Trombolisis dirigida por catéter en paciente con oclusión arterial periférica aguda / Catheter-directed thrombolysis in patients with acute peripheral arterial occlusion

Introducción: Las oclusiones arteriales periféricas agudas de menos de 14 días y de causa embólica y trombótica están asociadas a una alta morbimortalidad. La trombólisis dirigida por catéter representa en la actualidad una modalidad de tratamiento efectivo para la oclusión de vasos distales infrageniculares, que históricamente ha tenido malos resultados mediante embolectomía convencional, debido a la oclusión preexistente de vasos colaterales y al daño mecánico al endotelio, que conlleva esta técnica tradicional. Se decidió presentar este caso por ser la primera vez que se practica esta modalidad de tratamiento en Cuba. Objetivo: Exponer los resultados obtenidos con la aplicación de la trombolisis fibrinolitica mediante catéter en un paciente afectado por trombosis arterial periférica aguda. Presentación del caso: Paciente masculino de 57 años de edad con diagnóstico de trombosis arterial aguda de la arteria poplítea del miembro inferior izquierdo, con más de 24 horas de evolución de la isquemia y del compromiso de la viabilidad de la extremidad. Se utilizó el tratamiento fibrinolítico, mediante infusión de 250 000 unidades de Heberkinasa® en tres horas y se logró la mejoría del nivel de amputación. Conclusiones: El tratamiento fibrinolítico con Heberkinasa® fue útil en el paciente tratado porque redujo el nivel de amputación en el paciente, que presentó isquemia irreversible y criterio inicial de amputación supracondílea alto, en la extremidad comprometida(AU)

Introduction: Acute peripheral arterial occlusions of less than 14 days and of embolic and thrombotic cause are associated with a high morbidity and mortality. Catheter-directed thrombolysis currently represents an effective treatment modality for the occlusion of infragenicular distal vessels, which has historically had poor results by conventional embolectomy, due to the pre-existing occlusion of collateral vessels and the mechanical damage to the endothelium, which this traditional technique entails. It was decided to present this case because it is the first time that this modality of treatment is practiced in Cuba. Objective: Present the results obtained with the application of fibrinolytic thrombolysis by catheter in a patient affected by acute peripheral arterial thrombosis. Case presentation: A 57-year-old male patient diagnosed with acute arterial thrombosis of the popliteal artery of the left lower limb, with more than 24 hours of evolution of ischemia and compromised viability of the limb. Fibrinolytic treatment was used, by infusion of 250,000 units of Heberkinase® in three hours and the improvement of the amputation level was achieved. Conclusions: Fibrinolytic treatment with Heberkinase® was useful in the treated patient because it reduced the level of amputation in the patient, who presented irreversible ischemia and initial criteria of high supracondylar amputation in the compromised limb(AU)

Internal carotid artery thrombosis in COVID 19 / Trombosis de arteria carótida interna en COVID 19

Abstract Case description: 37-year-old female with PCR-RT swab for COVID-19 positive, with neurological manifestation as a result of internal carotid artery occlusion. Clinical findings: Nasal congestion and sneezing of 5 days duration; pulsatile headache in the left hemicranium 3 days prior to admission, with intensity 6/10 according to the visual analogue scale, accompanied by phosphenes, photophobia and diplopia; with subsequent developing right hemiparesis over a 26-hour period. Treatment and result: She was given medical management with oral antiplatelet agents and anticoagulants (subcutaneous and oral) during his hospitalization, it was not possible to perform thrombolysis and thrombectomy due to the high risk of complications. He was discharged at 14 days, without functional limitation, symmetrical strength in upper and lower limbs, bilateral visual acuity 20/20, denying headache. Clinical relevance: The case presented here describes a pattern in how data supporting an association between COVID-19 and stroke in young populations with or without typical vascular risk factors, sometimes with only mild respiratory symptoms, is increasing. Prospective studies are required to further evaluate this association, as well as anticoagulation studies to prevent these potentially life-threatening events.

