Background For acute ischemic stroke patients with matched defects on diffusion–perfusion imaging, the effects of reperfusion therapy remain poorly documented. The outcomes in a rare series of patients who had a matched defect and then underwent intra-arterial thrombolytic treatment (IAT) are reported.

Methods Medical record and MR image review between 1 January 1998 and 15 October 2008 revealed only eight acute ischemic stroke patients satisfying the atypical combination of both matched defect and IAT. Successful recanalization (SR), favorable clinical response (FCR) and symptomatic intracranial hemorrhage (SICH) were defined respectively as thrombolysis in cerebral infarction score ≥2 after IAT, discharge National Institutes of Health Stroke Scale (NIHSS) 0–1/≥8 point decrease from baseline and intracranial hemorrhage in infarct zone with ≥4 point increase in NIHSS Score within 24 h of IAT.

Results Median (range) baseline NIHSS score was 16.5 (6–22). Median (range) time delays from symptom onset to MRI and to IAT initiation were 200 (83–240) and 267.5 (160–360) min, respectively. Median (range) values of diffusion and perfusion lesion volumes were 119.5 (24–205) and 118 (18–207) ml. Out of eight patients, one (12.5%) achieved FCR, four (50%) had SICH and five (62.5%) died. Out of six patients with SR, one achieved FCR and four had SICH and died, and of two patients without SR, none had FCR or SICH and one died.

Conclusion Our data on rare patients with matched defects who nevertheless had attempted rescue with IAT confirm a poor risk–benefit ratio generated by low favorable responses and high mortality rates, especially in large ischemic lesions.