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Nagao Y, Inatomi Y, Naganuma M, Yonehara T, Nakajima M. Carotid Free-Floating Thrombus Treated With a Combined Technique Using Embotrap III for Distal Protection. Cureus 2024; 16:e53775. [PMID: 38465097 PMCID: PMC10921119 DOI: 10.7759/cureus.53775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Carotid free-floating thrombus (FFT) is a rare condition in patients with acute ischemic stroke. Recently, endovascular therapy for carotid FFT has been increasingly reported, but the strategy has not yet been established. We report a case of an acute stroke patient with a carotid FFT, who was successfully treated with a combination of the direct aspiration first-pass technique (ADAPT) and the Embotrap III (Cerenovus, Irvine, CA), specifically designed to prevent distal embolization. We propose the utility of distal embolic protection with Embotrap III for the treatment of patients with carotid FFT. A 71-year-old man who presented with sudden left hemiparesis was admitted to our hospital. Ultrasonography on admission revealed severe stenosis and an FFT at the origin of the right internal carotid artery. Thrombectomy with an aspiration catheter, accompanied by a stent retriever with distal basket Embotrap III for distal protection, was performed. After the FFT was safely aspirated, a carotid Wallstent (Boston Scientific, Marlborough, MA) was deployed in the stenosis. Follow-up ultrasonography showed neither FFT nor in-stent protrusion. The patient did not experience recurrence, as per clinical or radiological findings, and was discharged on day 11 without any neurological deficits. Embotrap III may be useful for a patient with a carotid FFT as distal protection during mechanical thrombectomies.
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Affiliation(s)
| | | | | | | | - Makoto Nakajima
- Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, JPN
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2
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Wu J, Zou Y, Meng X, Fan Z, van der Geest R, Cui F, Li J, Zhang T, Zhang F. Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography associated with the risk of acute ischemic stroke occurrence. Eur Radiol 2023:10.1007/s00330-023-10404-w. [PMID: 38001250 DOI: 10.1007/s00330-023-10404-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES Carotid atherosclerosis plays an essential role in the occurrence of ischemic stroke. This study aimed to investigate whether a larger burden of napkin-ring sign (NRS) plaques on cervicocerebral computed tomography angiography (CTA) increased the risk of acute ischemic stroke (AIS). METHODS This retrospective, single-center, cross-sectional study enrolled patients with NRS plaques identified in the subclavian arteries, brachiocephalic trunk, carotid arterial system, and vertebrobasilar circulation on contrast-enhanced cervicocerebral CTA. Patients were divided into AIS and non-AIS groups based on imaging within 12 h of symptom onset. Univariate and multivariate logistic regression analyses were performed to determine the risk factor of AIS occurrence. RESULTS A total of 202 patients (66.72 years ± 8.97, 157 men) were evaluated. Plaques with NRS in each subject of the AIS group (N = 98) were significantly more prevalent than that in the control group (N = 104) (1.96 ± 1.17 vs 1.41 ± 0.62). In the AIS group, there were substantially more NRS plaques on the ipsilateral side than contralateral side (1.55 ± 0.90 vs. 0.41 ± 0.66). NRS located on the ipsilateral side of the AIS showed an area under the receiver curve (AUC) of 0.86 to identify ischemic stroke. NRS plaque amounts were an independent risk factor for AIS occurrence (odds ratio, 1.86) after adjusting for other factors. CONCLUSIONS Increased incidence of napkin-ring sign plaques on cervicocerebral CTA was positively associated with AIS occurrence, which could aid in detecting asymptomatic atherosclerotic patients at high risk of AIS in routine screening or emergency settings. CLINICAL RELEVANCE STATEMENT Napkin-ring sign plaque provides an important imaging target for estimating acute ischemic stroke risk and identifying high-risk patients in routine screening or emergency settings, so that timely anti-atherosclerotic therapy can be used for prevention. KEY POINTS • This cross-sectional study investigated the association between high-risk carotid artery plaques and acute ischemic stroke. • Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography is positively associated with acute ischemic stroke occurrence. • Napkin-ring signs help identify risky patients prone to acute ischemic stroke to facilitate prevention.
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Affiliation(s)
- Jingping Wu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Ying Zou
- Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Xiao Meng
- Department of Nutrition, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Zhaoyang Fan
- Department of Radiology, University of Southern California, Los Angeles, CA, USA
| | - Rob van der Geest
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fang Cui
- Department of Neurology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Jianyong Li
- Department of Neurology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Tengyuan Zhang
- Department of Neurology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Fan Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
- Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China.
