Reversal of locked-in syndrome with anticoagulation, induced hypertension, and intravenous t-PA

Introduction: Widespread use of intravenous tissue plasminogen activator (t-PA) for acute ischemic stroke is limited by multiple contraindications to its use. Case report: This article describes a patient with stuttering symptoms of pontine ischemia caused by vertebrobasilar dissection who suddenly deteriorated into a locked-in state 32 hours after symptom onset. The quadriparesis was successfully reversed within 3 hours of onset with the combination of pharmacologically induced hypertension, anticoagulation, and intravenous t-PA. Discussion: Even in the face of numerous contraindications (including hypertension, anticoagulation, and treatment beyond 3 hours of symptom onset), intravenous t-PA can be used successfully in carefully selected cases.