Resumen Descripción del caso: Mujer de 37 años con hisopado PCR-RT para COVID-19 positivo, con manifestación neurológica por oclusión de la arteria carótida interna. Hallazgos clínicos: Congestión nasal y estornudos de 5 días de duración; cefalea pulsátil en hemicráneo izquierdo 3 días antes del ingreso, con intensidad 6/10 según la escala visual analógica, acompañada de fosfenos, fotofobia y diplopía; con posterior desarrollo de hemiparesia derecha durante un período de 26 horas. Tratamiento y resultado: Se le brindó manejo médico con antiagregantes plaquetarios orales y anticoagulantes (subcutáneos y orales) durante su internación, no fue posible realizar trombólisis y trombectomía por alto riesgo de complicaciones. Fue dado de alta a los 14 días, sin limitación funcional, fuerza simétrica en miembros superiores e inferiores, agudeza visual bilateral 20/20, negando cefalea. Relevancia clínica: Se describe un patrón que indica cómo están aumentando los datos que apoyan una asociación entre COVID-19 y el accidente cerebrovascular en poblaciones jóvenes con o sin factores de riesgo vascular típicos, a veces con solo síntomas respiratorios leves. Se requieren estudios prospectivos para evaluar más a fondo esta asociación, así como estudios de anticoagulación para prevenir estos eventos potencialmente mortales.

Utilidad de la ecografía Doppler en el diagnóstico de la trombosis carotidea traumática / Usefulness of Doppler echography for the diagnosis of traumatic carotid thrombosis

Los traumatismos del sistema arterial carotideo son raros y tienen alta mortalidad. Se presenta un caso de trombosis de la arteria carótida interna derecha por una herida por arma de fuego a nivel del cuello con el objetivo de evidenciar en la práctica médica la utilidad de la ecografía Doppler para el diagnóstico temprano de estas lesiones, a pesar de reportarse en la literatura la angiografía, la resonancia magnética nuclear y la angiorresonancia como estudios de elección. Con este caso se pudo afirmar que la trombosis carotidea traumática tiene una incidencia baja, pero no descartable en los traumas de la región cervical. Por esta causa, son frecuentes las complicaciones neurológicas dadas por la oclusión arterial y la ecografía Doppler resultó muy útil en el diagnóstico temprano del paciente.

Carotid artery system traumas are rare and show high mortality rates. The case of right internal carotid artery thrombosis caused by a gunshot injury in the neck was presented in this report to show evidence of the usefulness of Doppler echography in the medical practice for the early diagnosis of these lesions in spite of the fact that literature highlights angiography, nuclear magnetic resonance and angioresonance as the imaging studies of choice. This case confirmed that carotid thrombosis due to trauma has low incidence but it can not be ignored in the cervical región traumas. For these reasons, the neurological complications stemming from artery occlusion are frequent and Doppler echography turned to be very useful for the early diagnosis of this illness in a patient.

Carotid free-floating thrombus in woman with meningioma: a case report and review of the literature.

OBJECTIVE: Several reports have previously described the coexistence of severe carotid artery disorders and brain tumors, in particular meningioma, mainly consisting of arterial occlusion or obstruction due to direct compression by tumor mass, with possible presence of transient neurological symptoms as well as complete cerebral infarction. Free-floating thrombus (FFT) is an uncommon condition, characterized by the presence of thrombotic material partially attached to the arterial wall with evidence of heartbeat associated floating. To our knowledge, our case represents the first report in literature about presence of internal carotid FFT in patient affected by meningioma. CASE REPORT: In this report, sharing singular images and videos of this uncommon condition, we present the first case of a right internal carotid artery FFT in a 59-year-old woman affected by meningioma, successfully treated with antiplatelet medication together with anticoagulation and high dose of statins. CONCLUSIONS: Our case confirms the possible association between carotid artery disorders and meningioma, involving for the first time a FFT. These findings make desirable to explore carotid district in patients with brain tumors, especially meningioma, even if symptoms suggestive of ischemic suffering are not present, in order to make an early diagnosis, so preventing marked ischemic events.