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3
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Pan J, Wang JW, Cai XF, Lu KF, Wang ZZ, Guo SY. Intracranial large artery embolism due to carotid thrombosis caused by a neck massager: A case report. World J Clin Cases 2023; 11:2489-2495. [PMID: 37123320 PMCID: PMC10130990 DOI: 10.12998/wjcc.v11.i11.2489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/02/2023] [Accepted: 03/20/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND There are few reported cases of intracranial large artery embolism due to carotid thrombosis caused by a neck massager. Herein we report such a case.
CASE SUMMARY A 49-year-old woman presented with left limb weakness and dysarthria after a history of neck massage for 1 mo. Neurological examination showed left central facial paralysis and left hemiparesis with a National Institutes of Health Stroke Scale score of 12. Brain magnetic resonance imaging revealed restricted diffusion on diffusion-weighted imaging in the right parietal and temporal lobes. Computed tomography angiography (CTA) indicated M3 segment embolism of the right middle cerebral artery. Neck CTA revealed thrombosis of the bilateral common carotid arteries. Carotid ultrasound showed thrombosis in the bilateral common carotid arteries (approximately 2 cm below the proximal end of the carotid sinus), and contrast-enhanced ultrasound did not suggest enhancement. No hypertension, diabetes, heart disease, vasculitis, or thrombophilia was found after admission. After 1 wk of treatment with aspirin 200 mg and atorvastatin 40 mg, a carotid ultrasound reexamination showed that the thrombosis had significantly reduced.
CONCLUSION Neck massager may cause carotid artery thrombosis.
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Affiliation(s)
- Jie Pan
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou 310014, Zhejiang Province, China
| | - Jing-Wen Wang
- Department of Neurology, Tiantai People's Hospital of Zhejiang Province, Taizhou 317200, Zhejiang Province, China
| | - Xiao-Feng Cai
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou 310014, Zhejiang Province, China
| | - Ke-Feng Lu
- Department of Ultrasound Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310014, Zhejiang Province, China
| | - Zhen-Zhen Wang
- Department of Ultrasound Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310014, Zhejiang Province, China
| | - Shun-Yuan Guo
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou 310014, Zhejiang Province, China
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Wang P, Wang Z, Pan J, Lu K, Sun L, Geng Y. Case report: Ultrasound-Assisted endovascular therapy for carotid artery floating thrombus. Front Cardiovasc Med 2022; 9:961760. [PMID: 36187000 PMCID: PMC9519131 DOI: 10.3389/fcvm.2022.961760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background Carotid free-floating thrombus (CFFT) is a rare but sometimes emergent condition. There has been controversy over the optimal treatment strategy. Emerging evidence suggests that endovascular thrombectomy (EVT) may be an alternative to surgery. Accurate alignment of the aspiration catheter and thrombus during EVT is critical but has, so far, remained unresolved. Case summary This is a rare case of CFFT presenting with acute right-sided facial droop and moderate dysarthria in a 77-year-old man. He was in sinus rhythm with a blood pressure of 110/82 mmHg. Both non-contrast CT (NCCT) and head CT angiography (CTA) were unremarkable, while whole-brain CT perfusion (WB-CTP) suggested left hemisphere core infarction. Delayed imaging of the left internal carotid system by 4D-CTA suggested severe proximal obstructive disease, as confirmed by carotid CTA and ultrasonography. The initial two aspirations under DSA were invalid due to the challenging anatomical angle between the thrombus and the catheter. The success of CFFT removal was achieved with a pressure-assisted ultrasound-guided approach that helps to compress the catheter tip toward the thrombus. Conclusion We innovatively report a successful ultrasound-guided EVT for CFFT. Ultrasound assistance can provide quick and effective guidance and may guide tailored aspirations during EVT.
