title: The challenge of basilar artery occlusion wake-up stroke: too late for intravenous thrombolysis?
abstract: We describe the case of a patient carried to our emergency department, with the wake-up finding of dysarthria, right hemiplegia and worsening consciousness impairment (NIHSS 12). After performing a CT angiography, which showed complete basilar occlusion, we determined the MR DWI-FLAIR mismatch to estimate the stroke onset time. Because of the favorable mismatch (DWI hyperintensity in the left pons, no FLAIR hyperintensity in the same region), the patient underwent thrombolysis with sudden neurological improvement. In addition, the DWI hyperintensity first observed in the left pons totally regressed after thrombolysis. Wake-up stroke constitutes about 14 % of all strokes, while the percentage of basilar artery occlusion wake-up strokes is still unknown. Although thrombolysis in patients with unknown-onset time is still an off-label therapy, basilar artery occlusion is a potentially fatal event. In our case we used RM DWI-FLAIR mismatch to rapidly estimate the stroke onset time and to treat the patient with an off-label but potentially effective and safe therapy.
authors.affiliation: Institute of Neurology, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy. pietro.caliandro@policlinicogemelli.it.|Fondazione Don Carlo Gnocchi Onlus, Milan, Italy. pietro.caliandro@policlinicogemelli.it.
authors.forename: Pietro
authors.initials: P
authors.lastname: Caliandro
authors.affiliation: Institute of Neurology, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Reale
authors.affiliation: Institute of Radiology, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Tartaglione
authors.affiliation: Institute of Neurology, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy.|IRCCS San Raffaele Pisana, Rome, Italy.
authors.forename: Paolo Maria
authors.initials: PM
authors.lastname: Rossini
mesh_terms: D001488:Basilar Artery / Q000000981:diagnostic imaging / Q000503:physiopathology*; D002545:Brain Ischemia / Q000150:complications* / Q000473:pathology; D038524:Diffusion Magnetic Resonance Imaging; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy*; D015912:Thrombolytic Therapy
keywords: Critical care; DWI-FLAIR mismatch; Stroke; Thrombolysis; Wake-up stroke