Acute ischaemic stroke is a debilitating disease and may lead to haemorrhagic transformation associated with few factors such as high National Institute of Health Stroke Scale (NIHSS), low Modified Rankin Score (MRS), cardio-embolic clot and others.1 We report herein a 61 years old man whom presented with left sided weakness and diagnosed with acute right middle cerebral artery (MCA) infarction. Thrombolytic therapy was not offered due to low Alberta Stroke Program Early CT (ASPECT) score and hence managed conservatively. However, within 24 hours, his Glasgow Coma Scale (GCS) reduced by 4 points and urgent Computed Tomography (CT) brain confirmed haemorrhagic transformation with midline shift. He underwent emergency surgical decompression and subsequently had prolonged hospital stay complicated by ventilated acquired pneumonia. He recovered after a course of antibiotic and discharged to a nursing home with MRS of 5.
Early endovascular thrombectomy leads to improved outcomes for patients with proximal occlusions when started within 6 h from onset of symptoms. We present a case illustrating the flow of events for a patient who underwent endovascular thrombectomy in our centre after conventional imaging - a brain non-contrast computed tomography (NCCT) and CT angiogram (CTA) - achieving a door-to-groin time of 195 min. The patient is a 65-year-old who presented with signs and symptoms of a left middle cerebral artery (MCA) territory infarct. His National Institute of Health Stroke Scale (NIHSS) score was 15 on presentation and his brain NCCT showed an Alberta Stroke Programme Early CT Score (ASPECTS) of 8. His CTA showed a left MCA distal M1 occlusion with focal calcification and stenosis of the proximal left internal carotid artery. He was subsequently thrombosed and underwent thrombectomy successfully, with a door-to-groin-puncture time of 195 min. A TICI 2b reperfusion was achieved. His NIHSS score improved to 9 over the next 2 days. For cases with straightforward NCCT and CTA with no contraindications, endovascular thrombectomy should be pursued without delay. A review of the current available literature for the usage of NCCT and CTA as well as the importance of ASPECTS scoring in patient selection for endovascular thrombectomy was included.