Embolic stroke with mobile thrombus in carotid artery induced by antiphospholipid antibody syndrome]

We report a 56-year-old woman suffering from an embolic brain infarction in her right frontal lobe. Carotid ultrasonogram showed a mass-shaped thrombus with little atherosclerotic change of underlying intima-media in the right common carotid artery. The thrombus was reduced with treatment and changed to mobile slender thrombus on admission. No other embolic sources were detected even using transesophageal echocardiography. Her blood test indicated existence of antiphospholipid antibody syndrome (APS) complicated with mixed connective tissue disease as an etiology of this uncommon carotid thrombus. The thrombus disappeared completely after two-week intensive antithrombotic therapy. This is a valuable report that arterial thrombi accompanied by APS could be detected by carotid ultrasound and observed until thrombus was disappeared. When we manage APS patients, it is important to rule out thrombus formation in the carotid artery using ultrasonography from the point of stroke prevention.     

Blunt traumatic dissection in common carotid artery with serial morphological changes detected by carotid ultrasonography in the acute phase]

A 68-year-old man was admitted to our hospital with left hemiparesis, unilateral spatial neglect, and anosognosia at nine hours after blunt neck trauma. Carotid ultrasonography and angiography revealed occlusion of the right common carotid artery. A second ultrasonographic examination detected a double lumen, intimal flap, and a movable thrombus at the occlusion site, with reversed flow in the external cerebral artery and antegrade flow in the internal cerebral artery. Magnetic resonance angiography showed occlusion of the M1 distal section of the right middle cerebral artery. We diagnosed dissection of the right common carotid artery and artery-to-artery embolism from the thrombus in the dissecting common carotid artery. We started anticoagulation on the second hospital day. The patient was able to walk independently at discharge. The finding of carotid dissection on ultrasonography varied during the acute phase. We observed a mural thrombus in the true lumen and vessel recanalization. Treated only by anticoagulants without surgical therapy, the patient had a good outcome without reattack or hyperperfusion syndrome.     

Intravascular ultrasound-guided thrombus retrieval with a multipurpose-angled catheter during carotid artery stenting

Intravascular ultrasound (IVUS) has provided invaluable real-time information during carotid artery stenting (CAS). We present a case of IVUS-guided thrombus extraction during CAS. A 46-year-old man underwent an urgent right CAS under proximal flow reversal for embolic protection for a hemodynamically significant symptomatic near-occlusion of the internal carotid artery. IVUS was used to evaluate immediate poststenting results and identify potential thromboembolic material extruding through the tines of the stent. An intraluminal thrombus was identified with IVUS after the stent was deployed. This led to the use of a second stent in an attempt to trap the thrombus. Ultimately, the thrombus was removed with the use of a multipurpose-angled catheter under IVUS guidance. The artery reconstituted almost completely after stent placement, and the patient's condition improved significantly. IVUS identification of intraluminal thrombus allowed additional maneuvers to be performed to prevent distal embolization and postprocedure stroke.     

Prediction of the extent of thrombus formation in the parent artery after endovascular occlusion of a distal anterior cerebral artery aneurysm using computational fluid dynamics

Endovascular coiling of a cerebral aneurysm and coil occlusion of the parent artery have been occasionally performed to treat cerebral aneurysms; however, it is difficult to predict the accurate extent of thrombus formation in the parent artery proximal to the coiled aneurysm and the coil-occluded parent artery preoperatively, and unexpected occlusion of the arterial branches can occur by thrombus extension into or in the parent artery. The authors describe a case of a distal anterior cerebral artery (ACA) aneurysm treated by endovascular parent artery occlusion (PAO) with preoperative computational fluid dynamics (CFD) prediction of the extent of thrombus formation. A 73-year-old woman presented with subarachnoid hemorrhage and an aneurysm that was located on the right pericallosal artery distal to the paracentral artery bifurcation. Endovascular coiling of the aneurysm and the pericallosal artery was planned. In advance of the treatment, CFD was performed to predict the extent of thrombus formation with specific wall shear stress and shear rate thresholds. The hemodynamic results indicated that coiling of the aneurysm resulted in thrombus formation in the pericallosal artery up to just distal to the paracentral artery ostium; therefore, the treatment was implemented according to the CFD prediction. Postoperative digital subtraction angiography revealed that the extent of thrombus formation was consistent with the preoperative CFD prediction. This technique may prevent unexpected occlusion of arterial branches.     

