Acute Middle Cerebral Artery Occlusion: Wake-Up Stroke, M1 Occlusion, Large Ischemic Core with Low ASPECTS Score, Treated by Single-Pass Thrombectomy, and Favorable Outcome

Whether mechanical thrombectomy is beneficial in acute ischemic stroke patients presenting with a large baseline ischemic core remains uncertain. We present our experience with a 79-year-old woman with a history of hypertension, hyperlipidemia, and peripheral vascular disease, who was admitted due to a right-hemispheric wake-up stroke with a baseline NIHSS of 18 points. She was last seen well 10 hours before admission. Her Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast head-computed tomography was 5. CT angiography showed a cutoff in the M1 segment of the right MCA. CT perfusion revealed a large ischemic core and mismatch ratio of 1.3. The patient underwent successful endovascular revascularization of the right MCA occlusion. The procedure was uneventful. Repeated head CT showed an ischemic stroke in the right MCA territory with a minor hemorrhagic transformation (HI1) and ASPECTS of 5 points. The patient had a good clinical outcome with NIHSS of 5 and mRS of 2 upon discharge. This case supports previous observations regarding the safety and effectiveness of mechanical thrombectomy in patients with large vessel occlusion and a large ischemic core. The feasibility of endovascular treatment in patients with large baseline ischemic core is the main topic of this chapter.