Evaluation of 111In-labeled EPep and FibPep as tracers for fibrin SPECT imaging.

Fibrin targeting is an attractive strategy for nuclear imaging of thrombosis, atherosclerosis and cancer. Recently, FibPep, an (111)In-labeled fibrin-binding peptide, was established as a tracer for fibrin SPECT imaging and was reported to allow sensitive detection of minute thrombi in mice using SPECT. In this study, we developed EPep, a novel (111)In-labeled fibrin-binding peptide containing the fibrin-binding domain of the clinically verified EP-2104R peptide, and sought to compare the potential of EPep and FibPep as tracers for fibrin SPECT imaging. In vitro, both EPep and FibPep showed high stability in serum, but were less stable in liver and kidney homogenate assays. Both peptide probes displayed comparable affinities toward human and mouse derived fibrin (Kd ≈ 1 µM), and similarly to FibPep, EPep showed fast blood clearance, low nontarget uptake and high thrombus uptake (6.8 ± 1.2% ID g(-1)) in a mouse carotid artery thrombosis model. Furthermore, EPep showed a similar affinity toward rat derived fibrin (Kd ≈ 1 µM), displayed high thrombus uptake in a rat carotid artery thrombosis model (0.74 ± 0.39% ID g(-1)), and allowed sensitive detection of thrombosis in rats using SPECT. In contrast, FibPep displayed a significantly lower affinity toward rat derived fibrin (Kd ≈ 14 µM) and low uptake in rat thrombi (0.06 ± 0.02% ID g(-1)) and did not allow clear visualization of carotid artery thrombosis in rats using SPECT. These results were confirmed ex vivo by autoradiography, which showed a 7-fold higher ratio of activity in the thrombus over the contralateral carotid artery for EPep in comparison to FibPep. These findings suggest that the FibPep binding fibrin epitope is not fully homologous between humans and rats, and that preclinical rat models of disease should not be employed to gauge the clinical potential of FibPep. In conclusion, both peptides showed approximately similar metabolic stability and affinity toward human and mouse derived fibrin, and displayed high thrombus uptake in a mouse carotid artery thrombosis model. Therefore, both EPep and FibPep are promising fibrin targeted tracers for translation into clinical settings to serve as novel tools for molecular imaging of fibrin.

Spontaneous free floating carotid artery thrombosis.

A 64-year-old man, with no history of trauma, presented with transient visual loss. He was diagnosed with amaurosis fugax and started on dipyridamole and simvastatin. An inconclusive ultrasound (US) Doppler was followed by CT angiogram (CTA) and MRI, which demonstrated free floating intraluminal thrombus in the distal right common carotid artery. ECG showed sinus rhythm and an echocardiogram showed no cardiac thrombus. Following discussion at the vascular multidisciplinary team the decision was made to treat with intravenous heparin followed by warfarin. He has been regularly followed up with CTA/USS, the most recent (Oct 2012) showing no evidence of thrombus. He has had no further symptoms. Despite no initial aetiology being found we suggest that his undiagnosed oesophageal carcinoma (diagnosed 5 months after initial presentation) could have been responsible for a hypercoagulability state giving an increased risk of thrombosis and leading to the thrombus in the common carotid artery.

Internal carotid thrombus in patients with inflammatory bowel disease: two cases.

