Marfan’s syndrome is a systemic disorder of connective tissue typically involving cardiovascular, musculoskeletal and ocular systems. Given the relative rarity of neurovascular complications in Marfan’s syndrome, there is currently little published data on the use of thrombolysis in patients with Marfan’s syndrome and acute ischaemic stroke. Of concern is the possibility of underlying cerebral artery dissection in patients with Marfan’s syndrome presenting with stroke and the risk of haemorrhagic complications with thrombolysis. We report the third known case of a patient with Marfan’s syndrome with an acute ischaemic stroke without evidence of cerebral artery dissection who received thrombolysis successfully with neurological improvement. A 47-year-old woman with a history of Marfan’s syndrome and previous left middle cerebral artery (MCA) territory infarct presented to our emergency department with sudden onset of right facial, arm and leg weakness with a NIHSS score of 15 and clinical examination findings of a right upper motor neurone facial palsy and right hemiparesis. CT brain revealed a dense right MCA sign and no evidence of haemorrhage. She received 0.9mg/kg of alteplase without complications. There was a suspicion for cerebral artery dissection but this was not evident on both CT angiography and MRI angiogram with black blood sequences. She recovered well with a NIHSS score of 1 and mild residual dysphasia. This case demonstrates that thrombolysis may be given safely in a patient with Marfan’s syndrome and acute ischaemic stroke and exclusion of underlying cerebral artery dissection should always be a consideration.

INTRODUCTION: Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED). METHODS: This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment. RESULTS: The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048). CONCLUSION The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.