Mechanical Thrombectomy in Wake-Up Stroke

Mechanical thrombectomy is very effective in the first few hours after onset of symptoms, in patients with acute ischemic stroke. It is approved within the first six hours of symptom onset, if there is occlusion of internal carotid artery or proximal middle cerebral artery, provided the NIHSS score is 6 or more. However, problem arises in patients who went to bed without any neurological deficits and woke up 6 hours or more later, with neurological deficits. In such cases, diffusion and perfusion MRI imaging can help us in decision making. If there is a diffusion-perfusion mismatch, then, patients can be taken up for mechanical thrombectomy. Area under threat of ischemia (shown by perfusion imaging) is much larger than the area already damaged (shown by diffusion imaging). Area affected on perfusion imaging, which is not affected on diffusion imaging, can be potentially salvaged by mechanical thrombectomy.

Here, I present the diffusion-perfusion MRI images in a 48-year old lady with wake-up stroke. She presented with right hemiparesis and aphasia. NIHSS score was 14. You can note a much larger area affected on perfusion images, as compared to diffusion images, suggestive of a diffusion perfusion mismatch.

Perfusion MRI image on left and diffusion MRI image on right

MR Angiogram of brain showed occlusion of proximal middle cerebral artery.

MR Angiogram showing proximal left middle cerebral artery occlusion

She was treated with mechanical thrombectomy and she showed significant clinical improvement.

Published by Dr Sudhir Kumar MD (Medicine) DM (Neurology)

I am a doctor with 25 years experience. I have worked as a neurologist for about 20 years. Educating public and healthcare professionals is very dear to me. This is possible due to my interactions with thousands of patients and their caregivers. I salute the patients who suffer and it is our duty to minimise suffering by preventing diseases and ensuring prompt diagnosis and treatment of those already affected.

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