History: A 92-year-old woman was found by her domestic help to have suddenly sustained a left-sided weakness in her limbs 30 minutes after she had seemed perfectly well. She had undergone a total hip replacement 4 weeks previously.
Admission findings: Her National Institutes of Health stroke scale (NIHSS) score was 18. She had a left hemiparesis with sensory deficits, left-sided neglect, dysarthria and aphasia.
Investigations: Stroke magnetic resonance imaging (MRI) confirmed the suspected diagnosis of ischemic infarction within the territory supplied by the right middle cerebral artery, with diffusion in the periventricular region and the cortex of the right basal temporal lobe.
Treatment and further course: Recombinant tissue plasminogen activator (rtPA) was administered intravenously. At completion of the infusion the neurological deficits had lessened. The NIHSS was reduced to 6 and ultimately was 0.
Conclusion: Patients older than 80 years who have sustained a stroke can benefit from rtPA administration. Stroke-MRI is a valuable tool in the early diagnosis and may improve the safety of thrombolysis, especially in borderline situations such as advanced age or in the face of a closing "time window". Currently the mismatch concept (greater perfusion deficit than diffusion abnormality) does not replace the time criterion.