Embolic Cerebral Infarction Caused by Intraluminal Thrombus in the Carotid Siphon Successfully Treated With Combination of Anticoagulant and Antiplatelet Drugs

Mechanical Thrombectomy Using a Large Dual-Layer Stent Retriever for Near-Occlusion of the Common Carotid Bifurcation Caused by a Giant Free-Floating Thrombus

Objective

We report a case of near-occlusion of the common carotid bifurcation caused by a giant free-floating thrombus (FFT) successfully treated with mechanical thrombectomy using a large dual-layer stent retriever.

Case Presentation

A 51-year-old man presented to our hospital with dysarthria, right hemiparalysis, and paresthesia. MRI revealed an acute infarction of the left cortical watershed zone, and MRA revealed decreased signals in the left common carotid bifurcation. Carotid ultrasonography demonstrated a giant FFT in the left common carotid bifurcation. Angiography revealed a giant thrombus extending from the left common carotid artery (CCA) to the internal carotid artery (ICA) and the external carotid artery. As direct aspiration from both a balloon-guided catheter (BGC) and an aspiration catheter (AC) was ineffective, we deployed a large dual-layer stent retriever from the ICA to the CCA with an AC-connected aspiration pump and retrieved it under manual aspiration through the BGC. The giant thrombus was successfully removed, and complete recanalization was achieved without distal embolisms.

Conclusion

Although there is no established treatment for giant thrombi in the carotid artery, mechanical thrombectomy using a large dual-layer stent retriever may be an effective treatment option.

Successful Mechanical Thrombectomy for Subocclusive Thrombus at the Origin of Lenticulostriate Artery

Optimal treatment of patients with intracranial subocclusive thrombus remains unclear. Such a rare case successfully managed with endovascular mechanical thrombectomy is presented. A 71-year-old man experienced a sudden onset of dysarthria and motor deficits. At the time of admission his National Institutes of Health Stroke Scale (NIHSS) score was 4. DWI demonstrated incomplete infarction within the left lenticulostriate artery (LSA) territory, MRA showed partial flow defect in the distal left M1 segment and non-visualization of the LSA, and ECG revealed atrial fibrillation, thus ischemic stroke caused by cardiogenic embolism was diagnosed. Tissue plasminogen activator was administered, but symptoms progressed and NIHSS score increased up to 8. Diagnostic angiogrpahy confirmed presence of the subocclusive thrombus within the distal left M1 segment and complete occlusion of LSA at its origin. Since conservative therapy was ineffective, mechanical thrombectomy utilizing ADAPT (a direct aspiration first-pass thrombectomy) technique was performed resulting in compete recanalization of the LSA accompanied by the prompt regress of neurological symptoms. Eventally, the patient demonstrated nearly full recovery (modified Rankin Scale score 1). Thus, mechanical thrombectomy should be considered as a reasonable option in cases of acute cerebral stroke caused by subocclusive thrombus and progressive neurological deficits despite standard conservative therapy. J. Med. Invest. 67 : 372-374, August, 2020.

[A case of internal carotid thrombus associated with brain infarction]

A 49-year-old man was transferred to our hospital with chief complaint of global aphasia and weakness of right upper and lower limbs. Brain MRI showed ultra-acute cerebral infarction in left anterior cerebral artery and middle cerebral artery territory and MRA showed occlusion of A2 and M2. Although t-PA was administrated intravenously, symptoms didn't improve and giant internal carotid thrombus (size 6 × 7 × 17 mm) was recognized at left internal carotid artery by carotid ultrasonography. After started anticoagulant therapy, thrombus was miniaturized gradually and finally disappeared. Anticoagulant therapy is effective to internal carotid thrombus and carotid ultrasonography is useful to confirm the effectiveness. We suggest that clinicians should enforce anticoagulant therapy for the first choice to internal carotid thrombus.

