1
|
Onalan A, Gurkas E, Balgetir F, Aytac E, Akpinar CK, Cetin H, Ciftaslan A, Kavak Genc S. Emergent endovascular treatment versus medical treatment for acute large vessel occlusions with nondisabling symptoms. Interv Neuroradiol 2024:15910199241286551. [PMID: 39360421 DOI: 10.1177/15910199241286551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024] Open
Abstract
OBJECTIVES The aim of this study is to analyze the effectiveness and safety of medical treatment (MT) versus endovascular treatment (EVT) in acute large vessel occlusion patients with mild nondisabling stroke symptoms. METHODS This study is a multicenter observational study in which data from patients at three stroke centers were prospectively obtained and retrospectively analyzed. Patients were included if they arrived for treatment within 6 h of stroke onset or last known well time and had a baseline National Institutes of Health Stroke Scale (NIHSS) score of ≤5. Primary outcome was modified Rankin Scale (mRS) score 0-2 at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), discharge NIHSS score, 90-day all-cause mortality and length of stay. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, treatment type admission and discharge NIHSS score, admission Alberta Stroke Program Early CT (ASPECT) score and length of stay. RESULTS Of the 82 patients included in the study, 42 were in the EVT group and 40 were in the MT group. The groups were similar in age (MT:66, EVT:64 age; p = .62), gender (MT:55%, EVT:54.8%; male) admission NIHSS score (MT:2, EVT:3 points; p = .26), ASPECT score (MT:10, EVT:9; p = .15). While discharge NIHSS score was found to be statistically significant between the groups (MT:1, EVT:2; p = .04). There was no difference between the two groups in terms of 90-day mRS scores (MT:1, EVT:1, p = .86) and mortality rates (MT:4, EVT:4; p = .94). In unadjusted analysis, sICH rates were similar between the MT and EVT groups (MT 5%, EVT 7.1%, p = .52). Neurological intensive care unit length of stay (MT:5 days, EVT:2 days p < .001), inpatient clinic length of stay (MT:3, EVT:2 days p = .041), and total length of stay (MT:9 days, EVT:4 days p < .001) were significantly longer in the MT group. CONCLUSIONS Our multicenter study demonstrated that MT with blood pressure augmentation and anticoagulation at hyperacute stage is an alternative option for emergency large vessel occlusion patients with nondisabling mild stroke symptoms.
Collapse
Affiliation(s)
- Aysenur Onalan
- Department of Neurology, Stroke Center, Kartal Dr Lutfi Kirdar City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Erdem Gurkas
- Department of Neurology, Stroke Center, Kartal Dr Lutfi Kirdar City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Ferhat Balgetir
- Department of Neurology, Stroke Center, Faculty of Medicine, Firat University, Elazığ, Turkey
| | - Emrah Aytac
- Department of Neurology, Stroke Center, Faculty of Medicine, Firat University, Elazığ, Turkey
| | | | - Hasan Cetin
- Department of Neurology, Stroke Center, Samsun University, Samsun, Turkey
| | - Asli Ciftaslan
- Department of Neurology, Stroke Center, Kartal Dr Lutfi Kirdar City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Sule Kavak Genc
- Department of Public Health, Faculty of Medicine, Firat University, Elazığ, Turkey
| |
Collapse
|
2
|
Jayyusi F, AlBarakat MM, Al-Rousan HH, Alawajneh MM, Alkasabrah AR, Abujaber M, Aldabbas ME, Abuelsamen M, Alshgerat Y, Sayuri Y, Alhertani N, BaniAmer M, Shari I, Brašić JR. The Efficacy of Medical Interventions for Free-Floating Thrombus in Cerebrovascular Events: A Systematic Review. Brain Sci 2024; 14:801. [PMID: 39199493 PMCID: PMC11352359 DOI: 10.3390/brainsci14080801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 08/03/2024] [Accepted: 08/07/2024] [Indexed: 09/01/2024] Open
Abstract
Although free-floating thrombus (FFT) poses a significant risk of stroke or transient ischemic attack (TIA), optimal management strategies are uncertain. To determine the state-of-the-art of medical interventions for FFT, we conducted a systematic review of the efficacy of various medical interventions and factors influencing FFT resolution and recurrence. A comprehensive search of Embase, PubMed, and ScienceDirect identified 61 studies encompassing 179 patients with FFT-related stroke or TIA treated with anticoagulants, antiplatelets, or their combinations. Primary outcomes assessed were stroke recurrence and thrombus resolution. Statistical analyses (Fisher's exact test, chi-square test, Mann-Whitney test, and Kruskal-Wallis test) utilized significance set at p < 0.05. Over a median follow-up of 7 months, thrombus resolution occurred in 65% of patients, while 11.2% experienced recurrence, primarily as TIAs. Cardioembolism was significantly less common in resolved cases (p = 0.025). Combination therapy (antiplatelets, anticoagulants, and statins) significantly enhanced clot resolution (OR 11.4; 95% CI 1.436-91.91; p = 0.021) compared to monotherapies. Ulcerated plaque was a significant predictor of recurrence (OR 8.2; 95% CI 1.02-66.07; p = 0.048). These findings underscore the superiority of combination therapy in FFT management and highlight the need for targeted interventions in patients with ulcerated plaques to mitigate recurrence risk.
Collapse
Affiliation(s)
- Fairoz Jayyusi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Majd M. AlBarakat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Habib H. Al-Rousan
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mohmmad M. Alawajneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Abdel Rahman Alkasabrah
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mo’tasem Abujaber
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mohammed E. Aldabbas
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mustafa Abuelsamen
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Yahya Alshgerat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Yahia Sayuri
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Nazeeh Alhertani
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mohammad BaniAmer
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Issa Shari
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - James Robert Brašić
- Department of Psychiatry, New York City Health and Hospitals/Bellevue, New York, NY 10016, USA
- Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY 10016, USA
- Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
3
|
Aboul-Nour H, Alshaer Q, Khalid FC, Osehobo E, Tarek MA, Mohammaden MH, Haussen DC, Dolia JN. Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus. J Stroke Cerebrovasc Dis 2024; 33:107760. [PMID: 38718871 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/30/2024] [Accepted: 05/05/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. METHODS Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. RESULTS During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years ± 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results. CONCLUSION Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.
Collapse
Affiliation(s)
- Hassan Aboul-Nour
- Departments of Neurology and Neurosurgery, University of Kentucky, College of Medicine, Lexington, KY, USA; Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Qasem Alshaer
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Ehizele Osehobo
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaydevsinh N Dolia
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
| |
Collapse
|
4
|
Onalan A, Gurkas E, Kursad Akpinar C, Aykac O, Uysal Kocabas Z, Dogan H, Temel M, Ozcan Ozdemir A. Safety and effectiveness of anticoagulation in the management of acute stroke and transient ischemic attack due to intracranial and extracranial non-occlusive thrombus. J Clin Neurosci 2024; 124:47-53. [PMID: 38643651 DOI: 10.1016/j.jocn.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION The awareness of nonocclusive thrombus has increased with the increasing frequency of imaging methods used for acute ischemic stroke; however, the best treatment for nonocclusive thrombi is still unknown. In this study, we examined how anticoagulants affect supra-aortic artery nonocclusive thrombus and clinical outcomes. MATERIALS AND METHODS This study included 52 patients with transient ischemic attack or stroke who were diagnosed with nonocclusive thrombi on computed tomography angiography at admission. Patients were treated with anticoagulant treatment and grouped according to treatment modality (either unfractionated heparin or low molecular weight heparin) and treatment duration. Primary safety outcome was major bleeding defined as immediate and clnically significant hemorrhage. Anticoagulant treatment was continued until the thrombus was resolved as determined by consecutive weekly computed tomography angiography controls. After thrombus resolution, treatment was directed according to the underlying etiology. Antiaggregation treatment was the preferred treatment after thrombus resolution for patients with no observed etiology. RESULTS The affected internal carotid arteries were most frequently located in the cervical segment (48 %). Complete resolution was achieved within 2 weeks in 50 patients (96 %). The involved vasculature included the following: the extracranial carotid artery segments (n = 26, 50 %), intracranial ICA segments (n = 10, 19 %), basilar artery segments (n = 8, 15 %) and MCA segments (n = 7, 13 %). The most common underlying pathologies were atherosclerosis (n = 17), atrial fibrillation (n = 17), undetermined embolic stroke (n = 8), dissection (n = 7), and malignancy (n = 2). No symptomatic intra- or extracranial bleeding complications due to anticoagulant use were observed in any patient during the study period. A good functional outcome (modified Rankin scale score 0-2) was achieved in 49 patients (94 %) at 3 months. There was no significant difference between treatment type and duration in terms of reinfarction (p = 0.97 and p = 0.78, respectively). CONCLUSION Anticoagulant treatment is safe and effective in symptomatic patients with intracranial or extracranial artery nonocclusive thrombus, regardless of the anticoagulant type, thrombus location and size.
