Medical Management of a Meningioma Presenting as an Ischemic Stroke: A Case Report and Review of the Literature.

An ischemic stroke caused by meningioma-induced arterial compression is exceedingly rare, with few reported cases of large cerebral artery occlusion due to extrinsic tumor mass effect. We report the case of a 76-year-old man who presented with a severe stroke (National Institutes of Health Stroke Scale (NIHSS) score of 20) caused by left middle cerebral artery (MCA) M1 segment occlusion from a sphenoid wing meningioma. Standard reperfusion therapies were not pursued; intravenous thrombolysis was contraindicated due to unknown symptom onset and tumor-associated hemorrhagic risk; mechanical thrombectomy was unlikely to succeed against extrinsic arterial compression; and emergent tumor resection posed excessive surgical risk given the patient's age, extensive infarction, and cerebral edema. Instead, intensive medical therapy was initiated, consisting of triple antiplatelet therapy (aspirin, clopidogrel, and ozagrel) and osmotic therapy with intravenous glycerol. Under this regimen, his condition stabilized, and follow-up MR angiography (MRA) at one week demonstrated reestablished flow in the previously occluded MCA, indicating spontaneous recanalization without any surgical or endovascular intervention. The infarct remained localized without hemorrhagic transformation. Given his advanced age, infarct burden, and favorable recovery, elective tumor resection was deferred. He underwent intensive rehabilitation and gradually improved to a modified Rankin Scale (mRS) score of four at discharge and an mRS score of two at one-year follow-up, without recurrent stroke. To our knowledge, this is one of the few reported cases of meningioma-related large-artery stroke managed successfully with medical therapy alone. Notably, this is the first documented case in which such treatment led to spontaneous MCA recanalization. This case highlights the potential for aggressive medical management to obviate emergent neurosurgery in select patients. Further study is warranted to identify candidates most likely to benefit from such an approach.