Diagnosis: TIA with stroke in evolution due to thrombosis of the left MCA.
A lady 70 years age was admitted to Al-Shmaisani hospital 15.10.1999 with sudden onset of aphasia 3 hours prior to admission for several minutes, then resolved to be replaced by echolalia , repeating the phrase “ Allah-Akbar “ to any question given to her. Her speech improved then , it was possible to know that , she was not complaining of headache . The patient had no arterial hypertension, nor diabetes mellitus. She had Parkinsonism since young age with tremor mostly in the right upper limb. CT-scan of the brain was performed prior to admission, demonstrating only mild oedema of the left hemisphere with comparison to the right (Fig A) with the presence of an old infarction of the left parieto-occipital area in the watershed area. The patient was admitted to the ICU and heparin infusion was started. The patient showed improvement in her neurological condition with return of speech. Cardiologic consultation ruled out cardiogenic cause of her problem. The patient the next morning suddenly deteriorated with dysphasia and right hemiparesis. Brain CT-scan was urgently performed. The clot could be seen in the left M1 with no flow distal to it (Fig B). Using Sildinger technique aortic arch angiogram was done showing a lot of tortousity , especially in the area of brachiocephalic trunk (fig.C). Right CCA angiogram was seen to be normal (Fig D and E). Left vertebral angiography was also normal. Left CCA angiogram performed at 12.50 and 12.54 showed throbmosis of the left M1 with narrowing of the main trunk and stop flow of the flow prior to the candelabra. The cortical branches were supplied by anastomic paths with insufficient amount of collateral circulation. (Fig F and G).
Stages of the thrombolysis
Using No 6 F catheter the tip was introduced as high as possible to the lumen of the left ICA. There was a web –type kinking of the artery, resisting more proximal introduction of the catheter tip. Infusing 25 ml actylase over 10 min to that point , repeat angiography did not show any change in the picture (Fig H). Another 5 ml infused over 3 min and control angiography showed the appearance of minimal flow in the M1 territory (Fig I). Another 5 ml infused and control angio showed dramatic changes with the appearance of the main trunk of M1 and the anterior major branch M2 (Fig J). Further 5 ml actylase infused and control angiography showed almost complete recovery of the flow and normalization of the caliber of the left MCA (Fig K) . Considering that the patient received 40 ml actylase , the procedure was stopped. Repeat brain CT-scan done immediately after the procedure showed disappearance of the thromb and reappearance of the flow in two M2 major branches. The patient was then returned to the ICU of the Al-Shmaisani hospital and heparinisation was continued. The right sided hemiparesis resolved and echolalia persisted for several day with periodic improvement . The patient upon discharge is walking and understanding all commands and producing words and phrases. Discharged to be kept in stugeron 25 mg twice daily, trivastal 50 mg tab twice daily , warfarin 3 mg one tab daily and senimet tab three times a day.
