An Interesting Case of Acute Stroke: When Many Things Went Wrong, but the Patient Laughed at Last!

Abstract

A 52-year-old lady with hypertrophic obstructive cardiomyopathy, atrial flutter, and old right hemispheric stroke in the background underwent implantable cardioverter-defibrillator implantation for complete heart block. She was yet to start her regular anticoagulant and presented to hospital emergency with acute right middle cerebral artery (MCA) territory stroke (NIH Stroke Scale/Score of 14). After ruling out absolute contraindications, she was given intravenous thrombolysis (did not have a blood vessel target for endovascular therapy). Post thrombolysis, she had clot mobilization from the internal carotid artery to the MCA and systemic embolization to kidneys and lower limbs. The patient underwent an urgent embolectomy and lower limbs were saved from amputation. Our case highlights the importance of checking peripheral pulses in acute stroke patients post thrombolysis. Though the patient had initial deterioration after thrombolysis, she gradually improved and later achieved satisfactory modified Rankin scale underscoring the ultimate potential benefits of thrombolysis in acute stroke. There is a high chance of thrombus formation in patients with atrial flutter who undergo recent cardiac procedure especially if they are off anticoagulation for even a short period. Hence, unnecessary apprehension of anticoagulant use in proper situations may create life-threatening complications.