A 48-year-old male presented to the Emergency Department with dense left hemiplegia, hemianopia and inattention (NIHSS=18) within one hour of symptom onset. He was alert, communicative and haemodynamically stable.
4 months prior to presentation, he had developed sigmoid colon perforation requiring ileostomy and was diagnosed with colorectal cancer with peritoneal and hepatic metastasis. He had since been staying with his parents who assisted with ADLs (mRS=3) and had experienced a flare of premorbid depression with passive suicidality. At the time of presentation, he was not on anticoagulation and had a normal coagulation profile. Multimodal stroke imaging demonstrated minimal established infarct on non-contrast CT brain but showed an occluded terminal internal carotid artery with 69mL core and 213mL penumbra.
Medical Oncology’s opinion was that the malignancy had potentially for cure/long term remission given favourable gene mutation and response to initial immunotherapy. The patient expressed a view that a scenario where he was still able to walk and take care of his dog would be a meaningful quality of life for him.
Decision ultimately was NOT for thrombolysis due to bleeding risk from hepatic metastasis and FOR endovascular thrombectomy (EVT) despite poor baseline function given reasonable medium-long-term prospects. EVT was ultimately unsuccessful despite 5 passes (mTICI=1). The patient was discharged to Rehabilitation (discharge NIHSS=14).
The case represented a significant treatment dilemma around 1) risks of thrombolysis, 2) suitability for EVT, 3) capacity of patient to participate in decision making, and 4) goals of rehabilitation given uncertain long-term prognosis.