Case Study: Multidisciplinary Management of Acute Ischemic Stroke with Thrombolytic Therapy

Abstract

This case study describes a 62-year-old male presenting with acute onset right-sided weakness and speech difficulty, diagnosed as acute ischemic stroke involving the left middle cerebral artery (MCA) territory. The patient received intravenous thrombolysis with alteplase within the therapeutic window, followed by early physiotherapy and multidisciplinary neurorehabilitation. Prompt diagnosis, rapid intervention, and coordinated post-stroke care led to significant functional recovery with near-complete neurological restoration at three months. This report emphasizes the importance of time-sensitive thrombolysis, neuroimaging precision, and collaborative rehabilitation in optimizing stroke outcomes and minimizing disability.

Introduction

Stroke remains one of the leading causes of mortality and long-term disability worldwide, accounting for approximately 11% of global deaths annually. Acute ischemic stroke, resulting from vascular occlusion, constitutes nearly 85% of all stroke cases. Early recognition and timely reperfusion therapy remain critical in minimizing neuronal damage and improving functional outcomes.
The integration of advanced neuroimaging, evidence-based thrombolytic protocols, and early rehabilitation strategies has redefined modern stroke management. This case demonstrates how a coordinated, multidisciplinary approach combining neurology, emergency medicine, radiology, physiotherapy, and nursing ensures superior recovery in acute ischemic stroke.

Patient Information

Age / Gender: 62-year-old male
Occupation: Retired school teacher
Marital Status: Married
Medical History: Hypertension (10 years), Type 2 diabetes mellitus (5 years)
Surgical History: None
Family History: Father had stroke at age 70
Social History: Non-smoker, no alcohol use, sedentary lifestyle
Current Medications: Amlodipine 5 mg, Metformin 500 mg
Chief Complaints: Sudden onset right-sided weakness and slurred speech for 2 hours

Clinical Findings

Symptoms:

• Sudden right arm and leg weakness

• Slurred speech (dysarthria)

• Mild facial asymmetry

• No loss of consciousness or seizure activity

Physical Examination:

• Temperature: 98.6°F

• Pulse: 84 bpm

• BP: 168/94 mmHg

• Neurological Findings:

  • Right upper limb power: 2/5

  • Right lower limb power: 3/5

  • Mild right facial droop

  • Slurred but comprehensible speech

  • NIH Stroke Scale (NIHSS): 9

Timeline

Initial Presentation (May 2024):
Patient presented to emergency within 2 hours of symptom onset. Stroke code activated; rapid assessment initiated.

Diagnostic Workup (Within 30 Minutes):

• CT Brain (Non-Contrast): No hemorrhage; early ischemic changes in left MCA territory.

• CT Angiography: Partial occlusion of left MCA branch.

• Blood Tests: Normal coagulation profile; glucose 138 mg/dL.

Therapeutic Decision:
Patient met inclusion criteria for thrombolysis (within 4.5-hour window). Consent obtained from family.

Treatment (Same Day):
Intravenous alteplase (tPA) administered at 0.9 mg/kg (10% bolus, remainder over 60 min). Strict BP control maintained.

Post-Thrombolysis Monitoring:
Admitted to stroke ICU for continuous monitoring. No evidence of hemorrhagic transformation.

Early Rehabilitation (Day 2):
Physiotherapy initiated focusing on limb mobilization, balance, and speech therapy.

Discharge (Day 5):
Patient discharged with mild residual weakness and scheduled for outpatient neurorehabilitation.

Follow-Up (3 Months Later):
Marked improvement - power 5/5 on both sides, speech normalized, NIHSS 1, independent ambulation.

Diagnostic Assessment

Laboratory Findings:

• CBC, renal, and liver profiles: Normal

• HbA1c: 6.8%

• Lipid Profile: LDL 142 mg/dL (elevated)

Imaging Findings:

• CT Brain (Day 1): Early ischemic signs, no hemorrhage

• MRI Brain (Day 2): Acute infarct in left MCA territory

• Carotid Doppler: Mild atherosclerotic plaque (20%) in left internal carotid artery

Risk Evaluation:

• Etiology: Large artery atherosclerosis

• ASA Classification: Class II

• Thrombolysis Risk: Low to moderate

Therapeutic Intervention

Step 1 – Emergency and Pre-Thrombolysis Management

• Rapid neurological evaluation (NIHSS scoring)

• Non-contrast CT to rule out hemorrhage

• Blood pressure optimization (<185/110 mmHg)

• IV access, cardiac monitoring, oxygen supplementation

• Informed consent obtained from family

Step 2 – Thrombolytic Therapy

• IV alteplase (tPA) administered within 2.5 hours of symptom onset

• Neurological assessment every 15 minutes during infusion

• No evidence of bleeding or deterioration post-therapy

Step 3 – Post-Thrombolysis and Rehabilitation

• Blood pressure maintained below 140/90 mmHg

• Initiated statin therapy (atorvastatin 40 mg) and antiplatelet (aspirin after 24 hours)

• Early physiotherapy: limb exercises, gait training

• Speech therapy for mild dysarthria

• Discharge planning with follow-up rehabilitation schedule

Challenges Faced

• Time Sensitivity: Rapid coordination required to initiate thrombolysis within 3-hour window.