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Affiliation(s)
- Peng Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhenzhen Wang
- Ultrasound Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Jie Pan
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Kefeng Lu
- Ultrasound Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Litao Sun
- Ultrasound Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
- *Correspondence: Litao Sun
| | - Yu Geng
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
- Yu Geng
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Lu M, Zhang L, Yuan F, Peng P, Zhang H, Liu S, He Y, Cai J, Zhao X. Comparison of carotid atherosclerotic plaque characteristics between symptomatic patients with transient ischemic attack and stroke using high-resolution magnetic resonance imaging. BMC Cardiovasc Disord 2022; 22:190. [PMID: 35448952 PMCID: PMC9026690 DOI: 10.1186/s12872-022-02624-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/07/2022] [Indexed: 12/25/2022] Open
Abstract
Background This study aimed to compare the characteristics of carotid plaques between patients with transient ischemic attack (TIA) and ischemic stroke using magnetic resonance (MR) imaging. Methods Patients with a recent ischemic stroke or TIA who exhibited atherosclerotic plaques of carotid arteries in the symptomatic sides determined by MR vessel wall imaging were recruited. The plaque morphology and compositions including intraplaque hemorrhage (IPH), lipid-rich necrotic-core (LRNC) and calcification were compared between TIA and stroke patients. Logistic regression was performed to relate the plaque characteristics to the types of ischemic events. Results A total of 270 patients with TIA or ischemic stroke were recruited. Stroke patients had a significantly higher prevalence of diabetes (42.2% vs. 28.2%, p = 0.021), greater mean wall area (35.1 ± 10.1 mm2 vs. 32.0 ± 7.7 mm2, p = 0.004), mean wall thickness (1.3 ± 0.2 mm vs. 1.2 ± 0.2 mm, p = 0.001), maximum normalized wall index (NWI)(63.9% ± 6.0% vs. 62.2% ± 5.9%, p = 0.023) and %volume of LRNC (9.7% ± 8.2% vs. 7.4% ± 7.9%, p = 0.025) in the carotid arteries compared to those with TIA. After adjustment for clinical factors, above characteristics of carotid arteries were significantly associated with the type of ischemic events. After further adjustment for maximum NWI, this association remained statistically significant (OR, 1.41; CI, 1.01–1.96; p = 0.041). Conclusions Ischemic stroke patients had larger plaque burden and greater proportion of LRNC in carotid plaques compared to those with TIA. This study suggests that ischemic stroke patients had more vulnerable plaques compared to those with TIA.
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Affiliation(s)
- Mingming Lu
- Institute of Geriatrics, State Key Laboratory of Kidney Disease, Beijing Key Laboratory of Aging and Geriatrics, The Second Medical Center, Chinese PLA General Hospital, Beijing, 100853, China.,Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Lichen Zhang
- Department of Radiology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Fei Yuan
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Peng Peng
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Hongtao Zhang
- Department of Radiology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Shitong Liu
- Department of Radiology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yao He
- Institute of Geriatrics, State Key Laboratory of Kidney Disease, Beijing Key Laboratory of Aging and Geriatrics, The Second Medical Center, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Jianming Cai
- Department of Radiology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
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6
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Lopez-Navarro ER, Greif G, Haensch CA, Ringelstein A, Larbig R. Ischemic stroke secondary to self-inflicted carotid sinus massage: a case report. J Med Case Rep 2021; 15:83. [PMID: 33618738 PMCID: PMC7901106 DOI: 10.1186/s13256-021-02680-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/13/2021] [Indexed: 12/12/2022] Open
Abstract
Background The risk of stroke after carotid sinus massage is greater if there is preexisting carotid stenosis or carotid plaques. We present the case of a patient with underlying 40% carotid stenosis, who developed a watershed stroke after a self-neck massage in our stroke unit. We show a well-documented case with magnetic resonance images before and after the neck massage. We report a case of a watershed brain infarct after a self-massage of the carotid sinus, with preexisting carotid artery stenosis. Neck massage continues to be a significant cause of stroke and should therefore not be performed by patients. Clinicians must be aware of the implications of a carotid sinus massage in both the outpatient and inpatient settings. Case presentation We admitted a 58-year-old white male patient, with no relevant medical history, to our department with a brain stem infarct. During his stay at our stroke unit, the patient performed a self-neck massage with consecutive bradycardia and asystole, resulting in left-side hemiparesis. The underlying cause of the hemodynamic stroke is believed to be secondary to this intensive neck massage performed by the patient. The patient also suffered from unknown right internal carotid artery stenosis. Conclusion Clinicians and patients must be aware that neck massage can lead to ischemic stroke. We postulate that repetitive impaired cardiac output can lead to a hemodynamic (watershed-type) stroke.