Collapse
Affiliation(s)
- Aysenur Onalan
- University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey Department of Neurology, Stroke Center, Turkey.
| | - Erdem Gurkas
- University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey Department of Neurology, Stroke Center, Turkey
| | | | - Ozlem Aykac
- Eskisehir Osmangazi University, Department of Neurology, Stroke Center, Eskisehir, Turkey
| | - Zehra Uysal Kocabas
- Eskisehir Osmangazi University, Department of Neurology, Stroke Center, Eskisehir, Turkey
| | - Hasan Dogan
- Samsun University, Department of Neurology, Stroke Center, Samsun, Turkey
| | - Musa Temel
- Sanliurfa Mehmet Akif Inan Research Hospital, Department of Neurology, Sanliurfa, Turkey
| | - Atilla Ozcan Ozdemir
- Eskisehir Osmangazi University, Department of Neurology, Stroke Center, Eskisehir, Turkey
| |
Collapse
|
5
|
Lin KX, Lin QQ, Fang L, Wang W, Wang N, Zhao WL. Dual Protection Combined Aspiration and Stentrievers Thrombectomy (DPCAS) Technique Treating for Giant Free-floating Carotid Artery Thrombus. Clin Neuroradiol 2024; 34:269-273. [PMID: 37676280 DOI: 10.1007/s00062-023-01341-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/26/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Kun-Xin Lin
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, 350005, Fuzhou, China
| | - Qian-Qian Lin
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, 350005, Fuzhou, China
| | - Ling Fang
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, 350005, Fuzhou, China
| | - Wei Wang
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, 350005, Fuzhou, China
| | - Ning Wang
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, 350005, Fuzhou, China.
| | - Wen-Long Zhao
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, 350005, Fuzhou, China.
| |
Collapse
|
6
|
Alhowaish TS, Alhamadh MS, Alsulayhim A, Alotaibi N, Alrashid AA, Alhabeeb AY, Alqirnas MQ, Alrushid E, Alnafisah MS, Anversha AA. Intraluminal Thrombus of the Extracranial Cerebral Arteries in Acute Ischemic Stroke: Manifestations, Treatment Strategies, and Outcome. Vasc Health Risk Manag 2024; 20:1-12. [PMID: 38192438 PMCID: PMC10771733 DOI: 10.2147/vhrm.s435227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024] Open
Abstract
Background Intraluminal thrombus (ILT) of the cervical arteries is an uncommon finding that can lead to acute or recurrent ischemic stroke. Currently, antithrombotic therapy in the form of antiplatelet and/or anticoagulation is considered the mainstay of treatment, but evidence of which one has a better outcome is lacking. Methods A retrospective cohort study included 28 patients diagnosed with acute stroke or transient ischemic attack with ILT of the extracranial arteries from 2013 to 2022. The primary efficacy outcome was assessed as recurrent stroke, and the primary safety outcome was assessed as hemorrhagic complications. Secondary outcomes were assessed as the resolution of thrombi by CT angiography (CTA) and clinical improvement by the Modified Rankin Scale (mRS) and NIH Stroke Scale (NIHSS). Results Out of 28 patients, more than half (57.1%; n = 16) were males with a mean age of 57.8 ± 9.5 years and an average BMI of 26.9 ± 4.5 kg/m2. As initial treatment, twenty-four patients received anticoagulation and four received antiplatelet agents. Recurrent strokes were found in four patients (14.29%), and all were initially treated with anticoagulation. One patient in the anticoagulation group had a significant retroperitoneal hemorrhage. None of the patients in the antiplatelets group had a recurrent stroke or bleeding event. Initial treatment with antiplatelet agents significantly improved the NIHSS on day 7 (P = 0.017). A significant improvement in NIHSS on day 90 was observed in the anticoagulant group (P = 0.011). In the follow-up CTA performed on 24 patients, 18 (75%) showed complete resolution (3 out of 3 (100%) in the antiplatelet group and 15 out of 21 (71.43%) in the anticoagulant group). Conclusion Initial treatment with anticoagulants improves neurologic outcomes in patients with ILT-induced acute ischemic stroke but carries the risk of recurrent stroke and bleeding. However, initial treatment with dual antiplatelet agents appears to have comparable efficacy without sequelae, particularly in atherosclerosis-induced ILT.
Collapse
Affiliation(s)
- Thamer S Alhowaish
- Division of Neurology, Department of Medicine, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs (MNGHA), Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Moustafa S Alhamadh
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard-Health Affairs, Riyadh, 14611, Kingdom of Saudi Arabia
| | - Abdullah Alsulayhim
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
- Radiology Department, King Abdul Aziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Najla Alotaibi
- College of Public Health, Oregon State University, Corvallis, OR, USA
| | - Azzam Abdulaziz Alrashid
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard-Health Affairs, Riyadh, 14611, Kingdom of Saudi Arabia
| | - Abdulrahman Yousef Alhabeeb
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard-Health Affairs, Riyadh, 14611, Kingdom of Saudi Arabia
| | - Muhannad Q Alqirnas
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard-Health Affairs, Riyadh, 14611, Kingdom of Saudi Arabia
| | - Eythar Alrushid
- Division of Neurology, Department of Medicine, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs (MNGHA), Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Mohammed S Alnafisah
- Division of Neurology, Department of Medicine, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs (MNGHA), Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Ajmal Ali Anversha
- Division of Neurology, Department of Medicine, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs (MNGHA), Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh, 11481, Kingdom of Saudi Arabia
| |
Collapse
|
7
|
Schartz D, Susa S, Ellens N, Akkipeddi SMK, Houk C, Bhalla T, Mattingly T, Hasan D, Bender MT. Symptomatic carotid artery intraluminal thrombus: risk of medical management failure and distal embolization. J Neurointerv Surg 2023:jnis-2023-021044. [PMID: 38041660 DOI: 10.1136/jnis-2023-021044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/11/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Carotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization and/or intracranial hemorrhage (ICH) may still occur. METHODS All patients with symptomatic ILT from 2016 to 2023 were identified from our tertiary care institution. Patients with MM failure (recurrent cerebral ischemia and/or symptomatic ICH) were compared with patients with MM non-failure. Differences in ILT volume and length were calculated. Receiver operator characteristic (ROC) curve analysis was used to identify the cut-off volume and length for risk of MM failure. RESULTS In total, 45 patients with ILT were identified with 41 treated with frontline MM. Of these 41 patients treated with MM, seven (17%) had MM failure with six (14.6%) having new embolic stroke and one (2.3%) with symptomatic ICH. Patients with MM failure had a significantly higher mean thrombus volume than MM non-failure patients (257 mm3 vs 59.6 mm3, P=0.0006). Likewise, patients with MM failure had significantly longer thrombus on average (21 mm vs 6.6 mm, P=0.0009). ROC curve analysis showed that an ILT volume of 90 mm3 resulted in a sensitivity of 71.4% and specificity of 85.3% for MM failure (AUC 0.775; CI 0.55 to 1.0, P=0.023). CONCLUSIONS Carotid ILTs that fail MM are significantly larger and longer. These findings suggest that a thrombus volume of 90 mm3 may serve as a guide for intervention with good sensitivity and specificity for risk of MM failure.
