43 | Acute ischemic stroke in a tachy-brady syndrome patient: a case of multidisciplinary team approach to diagnosis

Introduction. Ischemic stroke and atrial fibrillation are two highly prevalent conditions in the elderly population. Up to 30% of ischemic strokes have a cardioembolic etiology, which leads to a worse prognosis and a higher complication rate. Case Report. C.K., a 69-year-old woman, was admitted to our hospital for sudden speech impairment and right-sided hemiparesis. Pre-admission Rankin Scale 0. At neurological examination, complete aphasia, positive Babinski sign, and forced leftward gaze deviation were reported (National Institutes of Health Stroke Scale [NIHSS] was 20). Upon admission, new-onset atrial fibrillation was detected, and Multimodal Computed Tomography (CT) revealed an acute occlusion of the left internal carotid artery with an extensive area of hypoperfusion consistent with an ischemic penumbra (Alberta Stroke Program Early CT Score [ASPECTS] 10). Two and a half hours after symptom onset, systemic thrombolysis with tenecteplase followed by mechanical thrombectomy were performed, achieving complete reperfusion. An early post-procedural brain CT scan showed no signs of hemorrhagic transformation; however, a 24-hour follow-up detected a deep subacute ischemic area in the left hemisphere. The patient achieved complete neurological recovery (NIHSS 0). Due to the cardioembolic stroke etiology, anticoagulant therapy and beta-blockers were introduced; statin therapy was tailored to achieve lipid targets. However, 24-hour Holter monitoring revealed post-extrasystolic pauses, prompting beta-blocker discontinuation. After hospital discharge and a beta-blocker wash-out, a 7-day Holter assessment was repeated, which confirmed recurrent diurnal asystolic pauses (maximum 6 seconds), consistent with tachy-brady syndrome, leading to permanent pacemaker implantation. Conclusions. This case highlights that a multidisciplinary team approach is essential in stroke management. Our findings underline the importance of continuous care and of post-discharge follow-up.