A 42‑year‑old man with an acute right frontal infarct and right M1 (middle cerebral artery segment 1) stenosis received intravenous thrombolysis; two hours later he has worsening neurology with right gaze deviation, dense left hemiplegia, and repeat CT shows infarct expansion without hemorrhage. What is the next management step when no interventional radiologist is available?

Emergency Management of Neurological Deterioration Post-Thrombolysis

Immediate transfer to the nearest comprehensive stroke center with endovascular thrombectomy (EVT) capability is the priority, even if it requires ambulance transport to a distant facility, as this patient has clear evidence of large vessel occlusion (M1 stenosis) with failed IV thrombolysis and is still within a potentially salvageable time window. 1

Immediate Actions at Current Facility

Stabilization and Preparation for Transfer

• Activate emergency transfer protocols immediately to a comprehensive stroke center with 24/7 neurointerventional capabilities, as EVT is the definitive treatment for large vessel occlusion with failed thrombolysis 1

• Maintain blood pressure control with systolic BP target of 130-150 mmHg using short-acting, titratable agents to optimize cerebral perfusion without increasing hemorrhage risk 2, 3

• Ensure airway protection given the worsening neurological status with dense hemiplegia and gaze deviation, which suggests significant hemispheric involvement that may compromise consciousness 1

• Continue aspirin (if not already given) as antiplatelet therapy is appropriate in the absence of hemorrhage on repeat CT 3

Alternative Strategy: Mobile Interventional Stroke Team (MIST)

If the patient cannot be safely transported due to medical instability or if transfer time would exceed 2-3 hours, consider requesting a "drip-and-drive" approach where an interventional team from the EVT center travels to your facility 1. This strategy has been shown to decrease onset-to-treatment times, though it requires your facility to have appropriate angiography equipment 1.

Rationale for EVT Despite Failed Thrombolysis

Time Window Considerations

• The patient is likely still within the 6-hour window from symptom onset (or potentially up to 24 hours if advanced imaging criteria are met), making him eligible for mechanical thrombectomy 1

• Even accounting for the 2 hours post-thrombolysis, if initial symptom onset was recent, he remains a candidate for endovascular intervention 1

• Intra-arterial thrombolysis is indicated for M1 occlusions up to 6 hours from symptom onset, and mechanical thrombectomy devices may have even longer windows (up to 8 hours or beyond with appropriate imaging selection) 1

Evidence Supporting Rescue EVT

• Mechanical thrombectomy after failed IV thrombolysis is standard practice and was the treatment paradigm in major thrombectomy trials where many patients received IV tPA first 1, 4

• The expansion of infarct without hemorrhage indicates ongoing ischemia with salvageable penumbra, making him an ideal candidate for rescue thrombectomy 1

• Primary mechanical thrombectomy is safe even in patients with contraindications to thrombolysis, so prior thrombolysis administration does not preclude EVT 5

What NOT to Do

Critical Pitfalls to Avoid

• Do not delay transfer waiting for "stabilization" unless the patient is truly unstable from a cardiopulmonary standpoint—neurological deterioration from stroke is an indication FOR transfer, not against it 1

• Do not administer additional thrombolytic agents (either IV or intra-arterial) at your facility without interventional capability, as this increases hemorrhage risk without providing mechanical recanalization 1

• Do not use corticosteroids for cerebral edema, as they are ineffective and may worsen outcomes 2

• Do not perform hyperventilation except as a temporary bridge during transfer if signs of herniation develop, as prolonged hyperventilation causes cerebral vasoconstriction 2

Pre-Transfer Checklist

Essential Steps Before Departure

• Secure IV access with at least two large-bore peripheral lines 1

• Document baseline NIHSS score and exact time of neurological worsening for the receiving team 1

• Send CT images electronically to the receiving comprehensive stroke center for review by the neurointerventional team 1

• Prepare transfer paperwork including medication administration times, vital signs flowsheet, and laboratory results 1

• Notify receiving facility with pre-arrival notification to activate their stroke team and prepare the angiography suite 1

Monitoring During Transfer

• Continuous cardiac monitoring and pulse oximetry throughout transport 2

• Frequent neurological assessments every 15 minutes, particularly monitoring for signs of herniation (pupillary changes, posturing) 2

• Blood pressure monitoring with ability to titrate antihypertensive medications during transport 2, 3

Expected Outcomes at Receiving Facility

The comprehensive stroke center will likely proceed directly to the angiography suite for mechanical thrombectomy using stent retrievers and/or aspiration techniques 4, 6. The goal is achieving TICI 2b/3 recanalization, which maximizes probability of good functional outcome 3. Recanalization rates with modern devices range from 68-85% 1, 4.

The key message: Time is brain—every minute of delay costs 1.9 million neurons 1. Transfer should be initiated immediately without waiting for further deterioration or attempting additional medical management at a facility without EVT capability.