Collapse
Affiliation(s)
- Derrek Schartz
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Stephen Susa
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Nathaniel Ellens
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Clifton Houk
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas Mattingly
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David Hasan
- Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Matthew T Bender
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| |
Collapse
|
8
|
Wang Y, Yin J, Meng Y, Wu L, Li X, Xu Y, Wei Y. Symptomatic free-floating thrombus in the vertebral artery: a case description. Quant Imaging Med Surg 2023; 13:4002-4006. [PMID: 37284108 PMCID: PMC10240024 DOI: 10.21037/qims-22-1064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 03/10/2023] [Indexed: 10/03/2023]
Affiliation(s)
| | | | - Yan Meng
- Department of Neurology, Xingtai Third Hospital, Xingtai, China
| | - Lijuan Wu
- Department of Neurology, Xingtai Third Hospital, Xingtai, China
| | - Xiaoqiang Li
- Department of Neurology, Xingtai Third Hospital, Xingtai, China
| | - Yingdong Xu
- Department of Neurology, Xingtai Third Hospital, Xingtai, China
| | - Yuqing Wei
- Department of Neurology, Xingtai Third Hospital, Xingtai, China
| |
Collapse
|
9
|
Müller MD, Raptis N, Mordasini P, Z'Graggen W, Raabe A, Schucht P, Heldner MR, Bervini D. Natural history of carotid artery free-floating thrombus—A single center, consecutive cohort analysis. Front Neurol 2022; 13:993559. [PMID: 36237628 PMCID: PMC9553207 DOI: 10.3389/fneur.2022.993559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/30/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Carotid free-floating thrombus (CFFT) is a rare cause of stroke and is thought to be associated with a high risk of recurrent cerebrovascular ischaemic events. The existing data on the natural history and optimal treatment modalities of CFFT is scanty and no clear recommendations exist. Objective A retrospective analysis, single-center cohort of consecutive patients diagnosed with CFFT was conducted, investigating the risk for recurrent cerebrovascular ischaemic events. Methods We performed a single-center retrospective analysis including all patients presenting at our tertiary center between January 2005 and December 2020 with symptoms consistent with ischaemic stroke and/or transient ischaemic attack. Digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance angiography (MRA) were used to diagnose CFFT. In all included patients, CFFT was confirmed with a second imaging modality. CFFT was defined on imaging as a defect in contrast filling extending into the carotid lumen. We gathered information on vascular risk factors, diagnosis and follow-up methods, modality of treatment and neurological outcome. A survival analysis was performed, assessing the risk for recurrent cerebrovascular events. Results In total, N = 62 patients presenting with symptomatic CFFT were included. Mean age was 68 years, 69% (43/62) of patients were male, 52% (32/62) current or previous smokers, 76% (47/62) suffered from arterial hypertension, 68% (42/62) from dyslipidaemia, and 31% (19/62) from diabetes mellitus. Overall, 71% (44/62) of patients received any kind of intervention [endovascular or surgical carotid thrombo-endartectomy (CEA)] at any time point during follow-up. Sixteen percent of patients (10/62) received intervention within 48 h after diagnosis of CFFT. The survival analysis and Kaplan-Meier model censoring patients at the time of intervention or last follow-up showed that the risk for any recurrent ischaemic stroke was 19.7% within the first 7 days and 27.4% within 3 months after diagnosis. No patients experienced a new ischaemic stroke beyond 11 days after diagnosis of CFTT (n = 17). Conclusion The risk of recurrent ischaemic events in patients with CFFT is high, especially in the first week after diagnosis. Prospective studies are needed to further investigate the optimal management of these patients.
Collapse
Affiliation(s)
- Mandy D. Müller
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- *Correspondence: Mandy D. Müller
| | - Nikolaos Raptis
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Pasquale Mordasini
- Department of Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Werner Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Department of Neurology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- David Bervini
| |
Collapse
|
10
|
Weil EL, Klaas JP. Extensive intraluminal thrombus involving the extracranial internal carotid artery. Pract Neurol 2022; 22:332-333. [PMID: 35688620 DOI: 10.1136/practneurol-2022-003391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Erika L Weil
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - James P Klaas
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
11
|
Tinone G, Hoshino M, Lucato L, Comerlatti LR. Anticoagulation and Stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:72-79. [PMID: 35976322 PMCID: PMC9491440 DOI: 10.1590/0004-282x-anp-2022-s132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
In 2019, the American Heart Association did not recommend the emergent use of anticoagulation to prevent recurrence or progression of acute ischemic stroke. However, its indication in patients with extracranial artery intraluminal thrombus with artery-to-artery cerebral embolization must be analyzed. In this article, we will also discuss other indications of anticoagulation. This treatment could be indicated in patients with ischemic stroke caused by embolization from cervical artery dissection, catastrophic antiphospholipid antibodies syndrome (APS) and some cases of Covid 19. For secondary prevention, anticoagulation is recommended for Cardioembolic stroke such as nonvalvular atrial fibrillation and other cardiopathies, some patients with cervical artery dissection, stroke associated with cancer, and thrombophilia such as APS. The timing to restart anticoagulation after a large ischemic stroke or after a cerebral hemorrhagic transformation always represent a challenge. Even in patients with high risk of thromboembolism it should be delayed at least two weeks, ideal after four weeks.
Collapse
Affiliation(s)
- Gisela Tinone
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brazil
| | - Mauricio Hoshino
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brazil
| | - Leandro Lucato
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Radiologia, São Paulo, SP, Brazil
| | - Luiz Roberto Comerlatti
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brazil
| |
Collapse
|
12
|
Efficacy and safety of intensified antithrombotic therapy followed by stenting in treatment of highly severe stenosis accompanied by thrombosis in carotid atherosclerosis. Clin Neurol Neurosurg 2022; 218:107274. [DOI: 10.1016/j.clineuro.2022.107274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/25/2022] [Accepted: 04/27/2022] [Indexed: 11/20/2022]
|
13
|
Christian ZK, Hoang AN, Dang H, Khan AB, Raper DM, Pallister ZS, Tanweer O. Use of transcarotid artery revascularization for mechanical thrombectomy and treatment of symptomatic high-grade carotid artery stenosis associated with free-floating thrombus: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21553. [PMID: 36130533 PMCID: PMC9379636 DOI: 10.3171/case21553] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge. In general, for patients with moderate to severe symptomatic ICA stenosis, carotid revascularization is recommended within 2 weeks of symptom onset; however, some physicians suggest that revascularization should be delayed in cases with FFT because some data suggest that early surgery with carotid endarterectomy or carotid stent poses a higher risk for stroke. Likewise, delayed revascularization with anticoagulation may increase risk of recurrent stroke. Few reports on the management of FTT included the use of a transcarotid artery revascularization (TCAR) approach for carotid revascularization with mechanical aspiration thrombectomy. OBSERVATIONS This report described the use of TCAR for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right ICA stenosis along with a large FFT extending into the bulb and the external carotid artery. LESSONS The TCAR approach for mechanical thrombectomy and carotid stenting is a safe alternative for early revascularization with low periprocedural stroke risks.
Collapse
Affiliation(s)
| | | | | | | | | | - Zachary S. Pallister
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas; and
| | | |
Collapse
|
14
|
Martinez-Gutierrez JC, Roy AT, D'Amato S, Berkman JM, Montes D, Kimball CA, Rordorf GA, Chibnik LB, Romero JM, Silverman SB. Preoperative antithrombotic treatment in acutely symptomatic carotid artery stenosis. J Stroke Cerebrovasc Dis 2022; 31:106396. [PMID: 35219972 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA). MATERIALS AND METHODS A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage. RESULTS Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002). CONCLUSIONS Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.
Collapse
Affiliation(s)
- Juan Carlos Martinez-Gutierrez
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| | - Alexis T Roy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Salvatore D'Amato
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Jillian M Berkman
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Daniel Montes
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Cheryl A Kimball
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Guy A Rordorf
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Lori B Chibnik
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Javier M Romero
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| |
Collapse
|
15
|
Culleton S, Wiggins R, McNally JS. Imaging spectrum of extracranial arterial vascular pathology: pearls for the radiologist. Clin Radiol 2021; 77:167-178. [PMID: 34799048 DOI: 10.1016/j.crad.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022]
Abstract
Non-invasive imaging plays an increasingly important role in assessing the extracranial vasculature. The applications of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) continue to expand with growing demand for stroke imaging and anatomical assessment preceding vascular intervention. Imaging of the neck is performed for a variety of clinical indications with different imaging protocols. Even on non-dedicated vascular imaging, such as soft-tissue studies, the neck vessels and the proximal aortic arch are readily evaluable, providing an opportunity to promptly identify critical vascular abnormalities with significant therapeutic implications. Vascular abnormalities can have non-specific clinical signs and symptoms resulting in delays in both diagnosis and treatment. Understanding the common locations and appearances of vascular pathologies will help the radiologist to develop a systematic search strategy for evaluating neck imaging. Not only is identifying the pathology of paramount importance but also understanding how imaging further prognosticates and determines treatment options. As imaging techniques advance, further vascular radiological features are recognised with therapeutic implications, particularly for stroke. Such features include plaque morphology and vulnerability with imaging helping to identify those at high risk of stroke and recurrent strokes. Using clinical cases from a quaternary care academic medical centre a spectrum of clinically relevant arterial pathologies and associated features that could add further benefit to the radiology report are illustrated. A suggested systematic approach to evaluating the vasculature on neck imaging is also presented.
