Aims/Background: In-hospital progressive stroke in patients with pre-existing large artery occlusion presents a therapeutic dilemma, particularly when standard reperfusion strategies are unsuitable. This case report aims to illustrate a mechanism-guided medical approach in this complex scenario. Case Presentation: We report the case of a 65-year-old male patient with chronic left vertebral artery occlusion, hospitalised for dizziness, who experienced acute neurological deterioration with a National Institutes of Health Stroke Scale (NIHSS) score ranging from 2 to 14. Magnetic resonance imaging confirmed a new pontine infarction. Endovascular therapy was deferred due to suspected artery-to-artery embolism from an unstable plaque. Instead, argatroban infusion combined with antiplatelet therapy was initiated within 5 h. Results: The patient showed gradual improvement, and follow-up imaging demonstrated complete thrombus resolution. The NIHSS score was reduced to 4 at discharge. Conclusion: This case highlights the successful use of a mechanism-guided approach with argatroban for thrombolysis-naïve posterior circulation stroke, effectively balancing the thrombotic and haemorrhagic risks. This suggests that personalised anticoagulation may optimise outcomes in similar complex scenarios in which standard reperfusion is unsuitable.
She et al. (Fri,) studied this question.