Increased ischemic stroke risk is observed in patients with inflammatory bowel disease (IBD). Causes and physiopathological aspects of cerebral infarct, in this specific population, are less often described. There is little information to provide guidelines for the best curative and preventive treatment. We report 2 cases of ischemic strokes due to internal carotid thrombus in patients during active phase of IBD. Ulceration of early atherosclerotic plaques activated by a hypercoagulation state may cause a thrombus. A combined therapy with heparin and corticosteroids was used for both our patients. Lysis of the thrombus was obtained after several days without surgical treatment and shown by ultrasonography. These cases highlight an aetiology of stroke in patients with IBD and use of a synergic treatment to respond to hypercoagulability in link with IBD. Benefits and safety of this therapy should be confirmed with clinical studies.

Delayed development of brain abscesses following stent-graft placement in a head and neck cancer patient presenting with carotid blowout syndrome.

We describe the delayed development of intracranial abscesses following emergent treatment with a covered stent-graft for carotid blowout syndrome (CBS) in a patient with head and neck cancer. The patient presented with hemoptysis and frank arterial bleeding through the tracheostomy site. A self-expandable stent-graft was deployed across a small pseudoaneurysm arising from the right common carotid artery (RCCA) and resulted in immediate hemostasis. Three months later, the patient suffered a recurrent hemorrhage. CT of the neck demonstrated periluminal fluid around the caudal aspect of the stent-graft with intraluminal thrombus and a small pseudoaneurysm. Subsequently, the patient underwent a balloon test occlusion study and endovascular sacrifice of the RCCA and right internal carotid artery. MRI of the brain demonstrated at least four ring-enhancing lesions within the right cerebral hemisphere consistent with intracranial abscesses that resolved with broad-spectrum antibiotic coverage.

Cisplatin-associated occlusion of the internal carotid artery.

BACKGROUND: Cisplatin is a highly effective antineoplastic agent used also in germ cell cancer. Thromboembolic complications like pulmonary embolism, myocardial infarction and stroke have occasionally been reported. CASE REPORT: A 46-year-old man with seminoma and without any cerebrovascular risk factors developed an acute stroke with complete right-sided hemiparesis and global aphasia, during the second cycle of cisplatin-based chemotherapy. After exclusion of an intracerebral bleeding, a systemic thrombolysis was performed. Further diagnostics revealed an acute occlusion of the left carotid internal artery with infarction in the territory of the middle cerebral artery. The patient slowly recovered; however, a moderate aphasia and partial hemiparesis persisted whereas the tumor was in complete remission. Months later, the patient developed symptomatic epilepsy. CONCLUSIONS: Ischemic stroke associated with cisplatin-based chemotherapy is rare, but may be disabling or even fatal. With regard to the literature, several precautions are discussed to minimize the risk of these major side effects.

Carotid artery thrombosis and delayed stroke associated with the use of a shoulder belt in a teenager.

Blunt carotid artery injury caused by shoulder belts is rare and requires a high index of suspicion to diagnose before the onset of neurologic sequelae. Neurologic abnormalities may be erroneously attributed to concomitant head trauma, and the onset of neurologic abnormalities may be delayed for hours or days. The case of a young, teenaged driver with a "seatbelt sign" and presentation of signs and symptoms of carotid artery thrombosis 13 days after injury is described. Occult vascular injury should be suspected if neurologic deterioration occurs after a lucid interval and/or computed tomography of the head is inconsistent with neurologic findings. Screening criteria and possible screening modalities are discussed.

Carotid and coronary artery occlusion in a patient with Takayasu arteritis.

Takayasu arteritis (TA) is a chronic inflammatory disease involving the aorta and its principal branches, leading to narrowing and occlusion of the vessels. Since the clinical manifestations depend on the location and severity of the lesions, stroke may be the initial presentation of the disease. Here we report the case of a young man with TA and complete thrombotic occlusion of the right common carotid artery who underwent surgical intervention at our institution. His postoperative computed tomography angiogram performed after 3 months revealed also total occlusion of the left anterior descending coronary artery from its proximal portion.

Atherothrombotic ischemic stroke in patients with atrial fibrillation.

