Bilateral Middle Cerebral Artery Occlusion In Rapid Succession During Thrombolysis

A 76-year-old female developed acute left hemiplegia, dysarthria, right gaze preference, and cerebral ptosis. Computed tomography (CT) scan demonstrated an Alberta Stroke Program Early CT Score (ASPECTS) of 10 and a hyperdense right middle cerebral artery (MCA) (Figure 1A and B). Shortly after the bolus of Tissue Plasminogen Activator (tPA) with the infusion running, she abruptly became comatose. A repeat CT scan showed the resolution of her gaze preference and a new hyperdense left MCA sign (Figure 1C and D). Cerebral angiogram confirmed complete occlusion of the proximal MCA bilaterally (Figure 2). Despite attempts at clot retrieval, flow was partially restored. Transesophageal echocardiogram demonstrated left atrial enlargement without thrombus