LAUSR

A 38-year-old right-handed man presented to our centre with an acute ischemic stroke. He had a history of total anomalous pulmonary venous return corrected at 7 months of age and was lost to follow-up. He was otherwise healthy with no prior history of stroke or cardiac risk factors. On arrival, his National Institutes of Health Stroke Scale was 8. He had right-sided facial droop and expressive aphasia. He was able to follow 2-step commands and was alert, but was unable to state his age or month. His pupils were equal and reactive with intact visual fields and normal extraocular movements. There was right-sided upper extremity weakness graded 2/5 on the Medical Research Council scale. His blood pressure was 159/82, with a heart rate of 41, and oxygen saturation of 100% on room air. CT head and CT angiogram showed a left middle cerebral artery M2 branch occlusion and minimal early infarct changes, with an Alberta Stroke Program Early CT Score of 8. An ECG showed newly identified atrial fibrillation. IV tPA (intravenous tissue-type plasminogen activator) was administered, and the endovascular team were alerted. Midway through the tPA infusion, before thrombectomy, he had a generalized tonic-clonic seizure requiring discontinuation of the infusion and management with a phenytoin load. He had depressed level of consciousness and was intubated for airway protection. A repeat CT head showed no intracranial hemorrhage. He subsequently underwent successful mechanical thrombectomy with achieved Thrombolysis in Cerebral Infarction score 2b reperfusion. He received vasopressor support with phenylephrine intraprocedurally. Postprocedure, he spontaneously converted to junctional rhythm with bradycardia and hypotension, which required treatment with atropine. Transesophageal echocardiogram excluded the presence of intracardiac thrombus, but demonstrated moderate left atrial and severe right atrial dilatation. While his left ventricular systolic function was normal, his right ventricle was dilated with moderately depressed systolic function. Right-to-left shunt was excluded by bubble study. Follow-up neuroimaging confirmed an established left middle cerebral artery branch infarct. He was started on oral anticoagulation with apixaban. At the time of transfer to inpatient rehabilitation, he had mild expressive dysphasia and 3/5 pyramidal arm weakness. He subsequently made a complete recovery with regards to his language, with subtle deficits of fine finger movements and pronator drift on the right within 1 month of his event.