A 14-year-old male with a past medical history significant for a concussion and exercise-induced asthma presented to the Emergency Department (ED) via an ambulance after having sudden onset left-sided hemiparesis during basketball practice.
Prior to this, the patient's mother had reported that he had been complaining of headaches, neck pain, and intermittent palpitations. He had been using ibuprofen with some relief of the symptoms.
In the department, the patient was noted to have flaccid left-sided paralysis, with a left-sided facial droop (forehead sparing), and mild dysarthria. He was complaining of a 5/10 headache and nausea. The patient was otherwise alert and oriented.
Within thirty minutes of neurological focal loss and shortly after arriving in the department, the patient's symptoms improved significantly. He was noted to have 4/5 strength in his left upper and lower extremities, with a mild sensory deficit and pronator drift of the left upper and lower extremities. He was seen by a pediatric neurologist at that time and had an NIHSS of 2. Two hours after initial resolution, while having the braces in his mouth removed, he had complete return of his previous symptoms. The patient was sent to MRI at that time which was suboptimal but showed diminished caliber of the right internal carotid artery (R ICA) and diminished flow through the right middle cerebral artery (R MCA) (Figure 1).
The patient returned to the department and was noted to be disoriented. Shortly after, he had a generalized seizure that lasted two minutes and resolved after lorazepam administration. He was intubated, CT angiogram was performed at approximately 6 hours after waxing and waning symptoms and showed an R MCA occlusion (Figures 2 and 3), and interventional radiology was contacted at this time. Arterial puncture was performed at seven hours and thirty-seven minutes from initial presentation to the Emergency Department. Interventional neuroradiology was able to perform a mechanical thrombectomy of the R ICA and R MCA with successful clot retrieval (Figure 4). Specifically, eight hours and 24 minute after arrival, a second pass with a Trevo retriever 4 x 30 mm (Stryker) with intermediate catheter aspiration was performed with a Catalyst 6 (Stryker). Base catheter was a FlowGate (Stryker).
The patient was extubated the following day. At that time, he had 4/5 strength in the left upper and lower extremities and a mild facial droop. After discharge, the patient participated in intensive physical therapy and occupational therapy with significant improvement in symptoms. At short-term follow-up, the patient had returned to school and was running track. Serial follow-up MRIs were obtained. At over 3 months postevent, brain MRI showed sequela of prior multifocal infarcts in the right cerebral hemisphere conforming to the R MCA vascular territory, with extensive multifocal encephalomalacia and gliosis. At over 6 months postevent, MRI showed stable sequela of multifocal infarcts in the R MCA territory. No new lesions within the brain were seen. Clinically, at over 6 months postevent, his only physical deficit from the AIS was decreased fine movement dexterity of his left fingers.