Collapse
Affiliation(s)
- S Culleton
- Department of Radiology, University of Utah Health Sciences Centre, Salt Lake City, UT, USA.
| | - R Wiggins
- Department of Radiology, University of Utah Health Sciences Centre, Salt Lake City, UT, USA
| | - J S McNally
- Department of Radiology, University of Utah Health Sciences Centre, Salt Lake City, UT, USA
| |
Collapse
|
16
|
Torres C, Lum C, Puac-Polanco P, Stotts G, Shamy MCF, Blacquiere D, Lun R, Dave P, Bharatha A, Menon BK, Thornhill R, Momoli F, Dowlatshahi D. Differentiating Carotid Free-Floating Thrombus From Atheromatous Plaque Using Intraluminal Filling Defect Length on CTA: A Validation Study. Neurology 2021; 97:e785-e793. [PMID: 34426550 DOI: 10.1212/wnl.0000000000012368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/26/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To validate a previously proposed filling defect length threshold of >3.8 mm on CT angiography (CTA) to discriminate between free-floating thrombus (FFT) and plaque of atheroma. METHODS This was a prospective multicenter observational study of 100 participants presenting with TIA/stroke symptoms and a carotid intraluminal filling defect on initial CTA. Follow-up CTA was obtained within 1 week and at weeks 2 and 4 if the intraluminal filling defect was unchanged in length. Resolution or decreased length was diagnostic of FFT, whereas its static appearance after 4 weeks was indicative of plaque. Diagnostic accuracy of FFT length was assessed by receiver operating characteristic analysis. RESULTS Ninety-five participants (mean [SD] age 68 [13] years, 61 men, 83 participants with FFT, 12 participants with a plaque) were evaluated. The >3.8-mm threshold had a sensitivity of 88% (73 of 83) (95% confidence interval [CI] 78%-94%) and specificity of 83% (10 of 12) (95% CI 51%-97%) (area under the curve 0.91, p < 0.001) for the diagnosis of FFT. The optimal length threshold was >3.64 mm with a sensitivity of 89% (74 of 83) (95% CI 80%-95%) and specificity of 83% (10 of 12) (95% CI 51%-97%). Adjusted logistic regression showed that every 1-mm increase in intraluminal filling defect length is associated with an increase in odds of FFT of 4.6 (95% CI 1.9-11.1, p = 0.01). CONCLUSION CTA enables accurate differentiation of FFT vs plaque using craniocaudal length thresholds. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02405845. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in patients with TIA/stroke symptoms, the presence of CTA-identified filling defects of lengths >3.8 mm accurately discriminates FFT from atheromatous plaque.
Collapse
Affiliation(s)
- Carlos Torres
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada.
| | - Cheemun Lum
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Paulo Puac-Polanco
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Grant Stotts
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Michel Christopher Frank Shamy
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Dylan Blacquiere
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Ronda Lun
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Prasham Dave
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Aditya Bharatha
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Bijoy K Menon
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Rebecca Thornhill
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Franco Momoli
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Dar Dowlatshahi
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| |
Collapse
|
17
|
Koneru S, Jillella DV, Nogueira RG. Cardio-Cerebral Infarction, Free-Floating Thrombosis and Hyperperfusion in COVID-19. Neurol Int 2021; 13:266-268. [PMID: 34208052 PMCID: PMC8293395 DOI: 10.3390/neurolint13020027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 11/28/2022] Open
Abstract
Cardio-cerebral infarction, which refers to an acute ischemic stroke (AIS) and acute myocardial infarction (AMI) that occur concurrently, is an uncommon phenomenon with a grave prognosis. Intraluminal carotid thrombus (ICT) is an infrequently encountered cause of ischemic stroke and can be associated with an underlying hypercoagulable state. One severe yet prevalent complication of infection with Coronavirus Disease 2019 (COVID-19) is thrombosis from multi-pathway inflammatory responses. Here, we present a unique case of cardio-cerebral infarction, with a free-floating intraluminal thrombus in the left internal carotid artery, in the setting of recent COVID-19 infection, and with the etiology of both events attributed to a COVID-19 hypercoagulable state. CT perfusion imaging also showed an interesting imaging finding of hyperperfusion, which is believed to be a form of dysfunctional cerebral autoregulation.
Collapse
Affiliation(s)
- Sitara Koneru
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA; (S.K.); (R.G.N.)
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
| | - Dinesh V. Jillella
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA; (S.K.); (R.G.N.)
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
- Correspondence:
| | - Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA; (S.K.); (R.G.N.)
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
| |
Collapse
|
18
|
Kim KY, Lee SH. Free-floating and spinning thrombus of the basilar artery: A case report. Medicine (Baltimore) 2021; 100:e25696. [PMID: 34032693 PMCID: PMC8154379 DOI: 10.1097/md.0000000000025696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/08/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Free-floating thrombi in the intracranial artery are rare. We report a case of a free-floating and spinning thrombus caused by turbulent flow distal to the basilar artery stenosis. We compare thrombus changes in a series of images according to time and describe the approach to treatment and thrombosis resolution.</abstract>. PATIENT CONCERNS A 55-year-old man presented to the emergency department on March 21, 2020, with left-sided weakness, bilateral limb ataxia, and a one-day history of dysarthria. Brain magnetic resonance imaging showed multifocal infarctions in the pons and cerebellum with severe basilar stenosis. DIAGNOSES Digital subtraction angiography showed severe focal stenosis. A relatively large oval-shaped mobile thrombus was observed spinning due to turbulent flow at the distal portion of the stenosis. INTERVENTIONS We administered a combination antithrombotic regimen of warfarin and clopidogrel for 50 days. OUTCOMES No thrombus was observed on the third follow-up digital subtraction angiography. LESSONS No previous study has directly observed a mobile thrombus in the intracranial artery using digital subtraction angiography. We used a combination antithrombotic strategy, which was effective after long-term, rather than short-term, use.
Collapse
|
19
|
Sénémaud J, Bounkong G, Seddik L, Jaziri A, Touma J. Management of a Mobile Floating Carotid Plaque Responsible for Calcified Cerebral Emboli: A Double Sword of Damocles. EJVES Vasc Forum 2021; 47:69-72. [PMID: 34228771 PMCID: PMC8077171 DOI: 10.1016/j.ejvssr.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/18/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction The management of a rare case of calcified cerebral emboli associated with a mobile carotid plaque (MCP) is reported and discussed. Report A 76 year old patient presented with sudden weakness of the left lower limb one month ago, which resolved spontaneously. A cerebral magnetic resonance imaging showed recent multiple infarcts in the right middle cerebral artery (MCA) territory. Computed tomography cerebral angiogram (CTA) revealed calcified cerebral emboli (CCE) in the right MCA territory and an isolated calcified embolus in the M3 segment of the right MCA. No calcification was observed in the aorta. The echocardiogram findings were normal. Trans-oesophageal echocardiography did not show aortic or mitral valve calcifications. A cervical duplex ultrasound (DUS) was performed and demonstrated a highly mobile carotid plaque located in the right carotid bifurcation, contrasting with static CTA imaging showing a common calcified plaque, probably because the plaque appeared against the carotid wall during image acquisition. Antiplatelet and anticoagulation therapy were initiated, and carotid endarterectomy was performed on day two to prevent further embolisation. One month follow up including carotid DUS was satisfactory. Discussion A case of mobile carotid plaque responsible for CCE which was diagnosed with DUS dynamic imaging is described, emphasizing the importance of multimodal imaging in such settings. Though the treatment of MCP remains controversial because of the paucity of published cases, carotid endarterectomy was considered to be the safest option to prevent recurrent stroke. Additional clinical data including large series and controlled trials are required to determine the best management of mobile carotid plaques with less than 50% diameter carotid stenosis. A 76-year-old man presented with sudden weakness of the left lower limb one month ago, which spontaneously resolved. Cerebral MRI showed calcified emboli in the right middle cerebral artery territory. Aortic and cervical CTA along with cardiac valves interrogation were negative. Ultrasound imaging allowed the identification of a mobile right carotid plaque responsible of a <50% carotid stenosis. Carotid endarterectomy was performed to prevent stroke recurrence with favorable outcome.
