Capsular warning syndrome and resistance to dual antiplatelet therapy: A clinical dilemma

Background. Capsular warning syndrome (CWS) involves multiple stereotypical transient ischemic attacks (TIAs) within 24 hours, often preceding a more severe ischemic stroke. This serves as a critical warning sign, emphasizing the need for urgent medical intervention. Case report. We report a 65-year-old diabetic and hypertensive woman who experienced transient recurrent episodes of mouth deviation and slurred speech, lasting 10 seconds each, with full recovery. Initial MRI showed no abnormalities, and she was started on dual antiplatelets. Despite treatment, she developed sudden right-sided hemiplegia, with MRI showing a hyperacute non-hemorrhagic infarct in the left ganglio-capsular region. Intravenous tenecteplase was administered in accordance with the European Stroke Organization’s evidence-based recommendation, which supports its use as an effective alternative to alteplase for acute ischemic stroke within 4.5 hours of onset. Conclusion. This case highlights the importance of early identification of capsular warning syndrome (CWS). Despite dual antiplatelet therapy, CWS can progress to ischemic stroke, posing a treatment challenge. Further research is needed to establish optimal treatment protocols for CWS.