OBJECTIVES: About one in five patients with atrial fibrillation have significant carotid artery disease, but not all strokes are cardioembolic in origin in these patients. PURPOSE: We investigated stroke sub-types based mainly on clinical, carotid ultrasonographic, and neuroimaging findings in ischemic stroke patients with non-valvular atrial fibrillation (NVAF). PATIENTS AND METHODS: The etiology of stroke was classified as definite or probable cardioembolic, possible lacunar, or possible atherothrombotic, as proposed by Hart et al. and the TOAST criteria. Clinical features and risk factors (gender, age, diabetes mellitus, hypertension, hyperlipidemia, cigarette smoking, and alcohol consumption) were designated as clinical variables. RESULTS: One hundred and six of 1938 patients (5.5%) had NVAF. In patients with and without NVAF, hyperlipidemia was more common in patients without NVAF (p<0.001), while the prevalence of other risk factors was not statistically different. On the basis of the TOAST criteria, none of the patients with NVAF could be classified as having had an atherothrombotic stroke. According to the classification by Hart et al., of the patients with NVAF, 49 patients (46.3%) had a definite embolic stroke, 17 (16.0%) had a probable embolic stroke, 12 (11.3%) had a possible atherothrombotic stroke, 17 (16.0%) had a possible lacunar infarction, and 11 (10.4%) had a stroke of undetermined etiology. Besides the presence of significant carotid stenosis (p<0.001), none of the variables related to stroke were different among the sub-groups. CONCLUSION: Patients with significant carotid stenosis were more likely to develop atherothrombotic stroke, while other risk factors associated with stroke failed to point to an etiologic cause. It should also be emphasized that the conventional classification system failed to aid in the correct diagnosis and risk stratification in patients with multiple confounding risk factors.

Non-recurrent inferior laryngeal nerve with multiple arterial abnormalities.

Non-recurrent inferior laryngeal nerve (NRILN) is a rare embryologic anomaly that can increase the risk of injury during thyroid surgery. Although the association between the NRILN and an aberrant right subclavian artery has been reported, to date there have been no reports describing cases of NRILN with multiple vascular abnormalities. A 60-year-old man with papillary thyroid carcinoma and a history of right internal carotid artery occlusion by thrombosis was examined with magnetic resonance angiography (MRA). The right NRILN was found during a total thyroidectomy with surrounding lymph node dissection. MRA revealed an aberrant right subclavian artery and aplasia of the bilateral posterior communicating arteries composing the circle of Willis. This is the first clinical report demonstrating NRILN with multiple vascular abnormalities. Patients with NRILN must be examined for vascular anomalies and associated lesions such as aneurysms and thromboembolism.

Iatrogenic perforation of the internal carotid artery by a transarticular screw: an unusual case of repetitive ischemic stroke.

Iatrogenic injury to the carotid artery is an uncommon but well-recognized complication of medical procedures, including cervical spine surgery. A 60-year-old man showed, over an 8-month period, evidence of recurrent cerebral infarcts in the right carotid artery territory. Repeated cardiovascular screening investigations did not lead towards an etiologic factor. Three years earlier, the patient underwent an atlantoaxial fixation procedure by means of transarticular screws because of a traumatic subluxation. An intra-arterial digital substraction angiography showed malpositioning of the fixation screw on the right side with a high grade stenotic lesion of the internal carotid artery and a pseudoaneurysm. The patient was successfully treated with endovascular stenting. Our case report illustrates the relative importance of iatrogenic carotid injury in the differential diagnosis of stroke after cervical spine surgery.

Free-floating thrombus of the carotid artery: literature review and case reports.

