recanalized using intra-arterial tissue plasminogen activator. The patient had dramatic clinical improvement after the procedure, with almost complete resolution of her deficits.
Conclusion: Acute middle cerebral artery thrombosis is occasionally associated with acute thrombotic occlusion of the parent internal carotid artery. In this situation, carotid occlusion may be treated first with percutaneous transluminal balloon angioplasty. Intra-arterial thrombolysis may then be applied directly to the site of middle cerebral artery thrombosis, improving chances for overall recanalization and excellent clinical response.
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