Collapse
Affiliation(s)
- Jean Sénémaud
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France
| | - Gaël Bounkong
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France
| | - Lilia Seddik
- Department of Neurology, Henri Mondor University Hospital, Créteil, France
| | - Asma Jaziri
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France
| | - Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France
| |
Collapse
|
20
|
Denezpi TM, Green RS, Carlson AP. Use of distal protection filter device for rescue mechanical thrombectomy for symptomatic free-floating thrombus of the cervical internal carotid artery. Interv Neuroradiol 2020; 27:440-443. [PMID: 33269972 DOI: 10.1177/1591019920974517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intraluminal free floating thrombus (FFT) of the cervical internal carotid artery (ICA) is a potentially high-risk lesion for recurrent ischemic strokes, with no single optimal treatment established. OBJECTIVE To describe a novel interventional technique for mechanical thrombectomy of intraluminal free floating thrombus using a distal protection filter device and aspiration. METHODS We identified two cases where anticoagulation was contraindicated in patients with intraluminal FFT and minimal underlying stenosis. In both cases, a distal protection device was used to extract the thrombus under proximal flow arrest and aspiration. RESULTS Mechanical thrombectomy was successful in both cases, one with "en bloc" removal of the thrombus and one with piecemeal removal. Neither case showed any residual angiographic stenosis or atherosclerotic disease. CONCLUSION Mechanical thrombectomy using a distal protection device is a novel and technically feasible approach for select cases of cervical intraluminal thrombus. This may represent a therapeutic option in select cases with high risk of anticoagulation and in the unusual subset of younger patients with minimal atherosclerotidc disease.
Collapse
Affiliation(s)
- Taryn M Denezpi
- Department of Neurosurgery, 1104University of New Mexico, Albuquerque, NM, USA
| | - Ross S Green
- Department of Neurosurgery, 1104University of New Mexico, Albuquerque, NM, USA
| | - Andrew P Carlson
- Department of Neurosurgery, 1104University of New Mexico, Albuquerque, NM, USA
| |
Collapse
|
21
|
Papadoulas S, Moulakakis K, Kouri N, Zampakis P, Kakkos SK. Free-Floating Thrombus in the Distal Internal Carotid Artery Causing a Stroke. Int J Angiol 2020; 30:170-172. [PMID: 34054277 DOI: 10.1055/s-0040-1720973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
We present a patient suffering from a stroke with a free-floating thrombus extending up to the distal internal carotid artery. The thrombus was totally resolved after a 2-week anticoagulation regimen without leaving behind any severe residual stenosis in the carotid bulb. The optimal treatment of this rare condition remains uncertain. We report some important treatment strategies that have been used in the literature, emphasizing the anticoagulation as the mainstay of therapy. Immediate surgical and interventional manipulations carry the risk of thrombus dislodgement and embolization and should be considered if there are recurrent symptoms despite medical management.
Collapse
Affiliation(s)
- Spyros Papadoulas
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | | | - Natasa Kouri
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | - Petros Zampakis
- Departement of Radiology, University Hospital of Patras, Patras, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| |
Collapse
|
22
|
|
23
|
Carotid Thrombosis in a Crack Cocaine Smoker Woman. Case Rep Vasc Med 2020; 2020:4894825. [PMID: 33083091 PMCID: PMC7557910 DOI: 10.1155/2020/4894825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 08/19/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction We report a case of stroke in a crack smoker with occlusion of the middle cerebral artery and a large thrombus in the carotid artery. Case Presentation. A 34-year-old female presented with left upper arm weakness, associated with paresthesia with onset of symptoms more than 24 hours before. Angio-RM sequences showed an area of ischemia, with occlusion of the M2 segment of the middle cerebral artery. Carotid ultrasound showed a soft plaque with distal end floating. Anticoagulant treatment was started, and seriated ultrasound evaluations showed its gradual dissolution. Conclusions In atherothromboembolic stroke from carotid thrombosis, repeated ultrasound studies may be useful for either diagnosis and monitoring the efficacy of anticoagulant therapy.
Collapse
|
24
|
George J, Kirkland Z, Lattanzio N, Coleman J, Stone D. To Anticoagulate or Not: Acute Stroke in a COVID-19 Patient With Gastrointestinal Bleed. Cureus 2020; 12:e10554. [PMID: 33101801 PMCID: PMC7575320 DOI: 10.7759/cureus.10554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/19/2020] [Indexed: 11/05/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a member of the coronavirus family, which comprises enveloped positive sense ribonucleic acid (RNA) viruses responsible for pandemic outbreaks including Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV), Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV), and most recently coronavirus disease 2019 (COVID-19). A 30-year-old previously healthy male diagnosed 11 days earlier with COVID-19 presented with right-sided weakness and dysarthria. The patient was found to have an acute left carotid thrombus with embolic multifocal infarcts throughout the left cerebral hemisphere. He was treated acutely with intravenous heparin however developed gastrointestinal bleeding, prompting discontinuation of anticoagulation. Follow up CT angiography 12 days following his stroke demonstrated complete resolution of the thrombus. Since discharge, the patient has been managed with antiplatelet therapy alone with complete neurologic recovery. Large vessel strokes amongst young patients have been a growing concern during the SARS-CoV-2 outbreak. The use of acute therapeutic and prophylactic anticoagulation is based on risk assessment. Albeit, the utility of anticoagulation in COVID-19 patients remains undetermined. Prevention of stroke recurrence is a clinical priority for providers treating large vessel stroke patients. More research is required to establish the effectiveness of anticoagulation and antiplatelet therapy for stroke prevention in patients diagnosed with COVID-19.
Collapse
Affiliation(s)
- Justin George
- Internal Medicine, Sarasota Memorial Hospital, Sarasota, USA
| | - Zachary Kirkland
- Internal Medicine, Sarasota Memorial Hospital, Florida State University, Sarasota, USA
| | - Natalia Lattanzio
- Internal Medicine, Sarasota Memorial Hospital, Florida State University, Sarasota, USA
| | | | - David Stone
- Neurology, Sarasota Memorial Hospital, Sarasota, USA
| |
Collapse
|
25
|
Mohamud AY, Griffith B, Rehman M, Miller D, Chebl A, Patel SC, Howell B, Kole M, Marin H. Intraluminal Carotid Artery Thrombus in COVID-19: Another Danger of Cytokine Storm? AJNR Am J Neuroradiol 2020; 41:1677-1682. [PMID: 32616585 DOI: 10.3174/ajnr.a6674] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is associated with a severe inflammatory response. Inflammation affects atherosclerotic plaque vulnerability and promotes a thrombogenic environment. We report a series of 6 patients with COVID-19 with acute ischemic stroke due to intraluminal carotid artery thrombus presenting during an 8-day period. Six patients were included (5 men) with a mean age of 65.8 years (range, 55-78 years). COVID-19 was diagnosed by detection of Severe Acute Respiratory Syndrome coronavirus 2 in 5 patients and was presumed due to typical clinical and imaging findings in 1 patient. All patients had vascular risk factors including diabetes (83%), hyperlipidemia (100%), and smoking (17%). Four patients presented with large infarcts with initial NIHSS scores of 24-30. During their hospitalization, all patients had elevated D-dimer and C-reactive protein levels, 5 patients had elevated lactate dehydrogenase and ferritin levels, 3 had elevated interleukin-6 levels, and 2 had elevated troponin levels. Inflammation related to COVID-19 may result in rupture of vulnerable atherosclerotic plaques, resulting in thrombosis and acute ischemic stroke.