Giant cell arteritis with spinal cord infarction and basilar artery thrombosis.

A patient with active giant cell arteritis developed paraparesis and dissociated sensory loss due to infarction in the anterior spinal artery territory at the level of T12. Three days later fatal basilar artery thrombosis occurred. No occlusive lesion was found to explain the anterior spinal artery syndrome but this was associated with active arteritis. Alternative possibilities are that thrombus was present in involved cervical feeding vessels, or that emboli arose from intimal involvement in larger vessels, or that the event was related to thrombocytosis.     

Traumatic posterior cerebral artery occlusion in a 14-month-old child

Following a head injury, a 14-month-old male presented with neck stiffness and 24 hours later developed bilateral lateral rectus palsies. An unenhanced cerebral computed tomographic scan performed on admission revealed evidence of subarachnoid hemorrhage, cerebral edema, and mild-to-moderate compensated supratentorial hydrocephalus. A second scan performed 96 hours after the head injury revealed a mural thrombus at the tip of the basilar artery without any evidence of infarction. A third scan performed 12 days later revealed that the thrombus had resolved. However, a left posterior cerebral artery territory infarct was visualized. We postulate that the thrombus had embolized to the left posterior cerebral artery and caused occlusion of its cortical branch and subsequent infarction. A magnetic resonance angiography performed 20 days later excluded any vascular abnormality. The bilateral lateral rectus palsies persisted at the 6-month follow-up. To our knowledge, a head injury leading to a posterior cerebral artery territory infarct has not been reported earlier in a young child.     

Thromboembolic stroke associated with thoracic outlet syndrome

Thoracic outlet syndrome occurs due to compression of the neurovascular structures as they exit the thorax. Subclavian arterial compression is usually due to a cervical rib, and is rarely associated with thromboembolic stroke. The mechanism of cerebral embolisation associated with the thoracic outlet syndrome is poorly understood, but may be due to retrograde propagation of thrombus or transient retrograde flow within the subclavian artery exacerbated by arm abduction. We report an illustrative patient and review the clinical features, imaging findings and management of stroke associated with thoracic outlet syndrome.     

Endovascular Rescue Method for Undesirably Stretched Coil

Undesirable detachment or stretching of coils within the parent artery during aneurysm embolization can be related with thrombus formation, which can be caused occlusion of parent artery or embolic event(s). To escape from this situation, several rescue methods have been reported. A case with undesirably stretched coil in which another rescue method was used, is presented. When the stretched coil is still located in the coil delivery microcatheter, the stretched coil can be removed safely using a snare and a handmade monorail microcatheter. After a snare is lodged in the handmade monorail microcatheter, the snare is introduced over the coil delivery micorcatheter and located in the distal part of the stretched coil. After then, the handmade monorail microcatheter captures the stretched coil and the snare as one unit. This technique using a handmade monorail microcatheter and a snare can be a good rescue modality for the undesirably stretched coil, still remained within the coil delivery microcatheter.     

Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult

ObjectivesSilent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history.Materials and methodsHerein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction.ResultsA 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms.ConclusionsSilent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.     

Recurrent embolic stroke originating from an internal carotid aneurysm in a young adult

An unruptured intracranial aneurysm is an uncommon but possible embolic source to the brain. We report a young patient who developed recurrent ischemic strokes occurring mainly in the left internal carotid arterial territory within a short interval; the first stroke occurred midway through a long-distance race, and the second stroke occurred immediately following a bowel movement. The angiographical contrast deficit indicated a thrombus in the left anterior cerebral artery as a result of the embolism. A saccular aneurysm of the left distal internal carotid artery was the only detectable potential embolic source. Initially anticoagulant therapy was given, and then surgical clipping of the aneurysm was performed. The patient has been free from stroke recurrence. As a cause of ischemic stroke in young adults, a carotid saccular aneurysm should be considered. Hard exercise and a Valsalva maneuver may be important triggers of thrombus detachment from the aneurysm.     

