Acute Ischemic Stroke in a Marathon Runner: Last Known Well at Mile 22 Case Report

Acute Ischemic Stroke (AIS) with an onset while running a marathon is a rare but time-sensitive medical emergency that requires navigation of event medical resources. The Bank of America Chicago Marathon is a 26.2-mile city-wide race supported by emergency medical services (EMS) teams and course medical stations with centralized event medical direction to direct prehospital patient care and transport destination. We present a case report of a runner that experienced sudden onset of neurologic deficit while running a marathon that required event EMS medical direction and coordinated EMS transport to a stroke center during a city-wide race. A 58-year-old male runner without medical history experienced an acute onset of right sided visual deficit at mile 22 of the Chicago Marathon. He completed the race and presented to a medical tent an hour after onset with persistent visual symptoms and confusion. His blood glucose was 66 mg/dL and he received dextrose. After consultation with event EMS medical direction, he was transported by ambulance to a Comprehensive Stroke Center. His computed tomography (CT) scan showed a left occipital lobe hypodensity and thrombus of the left middle cerebral artery M3 segment. The CT angiography showed an atherosclerotic plaque in the left common carotid artery. He received Tenecteplase with improvement in symptoms. He was admitted to the neurological intensive care unit on a heparin drip and discharged three days later with complete resolution of symptoms on atorvastatin and rivaroxaban. Endurance running or other physical activities with excessive exercise over an extended period can increase the risk of stroke due to multiple underlying vascular effects. Studies have shown that marathon running increases circulating endothelial and thrombocyte derived microparticles which is consistent with an acute pro-thrombotic and pro-inflammatory state. Additionally, exercise-induced hypertension increases morbidity and is a risk factor for cardiac and cerebral vascular diseases. Acute ischemic stroke can result from vascular events during physical exertion of a marathon. The EMS and event medical teams in collaboration with centralized marathon medical direction should identify stroke symptoms and transport patients to an appropriate stroke center for time critical diagnosis and intervention within a system of care.