Collapse
Affiliation(s)
- A Y Mohamud
- From the Departments of Neurology (A.Y.M., M.R., D.M., A.C., B.H.)
| | | | - M Rehman
- From the Departments of Neurology (A.Y.M., M.R., D.M., A.C., B.H.)
| | - D Miller
- From the Departments of Neurology (A.Y.M., M.R., D.M., A.C., B.H.)
| | - A Chebl
- From the Departments of Neurology (A.Y.M., M.R., D.M., A.C., B.H.)
| | | | - B Howell
- From the Departments of Neurology (A.Y.M., M.R., D.M., A.C., B.H.)
| | - M Kole
- Neurosurgery (M.K.), Henry Ford Health System, Detroit, Michigan
| | - H Marin
- Radiology (B.G., S.C.P., H.M.)
| |
Collapse
|
26
|
Settembrini AM, Gronert C, Sebastian Debus E. Acute Hemispheric Stroke: Full Remission Following Surgical Thrombectomy. EJVES Vasc Forum 2020; 47:31-34. [PMID: 33937891 PMCID: PMC8074627 DOI: 10.1016/j.ejvsvf.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Carotid occlusion because of embolisation or as a distal extension of thrombus formation in an ulcerated plaque can be the cause of a devastating stroke, caused by sudden occlusion of the internal carotid artery (ICA). Often, invasive treatments are not an option because of the limited time frame. In rare situations of acute stroke onset and admission to therapy within six hours however, aggressive recanalisation may be considered. This technical note demonstrates surgical transcatheter embolectomy of intra-extra cranial ICA by reducing inflow by placing a clamp on the common carotid artery (CCA) before puncture cranial to the clamp. Patient and technique A 67 year old man was admitted as an emergency seven hours after an acute hemispheric stroke with paraplegia of his left arm and full consciousness. An immediate duplex scan showed more than 90% stenosis of the carotid bifurcation with low echolucent plaque material extending proximally up to the intracranial ICA. CT angiography confirmed the stenosis and a sub-occlusive thrombosis of the ICA up to the M1 segment of the middle cerebral artery (MCA). Because the onset of clinical symptoms was more than six hours previously, the patient was not within the clinical window for endovascular therapy. Following interdisciplinary consensus, surgical over the wire thrombectomy with endarterectomy with complete removal of the thrombus and subsequent thrombo-endarterectomy of the carotid bifurcation and bovine patch plasty was performed. The patient was discharged with statin and antiplatelet treatment on the second post-operative day with full remission of symptoms. Conclusions Immediate surgical transcatheter recanalisation of acute intra-extracerebral ICA thrombus with inflow reduction can be a valid procedure to improve cerebral circulation, leading to full remission of stroke symptoms.
Collapse
Affiliation(s)
- Alberto M Settembrini
- Fondazione IRCCS Ca'Granda Policlinico, Milan, Italy.,Department for Vascular Medicine, Vascular Surgery, Angiology and Endovascular Therapy, University Heart and Vascular Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Catharina Gronert
- Department for Vascular Medicine, Vascular Surgery, Angiology and Endovascular Therapy, University Heart and Vascular Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department for Vascular Medicine, Vascular Surgery, Angiology and Endovascular Therapy, University Heart and Vascular Centre, Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
27
|
Carotid Stenting as Definitive Treatment for Free Floating Thrombus-Review of 7 Cases. Clin Neuroradiol 2020; 31:449-455. [PMID: 32221623 PMCID: PMC8211580 DOI: 10.1007/s00062-020-00898-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/04/2020] [Indexed: 11/13/2022]
Abstract
Background and Purpose Free floating thrombus (FFT) is a rare condition. The optimal treatment strategy is yet to be determined although medical management with anticoagulation is the mainstay. This article reports experience of treating FFT with carotid stenting. Methods A retrospective analysis of a prospectively maintained database was performed to identify all patients with FFT treated with carotid stenting. For each patient the demographic data, clinical presentation, location of the thrombus, type of stent and use of adjunctive devices, e.g. balloon guide catheters, clinical and radiological follow-up information as well as complications were recorded. Results A total of 7 patients, 4 female, with mean age of 55.6 ± 14.5 years were identified. The median National Institutes of Health Stroke Scale (NIHSS) was 7 (range 0–13) at presentation. Free floating thrombus was seen on the left in the majority of cases (n = 6, 85.7%). None of the patients had intracranial large vessel occlusion. The FFT was located in the CCA in 2 cases (28.6%) and the proximal ICA in the remaining 5 cases (71.4%). The Wallstent was used in 5 patients and a cGuard stent used in 2 patients. In 1 patient 2 overlapping stents were used but a single stent was used in the remaining patients. In 6 cases a distal filter wire was used and in 2 cases a balloon guide catheter was used as embolic protection. There were no intraoperative complications and no cases of distal clot migration or intracranial large vessel occlusion during the procedure. At last follow-up (n = 7) 6 patients were recorded as modified Rankin Scale (mRS) ≤2 and 1 patient was mRS 3. Conclusion Free floating thrombus of the carotid arteries can be managed with stenting.
Collapse
|
28
|
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3416] [Impact Index Per Article: 683.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
Collapse
|
29
|
Singh RJ, Chakraborty D, Dey S, Ganesh A, Al Sultan AS, Eesa M, Wong JH, Goyal M, Hill MD, Menon BK. Intraluminal Thrombi in the Cervico-Cephalic Arteries. Stroke 2019; 50:357-364. [PMID: 30595130 DOI: 10.1161/strokeaha.118.023015] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Intraluminal thrombus (ILT) is an uncommon finding among patients with ischemic stroke. We report clinical-imaging manifestations, treatment offered, and outcome among patients with ischemic stroke/transient ischemic attack and ILT in their cervico-cephalic arteries. Methods- Sixty-one of 3750 consecutive patients with acute ischemic stroke/transient ischemic attack (within 24 hours of onset) and ILT on initial arch-to-vertex computed tomography angiography from April 2015 through September 2017 constituted the prospective study cohort. Functional outcome was assessed using the modified Rankin Scale score with functional independence at discharge defined as modified Rankin Scale score ≤2. Results- Prevalence of ILT on computed tomography angiography was 1.6% (95% CI, 1.2%-2.1%). Median age was 67 years (interquartile range, 56-73), and 40 subjects (65%) were male. The initial clinical presentation included transient ischemic attack in 12 (20%) and stroke in 49 patients (80%); most strokes (76%) were mild (National Institutes of Health Stroke Scale ≤5). The most common ILT location was cervical carotid or vertebral artery (n=48 [79%]) followed by intracranial (n=11 [18%]) and tandem lesions (n=2 [3%]). The most common initial treatment strategy was combination antithrombotics (heparin with single antiplatelet agent) among 57 patients (93%). Follow-up computed tomography angiography (n=59), after a median 6 days (interquartile range 4-10 days), revealed thrombus resolution in 44 patients (75% [completely in 27%]). Twenty four of 30 patients (80%) with >50% residual carotid stenosis underwent carotid revascularization (endarterectomy in 15 and stenting in 9 patients) without peri-procedural complications a median of 9 days after symptom onset. In-hospital stroke recurrence occurred in 4 patients (6.6%). Functional independence was achieved in 46 patients (75%) at discharge. Conclusions- Patients presenting with acute stroke/transient ischemic attack with ILT on baseline imaging have a favorable clinical course in hospital with low stroke recurrence, high rate of thrombus resolution, and good functional outcome when treated with combination antithrombotic therapy.
Collapse
Affiliation(s)
- Ravinder-Jeet Singh
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Debabrata Chakraborty
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Sadanand Dey
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Abdulaziz Sulaiman Al Sultan
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Muneer Eesa
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - John H Wong
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Michael D Hill
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Bijoy K Menon
- From the Calgary Stroke Program, The Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada
| |
Collapse
|
30
|
Fridman S, Lownie SP, Mandzia J. Diagnosis and management of carotid free-floating thrombus: A systematic literature review. Int J Stroke 2019; 14:247-256. [DOI: 10.1177/1747493019828554] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background There is no consensus regarding the management of carotid free-floating thrombi in patients with acute ischemic stroke and transient ischemic attack. Aims This systematic review aims to (1) describe the current imaging methods for diagnosis of carotid free-floating thrombi and its associated risk factors, (2) estimate the proportion of carotid free-floating thrombi diagnosed in stroke patients, (3) estimate the proportion of carotid free-floating thrombi patients treated medically and surgically, and (4) evaluate 30-day outcomes. Methods We searched MEDLINE, EMBASE, and manually for references reporting carotid free-floating thrombi from 1960 until June 2017. We estimated the frequency of carotid free-floating thrombi and evaluated 30-day outcomes using Cox regression. We defined the timing of surgical intervention as early (less than 72 h) and delayed (more or equal to 72 h). Summary of review We retrieved 525 carotid free-floating thrombi cases from 58 case series and 83 case reports. Carotid free-floating thrombi were present in 1.53% of stroke patients. Carotid free-floating thrombi diagnosis was made by digital subtraction angiography (38.1%), carotid duplex ultrasound (29.5%), and computed tomography angiography (29.5%). The 30-day risk of transient ischemic attack, silent brain ischemia, any stroke or death was 17.1%. In multivariate analyses, there were no differences in outcome for any anticoagulation regime or timing of revascularization procedure. Conclusions The diagnosis of carotid free-floating thrombi is more common due to the increased use of early noninvasive vascular imaging in transient ischemic attack and stroke. It poses a high short-term risk of stroke and death, but there is as yet no established treatment. The low quality of evidence in the carotid free-floating thrombi literature limits the interpretation of our results and warrants a large-scale prospective cohort study in carotid free-floating thrombi.