The use of CT-angiography for monitoring thrombus formation after balloon occlusion of a dissecting vertebral artery pseudoaneurysm

We present a 49-year-old man with a subarachnoid haemorrhage from a dissecting vertebral artery (VA) pseudoaneurysm treated with a proximal balloon occlusion. The clinical course was complicated by the sudden appearance of a lateral medullary syndrome (Wallenberg), which completely resolved after anticoagulant therapy. During this course, CT-angiography (CTA) enabled monitoring of both the progression and partial resolution of the thrombus in the occluded VA. An anatomical variant of a perforating artery originating from the VA proximal to the posterior inferior cerebral artery (PICA) was subsequently demonstrated, explaining the ischemic event. The value of CTA in clinical management is discussed. The prophylactic use of anticoagulant therapy especially in the case of a perforating artery to the lateral medulla originating proximally to the PICA, is suggested.     

An 80-year-old woman with progressive stroke, who had rheumatoid arthritis and antiphospholipid syndrome]

We report an 80-year-old woman who had rheumatoid arthritis and antiphospholipid syndrome. She was treated for rheumatoid arthritis since her thirties. At 76 years of age, she was diagnosed antiphospholipid syndrome serologically. She felt It. limb weakness and dysarthria and was admitted to the hospital on July 18, 2003. The brain MRI showed T2 hyperintensity signal on the rt. pre-central lobe. She was treated by the argatroban, edaravone, glycerol, and aspirin. However, she became bedridden and fed by NG-tube because her symptoms progressed in spite of the therapy. Progression of stroke stopped by adding heparin at last. After that, she repeated pneumonia. She was found dead on the bed August 2, 2003. The patient was discussed in a CPC. The chief discussant arrived at a conclusion that the cause of infarction was angitis due to rheumatoid arthritis. Other possibilities were multiple thrombus due to antiphospholipid syndrome, amyloid angiopathy, and atherosclerotic infarction. Post-mortem study revealed sputum obstruction in her bronchus, string deposition in her organs. The brain showed infarction on the rt. pre-central lobe. There were multiple thrombus in the leptomeningeal artery, but few atherosclerotic changes of the small arteries. Amyloid didn't deposit in the brain artery and the parenchyma. Pathologist concluded that her infarction was induced with multiple thrombus due to antiphospholipid syndrome.     

Paradoxical brain embolism with a floating deep venous thrombus detected by sonography of lower extremities]

A 68-year-old woman was admitted to our hospital due to brain embolism in the right middle cerebral artery. Patent foramen ovale was detected by transesophageal echocardiogram. The sonogram of the legs revealed a floating thrombus originating from the left posterior tibial vein and extended to the superficial femoral vein. Both right middle lobe and left upper lobe were defected in perfusion scans of lung. She was treated with administration of warfarin potassium and caval filters placed in the inferior vena cava and the azygos vein. Thereafter, she had never experienced brain embolism or pulmonary embolism. A floating deep venous thrombus, which is a high risk of pulmonary embolism, could be observed in patients with paradoxical brain embolism. It was suggested that sonography of veins in the legs is essential for detecting embolic sources of brain infarction, as well as evaluating the risk of pulmonary embolism.     

Ipsilateral Axial Lateropulsion as an Initial Symptom of Lateral Medullary Infarction: a Case Report

The dorsolateral medullary syndrome (Wallenberg''s syndrome) is produced by infarction of a wedge of lateral medulla posterior to the inferior olivary nucleus, and is usually caused by vertebral artery occlusion. Ipsilateral axial lateropulsion as an initial symptom of vertebral artery occlusion is rare, and the responsible anatomical structure is still uncertain. Here we describe a patient presenting with ipsilateral axial lateropulsion as an initial symptom of vertebral artery occlusion.     

