Massive MCA stroke requiring alteplase followed by thrombectomy in a 34-year-old female with alport syndrome

34-year-old-female with a medical history significant for Alport's syndrome, chronic kidney disease on dialysis, and hypertension, was brought to the emergency department for sudden onset aphasia and facial droop that began 30 min prior to arrival. She denied a history of prior strokes, recent illness, or fever. The vital signs on arrival as follows: blood pressure 151/71 mmHg, temperature of 98.4F, pulse of 77 beats/min, and respirations of 16 breaths/min. Upon examination, she appeared in mild distress with a left sided facial droop, right sided hemiparesis, and expressive aphasia, only answering to yes/no. Neurological examination revealed: expressive aphasia, intact sensation throughout the face and bilateral extremities, no effort in the right arm against gravity, some effort against gravity of the right leg, left arm and left leg had muscle strength of 5/5. Patient had an NIH stroke scale of 8. The remainder of the exam was unremarkable. Radiographic imaging with CT revealed no intracranial hemorrhage (Fig. 1) and the patient was given alteplase (tPA) injection 5.6 mg within 1 h of her arrival to the Emergency Department. After administration of tPA a CT perfusion scan was performed (Fig. 2). Imaging demonstrated decreased cerebral blood flow and prolonged mean transit time within the majority of the left middle cerebral artery territory, sparing the basal ganglia. This indicated a left middle cerebral artery M1 occlusion. Neurosurgery was consulted and the patient underwent thrombectomy. Her hospital course was complicated by hemorrhagic transformation (HT) on hospital day 2. The patient underwent MRI that showed a large left MCA distribution acute infarction with focal reperfusion hemorrhage and parenchymal hematoma measuring approximately 3 cm in each dimension (Fig. 3). This finding prompted emergent decompression and hemicraniectomy on day 2 of hospitalization. The patient was discharged on hospital day 17 to a rehab center.