Embolic Occlusion of the Anterior Cerebral Artery A2 Segment Treated with Concomitant Systemic Thrombolysis and Local Intra-Arterial Thrombolysis via the Contralateral Side

A 65-year-old man presented with acute onset right hemiparesis, which was pronounced in the lower extremity. The diagnostic workup revealed an acute embolic occlusion of the left anterior cerebral artery. The ipsilateral A1 segment had a small caliber. The biplane angiography suite was unavailable at the time, thus making thrombectomy or stent implantation potentially hazardous. Instead, local intra-arterial infusion of recombinant tissue plasminogen activator was performed. The injection of 2×10 mg recombinant tissue plasminogen activator at the site of the thrombus resulted in a partial recanalization and substantial and immediate clinical improvement. Follow-up magnetic resonance imaging showed only minor scattered ischemic lesions in the corresponding territory. Local intra-arterial thrombolysis remains a viable option in selected cases with distal, medium, or small-diameter vessel occlusion.