Collapse
Affiliation(s)
- Sebastian Fridman
- Department of Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada
| | - Stephen P Lownie
- Department of Clinical Neurological Sciences, Division of Neurosurgery, University of Western Ontario, London, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada
| |
Collapse
|
31
|
The Thrombolytic Effect of Diagnostic Ultrasound-Induced Microbubble Cavitation in Acute Carotid Thromboembolism. Invest Radiol 2018; 52:477-481. [PMID: 28383307 DOI: 10.1097/rli.0000000000000369] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute ischemic stroke is often due to thromboembolism forming over ruptured atherosclerotic plaque in the carotid artery (CA). The presence of intraluminal CA thrombus is associated with a high risk of thromboembolic cerebral ischemic events. The cavitation induced by diagnostic ultrasound high mechanical index (MI) impulses applied locally during a commercially available intravenous microbubble infusion has dissolved intravascular thrombi, especially when using longer pulse durations. The beneficial effects of this in acute carotid thromboembolism is not known. MATERIALS AND METHODS An oversized balloon injury was created in the distal extracranial common CA of 38 porcine carotid arteries. After this, a 70% to 80% stenosis was created in the mid common CA proximal to the injury site using partial balloon inflation. Acute thrombotic CA occlusions were created just distal to the balloon catheter by injecting fresh autologous arterial thrombi. After angiographic documentation of occlusion, the common carotid thrombosis was treated with either diagnostic low MI imaging alone (0.2 MI; Philips S5-1) applied through a tissue mimicking phantom (TMP) or intermittent diagnostic high MI stable cavitation (SC)-inducing impulses with a longer pulse duration (0.8 MI; 20 microseconds' pulse duration) or inertial cavitation (IC) impulses (1.2 MI; 20 microseconds' pulse duration). All treatment times were for 30 minutes. Intravenous ultrasound contrast (2% Definity; Lantheus Medical) was infused during the treatment period. Angiographic recanalization in 4 intracranial and extracranial vessels downstream from the CA occlusion (auricular, ascending pharyngeal, buccinator, and maxillary) was assessed with both magnetic resonance 3-dimensional time-of-flight and phase contrast angiography. All magnetic resonance images were interpreted by an independent neuroradiologist using the thrombolysis in cerebral infarction (TICI) scoring system. RESULTS By phase contrast angiography, at least mild recanalization (TICI 2a or higher) was seen in 64% of downstream vessels treated with SC impulses compared with 33% of IC treated and 29% of low MI alone treated downstream vessels (P = 0.001), whereas moderate or complete recanalization (TICI 2b or higher) was seen in 39% of SC treated vessels compared with 10% IC treated and 21% of low MI alone treated vessels (P = 0.001). CONCLUSIONS High MI 20-microsecond pulse duration impulses during a commercial microbubble infusion can be used to recanalize acutely thrombosed carotid arteries and restore downstream flow without anticoagulants. However, this effect is only seen with SC-inducing impulses and not at higher mechanical indices, when a paradoxical reversal of the thrombolytic effect is observed. Diagnostic ultrasound-induced SC can be a nonsurgical method of dissolving CA thrombi and preventing thromboembolization.
Collapse
|
32
|
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e46-e110. [PMID: 29367334 DOI: 10.1161/str.0000000000000158] [Citation(s) in RCA: 3520] [Impact Index Per Article: 586.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates. METHODS Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format. RESULTS These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. CONCLUSIONS These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
Collapse
|
33
|
Ludwig DR, Austin MJ, Wallace AN, Kamran M, Kansagra AP, Osbun JW, Cross DT, Moran CJ. Isolated Internal Carotid Artery Thrombus and Cerebral Infarction in a Patient with Necrotizing Pancreatitis: Case Report. J Stroke Cerebrovasc Dis 2017; 27:e1-e4. [PMID: 28893576 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/12/2017] [Indexed: 11/19/2022] Open
Abstract
Isolated internal carotid artery (ICA) thrombus in the absence of underlying atherosclerotic disease is a rare entity. We report a case of a patient presenting with right arm weakness, slurred speech, and altered mental status in the setting of acute on chronic pancreatitis. The patient was found to have scattered left cerebral hemisphere cortical infarctions, and catheter angiography confirmed the presence of intraluminal left ICA thrombus, with no evidence of atherosclerotic disease in the cervical or intracranial vasculature. Further workup also demonstrated the presence of anemia of chronic disease. The patient was initiated on anticoagulation, and follow-up imaging demonstrated a complete resolution of the left ICA thrombus. In the reported case, coagulopathy in the setting of acute on chronic pancreatitis was presumably the primary etiology. Anemia of chronic disease, related to a proinflammatory state, may also play a contributory role.
Collapse
Affiliation(s)
- Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri.
| | - Matthew J Austin
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Adam N Wallace
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Mudassar Kamran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|
34
|
Mahajan A, Goel G, Das B. Critical carotid bulb stenosis with intraluminal thrombus: Importance of delayed carotid stenting. J Neuroradiol 2017; 45:62-63. [PMID: 28964925 DOI: 10.1016/j.neurad.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 08/17/2017] [Accepted: 09/05/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Anshu Mahajan
- Neurointervention surgery, Institute of Neuroscience, Medanta, The Medicity, Gurgaon, 122001 Haryana, India.
| | - Gaurav Goel
- Neurointervention surgery, Institute of Neuroscience, Medanta, The Medicity, Gurgaon, 122001 Haryana, India.
| | - Biplab Das
- Neurointervention surgery, Institute of Neuroscience, Medanta, The Medicity, Gurgaon, 122001 Haryana, India.
| |
Collapse
|
35
|
Emergent vs. elective stenting of carotid stenosis with intraluminal carotid thrombus. J Neuroradiol 2017; 44:254-261. [DOI: 10.1016/j.neurad.2017.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/12/2017] [Accepted: 02/09/2017] [Indexed: 11/20/2022]
|
36
|
Stein L, Liang JW, Weinberger J. Resolution of Occlusive Carotid Artery Thrombus Treated with Anticoagulation as Demonstrated on Duplex Ultrasonography. J Neuroimaging 2017; 27:376-380. [PMID: 28488811 DOI: 10.1111/jon.12447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/12/2017] [Accepted: 04/12/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE While the majority of cerebral ischemic events due to carotid occlusive disease result from atherosclerotic plaque rupture, intraluminal carotid artery thrombus occasionally occurs in patients without preexisting carotid atherosclerosis. Identification of nonatherosclerotic thrombus as the cause of the carotid occlusive disease can obviate the need for an interventional procedure, and resolution of thrombus can be monitored with B-mode duplex ultrasonography. METHODS We reviewed 3 patients treated on The Mount Sinai Hospital Stroke Unit with anticoagulation for nonatherosclerotic carotid thrombi and followed with serial Doppler ultrasonogrpahy for resolution of thrombus. RESULTS Occlusive carotid thrombus was successfully treated in all 3 patients with systemic anticoagulation. B-mode duplex ultrasonography allowed for demonstration of resolving thrombus. CONCLUSION Differentiation between a stenotic plaque and occlusive thrombus can be achieved by ultrasonographic analysis of thrombus morphology, attachment site potential, and characteristics of a resolving thrombus. Systemic anticoagulation can safely and effectively eliminate the risk for future embolization and complete occlusion of the carotid artery in patients who present with transient ischemic events or completed infarcts of small size.