Cholesterol Crystal in Thrombus Removed by Mechanical Thrombectomy Should be a Strong Marker for Aortogenic Embolic Stroke

Aortogenic embolic stroke (AES) is an important stroke mechanism. However, as many stroke patients have aortic atheromatous lesions, it is unclear whether these lesions are the cause of these strokes. Cholesterol crystals are the solid, crystalline form of cholesterol that is found in atherosclerosis, but not in cardiac diseases such as atrial fibrillation, valvular diseases, and cardiomyopathy. Therefore, if a cholesterol crystal is found in a thrombus removed by mechanical thrombectomy (MT), this makes it possible to diagnose a patient as having an atheromatous lesion. Here, we report an AES case with a cholesterol crystal found in a thrombus removed by MT. A 67-year-old man was admitted due to consciousness disturbance, aphasia, and right hemiplegia. Diffusion-weighted imaging (DWI) showed a hyperintense area in the left frontal lobe, and magnetic resonance angiography demonstrated a branch occlusion of the left middle cerebral artery (MCA). MT was performed 1.5 h after stroke onset, with the thrombus removed and a left occluded MCA completely recanalized. Carotid duplex ultrasonography did not reveal any plaque in the carotid artery. Echocardiography did not show any abnormal function or findings, including thrombus. Transesophageal echocardiography showed a 4.9 mm atheromatous lesion at the aortic arch. Therefore, we suspected this patient as having an AES due to the embolic source of atheromatous lesion at the aortic arch. Pathological examination of the embolus revealed a cholesterol crystal cleft in the thrombus. Therefore, we diagnosed this patient as having AES caused by an atheromatous lesion at the aortic arch.     

Etiologic importance of the intimal flap of the external carotid artery in the development of postcarotid endarterectomy stroke

A technically unsatisfactory end point (transition from the removed diseased plaque to normal distal intima) leading to an intimal flap of the external carotid artery has been identified as a source of perioperative stroke. The mechanism involves thrombus formation with retrograde propagation of the thrombus and subsequent embolization of the internal carotid artery. This report describes three cases illustrating this mechanism and methods of identification and correction. This mechanism of postoperative stroke adds further justification for the routine use of intraoperative surveillance studies to document the technical result of endarterectomy involving the internal and external carotid arteries. When an unsatisfactory end point is identified in the external carotid artery, it should be corrected with the same sense of concern as a similar finding in the internal carotid artery.     

Trismus, pseudobulbar syndrome and cerebral deep venous thrombosis

We report a case of cerebral deep venous thrombosis that manifested clinically by a pseudobulbar syndrome with major trismus, abnormal movements and static cerebellar syndrome. To our knowledge, only three other cases of deep cerebral venous thrombosis associated with cerebellar or pseudobulbar syndrome have been published since 1985. The relatively good prognosis in our patient could be explained by the partially intact internal cerebral veins as well as use of early anticoagulant therapy. There was a spontaneous hyperdensity of the falx cerebri and the tentorium cerebelli on the brain CT scan, an aspect highly contributive to diagnosis. This hyperdensity of the falx cerebri was found in 19 out of 22 cases of deep venous thrombosis detailed in the literature.     

Artery‐to‐Artery Embolism with a Mobile Mural Thrombus Due to Rotational Vertebral Artery Occlusion

Rotational vertebral artery (VA) occlusion can cause ischemic strokes due to hemodynamic insufficiency and possibly artery‐to‐artery (A‐to‐A) embolism. The former is known as bow hunter's stroke. The latter has been proposed only from indirect evidence. We have described a 7‐year‐old boy with cerebral infarction associated with A‐to‐A embolism due to repetitive rotational VA occlusion. He had a mobile mural thrombus at the VA occlusion site on head rotation. Surgical treatment may effectively prevent recurrences.     

替罗非班治疗颈动脉漂浮血栓相关脑梗死

颈动脉漂浮血栓为一种细长的血管内漂浮物,多见于颈内动脉,常为动脉粥样硬化斑块破裂所致,可造成血管重度狭窄或者漂浮物脱落导致下游流域内多发脑栓塞,临床表现为神经功能缺损症状,严重者可出现恶性大脑中动脉脑梗死、脑疝等,并危及生命。其发病率及识别率低、病因多样,治疗方法包括颈内动脉支架置入术、颈内动脉内膜剥脱术以及抗凝、抗血小板聚集等治疗,但目前尚无指南可循。现报道应用替罗非班成功治疗颈动脉漂浮血栓相关脑梗死患者1例,以提高对颈动脉漂浮血栓相关脑梗死的认识,并为其治疗提供新的思路。