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Affiliation(s)
- Edgar R Lopez-Navarro
- Department of Neurology, Kliniken Maria Hilf, Viersener Str. 450, 41063, Moenchengladbach, Germany.
| | - Götz Greif
- Department of Neurology, Kliniken Maria Hilf, Viersener Str. 450, 41063, Moenchengladbach, Germany
| | - Carl-Albrecht Haensch
- Department of Neurology, Kliniken Maria Hilf, University of Witten/Herdecke, Moenchengladbach, Germany
| | - Adrian Ringelstein
- Department of Radiology and Neuroradiology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Robert Larbig
- Department of Cardiology, Kliniken Maria Hilf, Moenchengladbach, Germany
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7
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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: 0] [Impact Index Per Article: 0] [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.
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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
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Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines. J Clin Med 2020; 9:jcm9113460. [PMID: 33121192 PMCID: PMC7693974 DOI: 10.3390/jcm9113460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/15/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022] Open
Abstract
Patient selection for endovascular intervention in extracranial carotid disease is centered on vascular anatomy. We review anatomical considerations for non-traumatic disease and offer guidelines in patient selection and management. We conducted a systematic literature review without meta-analysis for studies involving anatomical considerations in extracranial carotid intervention for non-traumatic disease. Anatomical considerations discussed included aortic arch variants, degree of vessel stenosis, angulation, tortuosity, and anomalous origins, and atheromatous plaque morphology, composition, and location. Available literature suggests that anatomical risks of morbidity are largely secondary to increased procedural times and difficulties in intervention system delivery. We recommend the prioritization of endovascular techniques on an individual basis in cases where accessible systems and surgeon familiarity provide an acceptable likelihood of rapid access and device deployment.
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9
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Al-Jehani H, Alhamid MA, Alkhalaf Y, Alabbas F. A Case of Coincidental Free Floating Thrombus in the Vertebral Artery in a Patient Presenting with an Anterior Circulation Stroke and Literature Review. Neurointervention 2020; 15:144-153. [PMID: 32777873 PMCID: PMC7608498 DOI: 10.5469/neuroint.2020.00087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022] Open
Abstract
Free-floating thrombus (FFT) is a rare condition with unknown etiology as described by many case reports presented in previous literature. The patients usually present symptomatically while the other few patients remain asymptomatic and are usually discovered incidentally on computed tomography angiography (CTA). Most of the cases reported in the literature are of FFT in the internal carotid artery. We present a 59-year-old female as a case of FFT in the vertebral artery which was coincidently discovered on CTA in a patient initially presenting with an anterior circulation stroke. This case highlights the importance of early contrast-based vascular imaging in patients presenting with large vessel strokes that are cardioembolic in nature and the unique utilization of a direct aspiration first pass technique (ADAPT) for revascularization. Included herein an extensive review of the literature about the decision making in patients with FFT and a devised proposed practical approach to this entity.
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Affiliation(s)
- Hosam Al-Jehani
- Department of Neurosurgery, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia.,Department of Neurology and Neursurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - May Adel Alhamid
- Department of Neurology, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia
| | - Yousef Alkhalaf
- Department of Medicine, Royal Commision Hospital, Jubail, Saudi Arabia
| | - Faisal Alabbas
- Department of Neurosurgery, Interventional Radiology, King Fahad Hospital of The University, Imam Abdulrahman Bin Faisal, Dammam, Saudi Arabia
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Yamaoka A, Miyata K, Iihoshi S, Mikuni N. Endovascular treatment of asymptomatic free-floating thrombus in the carotid artery bifurcation: a direct aspiration first-pass technique under double balloon protection. BMJ Case Rep 2019; 12:12/8/e230295. [PMID: 31420432 PMCID: PMC6700566 DOI: 10.1136/bcr-2019-230295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Free-floating thrombus (FFT) in the carotid artery has been reported as a rare cause of acute ischaemic stroke. There are various treatment strategies, but higher risk of distal embolism may limit their applicability. A 77-year-old woman noticed right upper arm weakness. A CT angiogram revealed that a large floating thrombus had strayed across the carotid bifurcation, while another thrombus was present in the right axillary artery. As for the carotid FFT, in spite of anticoagulation therapy, the number of asymptomatic microthrombuses gradually increased on diffusion-weighted MRI. We performed endovascular therapy utilising two temporary occlusion balloon catheters and performed direct aspiration with a reperfusion catheter. The procedure was uneventful. We successfully performed a new endovascular technique for FFT in the carotid bifurcation. Our method is effective, minimally invasive and safe.