Collapse
Affiliation(s)
- Laura Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John W Liang
- Divisions of Cerebrovascular Disease, Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA.,Department of Neurology, Mount Sinai Downtown, New York, NY
| | - Jesse Weinberger
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
37
|
Sakai S, Uwatoko T, Ishitsuka K, Sugimori H. [A case of internal carotid thrombus associated with brain infarction]. Rinsho Shinkeigaku 2017; 57:14-20. [PMID: 28025410 DOI: 10.5692/clinicalneurol.cn-000951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Shota Sakai
- Department of Cerebrovascular Medicine, Saga-ken Medical Centre Koseikan
| | | | | | | |
Collapse
|
38
|
Roshal D. Embolic Stroke due to a Common Carotid Artery Thrombus in a Young Patient with Severe Iron-Deficiency Anemia without Thrombocytosis. Case Rep Neurol Med 2016; 2016:6920303. [PMID: 27752375 PMCID: PMC5056274 DOI: 10.1155/2016/6920303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/23/2016] [Accepted: 09/08/2016] [Indexed: 11/17/2022] Open
Abstract
This case report describes a 41-year-old previously healthy male who presented with stuttering transient ischemic symptoms and radiographic evidence of a left common carotid artery thrombus as well as acute and subacute ischemic infarcts in the left middle cerebral artery territory. An exhaustive stroke work-up did not provide a plausible etiology for his symptoms. His complete blood count and iron studies, however, revealed evidence of severe iron-deficiency anemia without reactive thrombocytosis. His stool guaiac test was positive. He was discharged home on oral antithrombotic agents and aggressive iron replacement therapy with a plan for repeat vascular imaging in 3 months and a colonoscopy. This case report suggests that severe iron-deficiency anemia with or without reactive thrombocytosis should be viewed as a possible hematologic condition associated with thrombotic tendencies and a risk factor for ischemic stroke, especially in young adults. Aggressive iron supplementation and short-term antithrombotic therapy with follow-up vascular imaging are a reasonable treatment for these patients.
Collapse
Affiliation(s)
- David Roshal
- Department of Neurology, Kennedy University Hospital, Stratford, USA
| |
Collapse
|
39
|
Scharf EL, Fugate JE, Hocker SE. Extensive Mobile Thrombus of the Internal Carotid Discovered After Intravenous Thrombolysis: What Do I Do Now? Neurohospitalist 2016; 7:96-99. [PMID: 28400904 DOI: 10.1177/1941874416663280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.
Collapse
|
40
|
Ellis JA, Banu M, Hossain SS, Singh-Moon R, Lavine SD, Bruce JN, Joshi S. Reassessing the Role of Intra-Arterial Drug Delivery for Glioblastoma Multiforme Treatment. JOURNAL OF DRUG DELIVERY 2015; 2015:405735. [PMID: 26819758 PMCID: PMC4706947 DOI: 10.1155/2015/405735] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/16/2015] [Indexed: 12/16/2022]
Abstract
Effective treatment for glioblastoma (GBM) will likely require targeted delivery of several specific pharmacological agents simultaneously. Intra-arterial (IA) delivery is one technique for targeting the tumor site with multiple agents. Although IA chemotherapy for glioblastoma (GBM) has been attempted since the 1950s, the predicted benefits remain unproven in clinical practice. This review focuses on innovative approaches to IA drug delivery in treating GBM. Guided by novel in vitro and in vivo optical measurements, newer pharmacokinetic models promise to better define the complex relationship between background cerebral blood flow and drug injection parameters. Advanced optical technologies and tracers, unique nanoparticles designs, new cellular targets, and rational drug formulations are continuously modifying the therapeutic landscape for GBM. Personalized treatment approaches are emerging; however, such tailored approaches will largely depend on effective drug delivery techniques and on the ability to simultaneously deliver multidrug regimens. These new paradigms for tumor-selective drug delivery herald dramatic improvements in the effectiveness of IA chemotherapy for GBM. Therefore, within this context of so-called "precision medicine," the role of IA delivery for GBM is thoroughly reassessed.
Collapse
Affiliation(s)
- Jason A. Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Matei Banu
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Shaolie S. Hossain
- Department of Molecular Cardiology, Texas Heart Institute, Houston, TX 77030, USA
| | - Rajinder Singh-Moon
- School of Engineering and Applied Science, Columbia University, New York, NY 10032, USA
| | - Sean D. Lavine
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Jeffrey N. Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Shailendra Joshi
- Department of Anesthesiology, Columbia University Medical Center, New York, NY 10032, USA
| |
Collapse
|
41
|
Mees B, Robinson D, Fell G, Chu P. Symptomatic free-floating carotid thrombus extending to the skull base. Neurol Clin Pract 2014; 4:536-537. [PMID: 29443147 DOI: 10.1212/cpj.0000000000000070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Barend Mees
- Vascular Unit, Austin Health, Heidelberg, Victoria, Australia (BM, DR, GF, PC) and Department of Vascular Surgery, MUMC+, Maastricht, The Netherlands (BM)
| | - Domenic Robinson
- Vascular Unit, Austin Health, Heidelberg, Victoria, Australia (BM, DR, GF, PC) and Department of Vascular Surgery, MUMC+, Maastricht, The Netherlands (BM)
| | - Gary Fell
- Vascular Unit, Austin Health, Heidelberg, Victoria, Australia (BM, DR, GF, PC) and Department of Vascular Surgery, MUMC+, Maastricht, The Netherlands (BM)
| | - Peter Chu
- Vascular Unit, Austin Health, Heidelberg, Victoria, Australia (BM, DR, GF, PC) and Department of Vascular Surgery, MUMC+, Maastricht, The Netherlands (BM)
| |
Collapse
|
42
|
Gülcü A, Gezer NS, Men S, Öz D, Yaka E, Öztürk V. Management of free-floating thrombus within the arcus aorta and supra-aortic arteries. Clin Neurol Neurosurg 2014; 125:198-206. [PMID: 25173962 DOI: 10.1016/j.clineuro.2014.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/18/2014] [Accepted: 08/07/2014] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Clinical management strategy and the best treatment option of free floating thrombus (FFT), detected in patients with acute ischemic cerebrovascular diseases is still uncertain due to the rarity of these conditions. Recent studies emphasize that FFT within cerebral vessels may not be a surgical emergency since complete dissolution without any further neurologic progression occurred in 86% of patients treated medically. The aim of this study was to investigate the effect of medical treatment on the fate of thrombus and the clinical status in acute cerebrovascular event patients with detected FFT in the artery feeding the compromised brain territory at the time of diagnosis. MATERIALS AND METHODS We have retrospectively reviewed the initial and follow up computed tomography angiography, diffusion-weighted magnetic resonance imaging examinations of 37 acute ischemic stroke patients with detected FFT and treated medically. The patients were evaluated for any change of the FFT, residual stenosis after the FFT shrunk or disappeared and neurologic outcome. RESULTS FFT was located in cervical carotid artery, intracranial artery and arcus aorta in 23, 6 and 5 of the patients respectively. Dissection accompanied the FFT in 3 patients. Recanalization was maintained in 34 patients however, three of them suffered from new infarctions. A total occlusion was detected in three patients. Two of them had new infarcts while one was stable during clinical follow-up period. CONCLUSION The results of our retrospective study have shown that FFT in the proximal aorta and supra-aortic arteries tend to resolve with anticoagulant and/or antiplatelet treatment without causing recurrent adverse events in most of the cases. Furthermore, resolution of the clot seems to provide a safer ground for a recanalization procedure like stenting or endarterectomy if needed.
Collapse
Affiliation(s)
- Aytaç Gülcü
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Naciye Sinem Gezer
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Süleyman Men
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Didem Öz
- Department of Neurology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Erdem Yaka
- Department of Neurology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Vesile Öztürk
- Department of Neurology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| |
Collapse
|
43
|
Jaberi A, Lum C, Stefanski P, Thornhill R, Iancu D, Petrcich W, Momoli F, Torres C, Dowlatshahi D. Computed tomography angiography intraluminal filling defect is predictive of internal carotid artery free-floating thrombus. Neuroradiology 2013; 56:15-23. [DOI: 10.1007/s00234-013-1298-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/22/2013] [Indexed: 01/11/2023]
|
44
|
Iron-Deficiency Anemia Leading to Transient Ischemic Attacks due to Intraluminal Carotid Artery Thrombus. Case Rep Neurol Med 2013; 2013:813415. [PMID: 24109530 PMCID: PMC3787622 DOI: 10.1155/2013/813415] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 08/14/2013] [Indexed: 11/30/2022] Open
Abstract
Reactive thrombocytosis secondary to iron-deficiency anemia (IDA) is a rare but recognized cause of stroke. We report the case of a patient with iron-deficiency anemia presenting with multiple transient ischemic attacks (TIA) due to intraluminal thrombus of an internal carotid artery. The putative mechanisms underlying anemia and stroke syndromes are not completely understood, and it is believed that iron deficiency may cause ischemic stroke by several potential mechanisms. Thrombocytosis is often associated with iron deficiency, and microcytosis produces a reduction in the red cell deformability and could produce a hypercoagulable state. The platelet count and function observed in iron-deficiency anemia could act synergistically to promote thrombus formation, especially in the setting of an underlying atherosclerotic disease. The presence of floating thrombus in a patient with clinical and MRI evidence of stroke represents a significant therapeutic dilemma and requires immediate decision about treatment.
Collapse
|