BACKGROUND: Free-floating thrombus (FFT) of the carotid artery is an uncommon entity that usually presents as an acute emergency. Management is based on case reports and series because the natural history and optimal treatment are unknown. This study was conducted to systematically review the world literature in an attempt to better understand FFT, its presentation, distribution, management, and outcome. METHOD: A literature search in all languages was performed of the PubMed database (> or =1950s) and Medline database (1966-November 2004). All relevant articles were reviewed and their references analyzed in a similar manner for further literature. Cases from the authors' institutions were reviewed as well. All cases within the reports were individually assessed for inclusion or exclusion. Inclusion required that the FFT originate or anchor within the carotid artery (ie, excluding emboli, arch thrombi with extensions into the carotid artery), be partially occluding (ie, excluding occlusions, "string-sign," microscopic thrombus), and ideally have an elongated or protrusive morphology, circumferential flow around the distal portion, and cyclical motion with the cardiac cycles. RESULTS: There were 61 reports reviewed, of which 43 contained FFT cases. These reports had 342 cases (including the current series) that were reviewed, of which 145 met our inclusion criteria. A database was created for qualitative and quantitative assessment of all cases. When data were pooled, appropriate statistical analysis was performed. A limitation of the study is that FFT is under-reported and ill defined, which limited the analysis in quantity and quality. In addition, reporting is not uniform, and therefore, significant data were not always present. In attempting to define FFT and include or exclude cases, subjectivity is inherent. CONCLUSIONS: FFT is more frequently reported in men than women, with a ratio of nearly 2:1 (P < .0001), and at a younger age than in most patients with carotid disease (P < .0001 when compared with North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial, and Asymptomatic Carotid Surgery Trial). Symptoms are present in 92% of patients. There was a trend for patients with FFT to be hypercoagulable (47% of those serologically tested). The internal carotid artery was the most commonly affected (75%), with atherosclerosis being the most common associated pathology. Medical and surgical management have both been used, with neither clearly superior to the other. Medical management for stabilizing neurologic deficits has less risk and less benefit than surgical intervention.

Detection and management of associated atherothrombotic locations in patients with a recent atherothrombotic ischemic stroke: results of the DETECT survey.

BACKGROUND: Cerebral infarction (CI), myocardial infarction, peripheral artery disease (PAD) and aortic atheroma are the main clinical manifestations of atherothrombosis. Long-term prevention after CI of atherothrombotic origin may require preventive measures at other sites, such as specific drug therapies, surgery, or angioplasty. Therefore the detection of other locations is potentially important. OBJECTIVES: The primary objective was to describe the other locations of atherothrombosis in patients hospitalized for a recent cerebral infarct of atherothrombotic origin. Secondary objectives were to describe their vascular risk factor profiles, and their management before and after the cerebral event. METHOD: This prospective, observational, multicenter survey was conducted in France between September 2003 and July 2004, mainly in neurological departments and stroke units. RESULTS: 753 patients were included (74% men; mean age 69.3 years). Previous coronary events had occurred in 119 (16%). Previous stroke or transient ischemic attacks had occurred in 233 (31%). PAD was already known in 109 (15%). A search for other atherothrombotic locations was positive in 216 patients (29%). The minimum prevalence for any associated atherothrombotic location (either present before or identified during hospitalization) was 47.5% for any location, 33.7% for coronary artery disease, 16.6% for aortic atheroma, and 22.7% for PAD. CONCLUSION: Fifty percent of the patients with recent atherothrombotic CI have other locations of atherothrombosis. For this reason, a systematic search for these other locations is recommended because of the possible therapeutic consequences. However, the question of the most appropriate period for this search after the cerebral event remains unsettled.

The case for urgent carotid endarterectomy.

The high mortality rate previously reported and the absence of proven advantage of urgent carotid endarterectomy over natural history, has discouraged consideration of this operation. We want to report on two patients with stroke in evolution and fluctuating stroke, who underwent immediate surgery with excellent results. With these cases we aim to demonstrate that selected patients with stroke in evolution or fluctuating stroke due to recent carotid thrombosis have a good prognosis after emergency surgery. We think that in these selected cases endovascular therapy is at this moment a waste of time.