Delayed Endovascular Thrombectomy for Ischemic Stroke in a Young Woman with No Known Risk Factors: A Case Report

Patient: Female, 26-year-old Final Diagnosis: Internal carotid artery dissection Symptoms: Dysarthria • gaze palsy • hemiplegia • sensory loss Medication: — Clinical Procedure: Endovascular stenting and mechanical thrombectomy Specialty: Neurology • Radiology OBJECTIVE: Unusual clinical course BACKGROUND: National guidelines and consensus statements suggest a 24-hour window for endovascular recanalization in patients presenting with acute ischemic stroke due to large-vessel occlusion. However, the safety and efficacy of extending the window for intervention remains to be definitively established. CASE REPORT: A healthy 26-year-old woman presented with headache, left-sided hemiplegia, and rightward gaze palsy 2 days after a minor trauma. Time last known well was approximately 50 hours prior to presentation. Computed tomography angiography revealed dissection of the distal right internal carotid artery and occlusion of the M1 segment of the right middle cerebral artery. Magnetic resonance imaging showed a small area of acute infarct in the right basal ganglia and right insular cortex, but suggested a large ischemic penumbra; this was confirmed with cerebral perfusion analysis. In light of the patient’s young age and potential for penumbral salvage, mechanical thrombectomy of an M1 thrombus and stenting of an internal carotid artery dissection were performed nearly 60 hours after the onset of symptoms. The patient demonstrated marked clinical improvement over the following days and was discharged home in excellent condition one week after presentation. Based on our clinical experience and other emerging data, we propose that extension of the 24-hour window for endovascular intervention may improve functional outcomes among select individuals. CONCLUSIONS: A 24-hour window for endovascular thrombectomy is appropriate for many patients presenting with acute ischemic stroke. However, in select individuals, extension of the window to 48 hours or beyond may improve functional outcomes.