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

Hiroshi Yamagami, Kazuo Kitagawa, Toshiho Ohtsuki, Masayasu Matsumoto, Masatsugu Hori
2005 Circulation Journal  
ntraluminal thrombus in the carotid artery is identified in less than 3% of patients who undergo cerebral angiography for investigation of ischemic cerebrovascular symptoms. 1,2 Carotid thrombi are usually associated with atherosclerotic stenotic lesions in the carotid bifurcation. To prevent recurrent stroke in these patients, the inhibition of distal embolism must be successful in addition to the resolution of intraluminal thrombus and surgical manipulation for stenotic lesion. The risk of
more » ... ion. The risk of distal embolism can be evaluated as a microembolic signals (MES) in transcranial Doppler (TCD) sonography. 3 Previous studies recommended anticoagulation for the resolution of intraluminal thombus, however, the significance of antiplatelet drugs has been rarely evaluated. 4 We report a patient with recurrent ischemic stroke and retinal artery embolism in whom intraluminal thrombus in the carotid siphon and frequent MES in the middle cerebral artery (MCA) were successfully resolved with combination therapy of anticoagulant and antiplatelet drugs. A 54-year-old man experienced right-hand numbness and difficulties with reading and writing in May 2000. A brain computed tomography revealed a low-density area with partial high density in the left parieto-temporal lobe. On admission to hospital in June, the patient's physical examination was normal and neurological examination revealed right-lower quadrantanopsia, slight right hemiparesis and sensory aphasia. Three weeks later, the patient suddenly developed a loss of vision in the left eye and became confused. Funduscopic examinations revealed branch occlusion of the left retinal artery. Laboratory tests showed the following abnormalities: thrombin-antithrombin III complex, 4.48 g/L (normal range, 0-3.0); D-dimer, 1.18 g/ml (0-0.50); -thromboglobulin, 473 ng/ml (<50); and platelet factor-4, 115 ng/ml (<20). Prothrombin time, activated partial thrombin time (APTT), protein S and C, anticardiolipin antibody and lupus anticoagulant were all within normal limits. Diffusion-weighted magnetic resonance imaging (MRI) showed small hyperintensity regions scattered within the left MCA territory (Fig 1A) . Magnetic resonance angiography (MRA) revealed intraluminal thrombus in the cavernous portion of the left internal carotid artery (Fig 1C) . TCD monitoring detected 53 MES over 30 min in the left MCA. To determine the embolic source, the following examinations were performed and showed normal findings: electrocardiogram (ECG), Holter ECG and transthoracic echocardiography. Carotid ultrasonography showed no atheromatous lesion in the carotid bifurcation. In transesophageal echocardiography (TEE), thrombus in the left atrium or patent foramen ovale was not detected, but an A 54-year-old-man experienced serial ischemic embolic strokes and retinal artery embolism in the left carotid territory. In the acute phase, intraluminal thrombus in the left carotid siphon and frequent microembolic signals (MES) in the left middle cerebral artery were detected with magnetic resonance angiography (MRA) and transcranial Doppler (TCD). The patient was initially treated with only heparin for 3 days; however, more than 30 MES per 30 min were still detected. After adding ticlopidine as an antiplatelet therapy, MES were suppressed completely. After starting combination therapy of heparin (later warfarin) and ticlopidine, repeated MRA confirmed resolution of carotid thrombus and ischemic stroke did not recur. For management of intraluminal thrombus in the carotid artery, MES with TCD was useful in evaluating the risk of distal embolism. Combination treatment with anticoagulants and ticlopidine can both resolve the thrombus and prevent distal embolism. (Circ J 2005; 69: 1147 -1149
doi:10.1253/circj.69.1147 pmid:16127202 fatcat:apmhfvtyknfzvfc3ch5ydyy4va