Recanalization and Remarkable Outcome after Subocclusive Thrombus: A Case Report

Minimal literature exists regarding subocclusive thrombi and their management in acute ischemic stroke, and no randomized trials or guidelines are currently available. We present the case of an 83-year-old man with multiple vascular risk factors and recent cardiac surgery who presented with a severe left middle cerebral artery (MCA) syndrome due to a subocclusive thrombus. Intravenous (IV) tissue plasminogen activator was contraindicated given the patient's recent surgery, and endovascular therapy was deferred given improvement in symptoms. He was placed on IV heparin. His symptoms improved with recanalization of the MCA. Optimal management of subocclusive thrombi, which appear to have better outcomes than occlusive thrombi, has yet to be elucidated. Acute anticoagulation and endovascular therapy may both be reasonable; however, there are minimal data supporting the use of either and further studies are needed to develop the most favorable treatment algorithm. In the meantime, management decisions should be made on a case-by-case basis by multidisciplinary care teams.

Frequency and clinical course of stroke and transient ischemic attack patients with intracranial nonocclusive thrombus on computed tomographic angiography

BACKGROUND AND PURPOSE

We sought to determine the frequency and clinical course of patients with acute ischemic stroke or transient ischemic attack (TIA) who had intracranial nonocclusive thrombus (iNOT) on CT angiography (CTA).

METHODS

We retrospectively (June 2002-March 2007) reviewed consecutive patients with acute ischemic stroke or TIA who had CTA performed acutely for diagnostic work-up. A neuroradiologist reviewed all cases with potential iNOT. Criteria to diagnose iNOT rather than occlusive thrombus or atherosclerotic stenosis were: (1) residual lumen present and eccentric; (2) nontapering thrombus; (3) smooth and well-defined thrombus margins; and (4) absence of vessel wall calcification. We defined functional independence at discharge as modified Rankin scale score </=2.

RESULTS

Of 865 patients, 23 (2.7%) exhibited iNOT on CTA (43% women, mean age 69+/-14 years, median National Institute of Health Stroke Scale score 3 [range, 0-23]; median onset-to-CTA time 3.5 hours [range, 0.9-75]). Four patients (17%) deteriorated clinically during the hospital course and had persistent new focal neurological deficits. All of them were functionally dependent at discharge. All 19 patients (83%) without persistent clinical deterioration (2 patients had recurrent TIAs) were functionally independent at discharge.

CONCLUSIONS

Intracranial nonocclusive thrombus on CTA is relatively uncommon. The majority of patients have a good clinical outcome. However, some patients deteriorate clinically and are functionally dependent at discharge.

Time Course of Platelet Activation and von Willebrand Factor in Patients With Non-Valvular Atrial Fibrillation After Ischemic Stroke Evaluation of Prognostic Determinants

BACKGROUND

The present study investigated serial changes in platelet activation (expressed by CD62p) and von Willebrand factor (VWF), and the correlation between increased CD62p expression, VWF and brain infarct volume (BIV: measured by magnetic resonance imaging), and prognostic determinants in non-valvular atrial fibrillation (NVAF) patients after acute ischemic stroke (IS).

METHODS AND RESULTS

CD62p expression and plasma VWF concentrations were serially measured (<48 h, on days 7, 21 and 90) using flow cytometry and enzyme-linked immunosorbent assay, respectively after acute IS in 61 NVAF patients. CD62p expression and VWF concentrations were also examined in 50 NVAF-risk control and 30 healthy individuals. The VWF concentration had no significant changes at 4 intervals among the patients and did not differ among 3 groups at acute stroke phase. CD62p expression was significantly higher in the acute phase after IS than in both control groups (both p<0.0001). However, CD62p expression declined to a significantly lower level on day 7 and to a substantially lower level thereafter (p<0.0001). CD62p expression did not differ on day 90 in the 3 groups (both p>0.5). Linear regression analysis showed that BIV and modified Rankin scale score (>3) were independently associated with increased CD62p expression (<48 h) (both p<0.01). Furthermore, the Cox proportional hazards model showed that BIV was the only independent predictor of intermediate-term (8.8+/-4.4 months) combined recurrent stroke and death.

CONCLUSIONS

The CD62p expression, which reflected increased BIV, was significantly increased in NVAF patients in acute-phase IS and substantially declined thereafter. The BIV was predictive of unfavorable intermediate-term clinical outcomes.