• Blood Pressure Control: Required IV antihypertensives pre-thrombolysis.

• Patient Anxiety: Family counseling and reassurance were crucial.

• Rehabilitation Adherence: Ensured through structured home exercise plan and tele-rehabilitation support.

Follow-Up and Outcomes

• 1 Week: Improved speech, limb strength 4/5

• 1 Month: Independent ambulation, NIHSS 3

• 3 Months: Near-complete neurological recovery, NIHSS 1

• 6 Months: Normal ADLs (Activities of Daily Living), resumed social activities

Discussion

This case illustrates how time-sensitive thrombolytic therapy, combined with structured multidisciplinary neurorehabilitation, significantly improves outcomes in acute ischemic stroke. Early diagnosis using neuroimaging and adherence to international stroke guidelines (AHA/ASA) are crucial for minimizing infarct volume and preventing long-term disability.
The patient benefited from prompt hospital arrival, rapid decision-making, and interdepartmental coordination between emergency, radiology, neurology, and physiotherapy teams.
Early mobilization, physiotherapy, and speech therapy promoted neuroplasticity, improving function and quality of life.
Studies confirm that intravenous thrombolysis within the first 4.5 hours increases the odds of favorable outcomes by 30–40%, aligning with this patient’s excellent recovery trajectory.
Continuous blood pressure control, statin therapy, and antiplatelet initiation were vital in secondary prevention. Family education and digital follow-up reinforced adherence to therapy and lifestyle modification, ensuring long-term wellness.

Key Takeaways

• Early recognition and thrombolysis are critical for optimal stroke recovery.

• CT/MRI imaging enables accurate diagnosis and treatment planning.

• Multidisciplinary rehabilitation accelerates neurological improvement.

• Strict control of risk factors prevents recurrence.

• Patient and family education are key to long-term outcomes.

Patient’s Perspective

“When my right side suddenly felt weak, I thought it was temporary. The doctors acted quickly, and treatment started immediately. Within days, I could move my arm again. The physiotherapy team motivated me daily, and now I can walk, talk, and live normally. I’m grateful for the coordinated care that gave me a second chance.”

Conclusion

This case underscores that integrating rapid thrombolytic intervention with early rehabilitation offers the best outcomes in acute ischemic stroke. The success depended on timely diagnosis, seamless interdepartmental communication, and patient-centered rehabilitation. Early administration of intravenous thrombolytics such as alteplase within the critical therapeutic window can significantly restore cerebral perfusion and minimize infarct size, directly influencing long-term functional outcomes. However, pharmacologic management alone is not sufficient; it must be complemented by a structured and multidisciplinary rehabilitation program initiated within the first 24 to 48 hours after stabilization.

Such multidisciplinary frameworks represent the future of neurology, emphasizing precision medicine, coordinated care, and recovery-focused outcomes. Collaboration among neurologists, physiatrists, physical therapists, occupational therapists, and speech-language pathologists ensures that patients receive individualized, goal-directed therapy addressing motor, cognitive, and speech deficits simultaneously. The inclusion of clinical pharmacists for medication optimization and nurses for continuous monitoring further strengthens this integrated model.

By leveraging technology, structured ERAS-like (Enhanced Recovery After Stroke) protocols, and patient engagement, healthcare systems can achieve faster recovery, lower disability rates, and improved quality of life for stroke survivors. Digital tools such as AI-based imaging for rapid stroke detection, tele-rehabilitation platforms, and wearable motion sensors are transforming post-stroke care by enabling remote monitoring and adaptive therapy plans. Moreover, involving caregivers in the recovery process and using outcome-tracking dashboards can help maintain adherence and motivation. As hospitals adopt these integrated, technology-driven pathways, stroke management will evolve toward proactive recovery optimization, ensuring not just survival, but meaningful neurological and functional restoration.

References

1. Powers WJ, et al. (2019). Guidelines for the Early Management of Acute Ischemic Stroke. Stroke.

2. Hacke W, et al. (2008). Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. NEJM.

3. Langhorne P, et al. (2011). Organized Inpatient (Stroke Unit) Care for Stroke. Cochrane Database Syst Rev.

4. Winstein CJ, et al. (2016). Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke.

5. NICE (2023). Stroke and Transient Ischaemic Attack in Over 16s: Diagnosis and Initial Management.

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