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Affiliation(s)
- Ayumu Yamaoka
- Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Kei Miyata
- Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Satoshi Iihoshi
- Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Nobuhiro Mikuni
- Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
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11
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Amabile AH, Dekerlegand RL, Muth S, O'Hara MC, Phillips JM, Ammons AA, Jacketti AK, Newby OJ, Schreiber B, Walter RJ, Lombardo A, Elcock JN. Proximity of the Carotid Bifurcation to the Laryngeal Prominence: Results of a Cadaver Study and Recommendations for Safe Pulse Palpation. J Geriatr Phys Ther 2019; 43:E53-E57. [PMID: 31373943 DOI: 10.1519/jpt.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND/PURPOSE The carotid bifurcation (CB) is the location of the carotid sinus and the baroreceptors and is also a major site for atherosclerotic plaque formation. Health care providers have therefore been cautioned to avoid the CB during carotid pulse palpation (CPP) to prevent triggering the baroreflex, occluding an artery, or propagating a thrombus. Potential risks of adverse events during CPP may be greater for older adults due to age-related vascular changes and increased risk of baroreceptor hypersensitivity. The exact location of the CB relative to easily identifiable landmarks has, however, not been well-studied. The purpose of this descriptive study was to identify the location of the CB relative to key landmarks in a cadaver sample and to make recommendations allowing clinicians to avoid the CB during CPP. METHODS The CB and other regional landmarks in 17 male and 20 female cadavers were exposed by dissection and pins were placed at all landmarks. Digital calipers were then used to measure the distance between the CB and all landmarks. RESULTS AND DISCUSSION The mean vertical distance from the laryngeal prominence (LP) to the CB was 25.14 mm for females and 36.13 mm for males. No CBs were located below the LP. Ninety-four percent of female CBs and 100% of male CBs were located above the LP, and 74% of female subjects and 87% of male subjects had CBs greater than 20.00 mm superior to the LP. No clinically relevant relationships were found between the CB and any of the other measured landmarks. CONCLUSIONS Based on this cadaver sample, CPP below the level of the LP in a supine individual would be unlikely to compress the CB and thus unlikely to trigger the baroreflex or occlude the region of greatest atherosclerotic buildup. If a pulse is not palpable below the LP, moving vertically up to 1 cm above the LP in a supine individual would be likely to compress the CB in only a small number of cases.
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Affiliation(s)
- Amy H Amabile
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert L Dekerlegand
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Stephanie Muth
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael C O'Hara
- Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania
| | | | - Alexis A Ammons
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ann-Katrin Jacketti
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Olivia J Newby
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Benjamin Schreiber
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan J Walter
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anthony Lombardo
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jamie N Elcock
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
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12
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Tolaymat B, Irizarry K, Reif M, Drucker CB, Aicher BO, Sarkar R, Toursavadkohi S, Monahan TS. Considerations beyond Stenosis for Carotid Endarterectomy in Treating Free-Floating Thrombus of the Carotid Artery. Ann Vasc Surg 2019; 60:221-228. [PMID: 31077769 DOI: 10.1016/j.avsg.2019.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/06/2019] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Free-floating thrombus (FFT) of the carotid artery is an uncommon condition that can present with neurologic symptoms, often in the setting of ischemic stroke. The literature pertaining to the incidence and optimal treatment of this condition is limited. Herein, we report our contemporary experience with FFT across a range of degrees of carotid stenosis. METHODS Medical records and imaging studies from a single academic medical center from January 2016 to July 2018 were retrospectively reviewed. Patient demographics, presentation, treatment, and follow-up were abstracted. RESULTS Six cases of FFT of the carotid artery with and without hemodynamically significant atherosclerotic disease were identified. All cases presented with ischemic stroke; one case had a hemorrhagic conversion. In each case, the FFT was visualized by at least one imaging modality including computed tomography angiography, magnetic resonance angiography, and duplex ultrasound. Three patients had >50% carotid stenosis and three had <50%. All cases were treated with endarterectomy. Four of the six patients received preoperative anticoagulation. There were no postoperative complications. Median follow-up was 252 days, with one case lost to follow-up. Four of the six patients have been without restenosis, recurrence of the thrombus, nor worsening or recurrent stroke on follow-up. The fifth patient developed restenosis but remained clinically stable. CONCLUSIONS Although current society guidelines do not recommend carotid endarterectomy as first-line treatment for symptomatic patients with <50% stenosis, it may be indicated in the context of FFT.
