Beating the Clock: Successful Thrombectomy 28 Hours After Stroke in a Young Adult With Internal Carotid Artery Dissection

Stroke is a significant diagnostic challenge in the young population. Aortic dissection is a prominent cause, among many other aetiologies, leading to subsequent neurological deficits as a result of large vessel occlusion. Neurological thrombectomy has revolutionised the management of stroke. Current clinical guidelines recommend thrombectomy within a defined time window after symptom onset. However, with advancements in modern medicine and neuroimaging, patient selection can now extend beyond the traditional time windows by identifying salvageable brain tissue. We present the case of a young man who experienced a fall and suffered a transient loss of consciousness. He went to sleep and subsequently woke up with left-sided weakness and speech disturbances. A CT scan of the head was performed, which showed a right-sided infarct. A CT angiogram showed a right internal carotid artery (ICA) dissection complicated by occlusion of the middle cerebral artery (MCA). A CT perfusion scan highlighted a large ischaemic penumbra with a small relative infarct core, well beyond the usual therapeutic window. Given the clinical status and favourable imaging profile, even though the patient had passed the thrombectomy window, the patient underwent a mechanical thrombectomy (approximately 28 hours post onset). The procedure resulted in successful revascularisation, and there was profound neurological recovery, which was reflected in a modified Rankin Scale score (mRS) of 1 and a National Institutes of Health Stroke Scale (NIHSS) score of 1, consistent with marked clinical recovery at the time of discharge. This case shows the importance of advanced imaging in guiding treatment decisions for patients with delayed presentation of ischaemic stroke. It underlines the significance of arterial dissection in a younger age group presenting with stroke symptoms. A thrombectomy beyond the usual norm may be a viable and effective treatment option when carefully selected in specific patients.