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Affiliation(s)
- Besher Tolaymat
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD.
| | - Karen Irizarry
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD
| | - Michaella Reif
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD
| | - Charles B Drucker
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD
| | - Brittany O Aicher
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD
| | - Rajabrata Sarkar
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD
| | - Shahab Toursavadkohi
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD; Veterans Affairs Maryland Health Care System, Department of Surgery, Baltimore, MD
| | - Thomas S Monahan
- University of Maryland School of Medicine, Division of Vascular Surgery, Department of Surgery, Baltimore, MD; Veterans Affairs Maryland Health Care System, Department of Surgery, Baltimore, MD
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13
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Ascoli Marchetti A, Diomedi M, Ascoli Marchetti S, Piccione E, Ippoliti A. Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: Surgical technical success and maintenance of pregnancy. SAGE Open Med Case Rep 2019; 7:2050313X19831117. [PMID: 30834118 PMCID: PMC6393941 DOI: 10.1177/2050313x19831117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/22/2019] [Indexed: 11/18/2022] Open
Abstract
Thrombosis, especially in pregnancy, is due to a prothrombotic state and involves the venous system. Localization in an arterial segment is rare. Floating carotid arterial thrombosis is a very rare occurrence, but it is very devastating. The authors report the case of a pregnant patient in whom are associated a thrombotic predisposition and a traumatic event of the neck which resulted in a limited dissection and a floating thrombosis of the common carotid artery. The onset was characterized by sudden neurological deficits, including numbness of the right-hand fingers and right limb weakness, which regressed after admission. The patient underwent a surgical operation with success. Her pregnancy continued, and an ultrasound scan 12 months later confirmed the patency of the prosthesis, in the absence of neurological symptoms. Hormonal changes may reveal the condition of thrombophilia, which, however, occurs more frequently in the venous system and is a condition related to the free-floating thrombus. No guidelines exist for medical or surgical management. The endovascular approach appears to present a greater risk of embolization as an alternative to open surgery. This case demonstrates that the prothrombotic state and the presence of neurological symptoms are suggestive of arterial thrombosis in pregnancy and that the multidisciplinary approach is mandatory to achieve good results.
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Affiliation(s)
- Andrea Ascoli Marchetti
- Vascular Surgery Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | - Emilio Piccione
- Gynecology and Obstetrics Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Arnaldo Ippoliti
- Vascular Surgery Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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14
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Yamaguchi S, Hamabe J, Yamashita A, Irie J, Yagi N, Suyama K. Rare Case of Floating Intimal Flap Associated with Atheromatous Carotid Plaque. World Neurosurg 2018; 122:98-101. [PMID: 30391611 DOI: 10.1016/j.wneu.2018.10.139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND A mobile carotid plaque can be detected by duplex ultrasonography and is a high-risk factor for embolic stroke. CASE DESCRIPTION We herein present a case involving an 80-year-old man with an asymptomatic carotid floating flap diagnosed by duplex ultrasonography and treated with carotid endarterectomy. Intraoperatively, an ulceration was found immediately proximal to the neck of the floating flap, and the shape and size of the ulceration were quite similar to those of the floating flap. In a histopathologic examination of the specimen resected by carotid endarterectomy, the plaque lacked the internal elastic lamina (IEL) at the ulceration, calcification was observed in the plaque and medial layer at the ulceration, and the floating flap consisted of the IEL accompanied by calcification, fibrin, and foamy cells. CONCLUSIONS Progression of the atheroma and Mönckeberg sclerosis might have affected disruption of the IEL, causing the IEL to finally peel off. A floating intimal flap accompanied by an atheroma without intraplaque hemorrhage is a rare cause of mobile plaque formation. This type of mobile plaque might not be dissolved by medical treatment alone. In such cases, surgical treatment is a suitable therapeutic choice to prevent stroke.
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Affiliation(s)
- Susumu Yamaguchi
- Department of Neurosurgery, Nagasaki Harbor Medical Center, Nagasaki, Japan.
| | - Junpei Hamabe
- Department of Neurology and Strokology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Aya Yamashita
- Department of Neurology and Strokology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Junji Irie
- Department of Pathology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Nobuhiro Yagi
- Department of Neurosurgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Kazuhiko Suyama
- Department of Neurosurgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
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15
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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.
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Affiliation(s)
- Shota Sakai
- Department of Cerebrovascular Medicine, Saga-ken Medical Centre Koseikan
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