Floating aortic arch thrombus involving the left common carotid artery complicated with ischemic stroke associated with cocaine use.

BACKGROUND: Floating aortic thrombi (FLOAT) are rare, with very few cases attributed to cocaine use. We report a new case of FLOAT involving the left common carotid artery due to cocaine use, for the first time, complicated with acute ischemic stroke. METHODS: We present in detail our case report, and then, a literature search in PubMed and Scopus was performed up to March 20, 2022, to review the reported cases of aortic thrombus associated with cocaine use. RESULTS: A 39-year-old man with a history of smoking and daily cocaine use was admitted to our stroke unit for acute left-hemispheric symptoms due to carotid-Sylvian occlusion. CT angiography of the supra-aortic trunks showed FLOAT involving the left common carotid artery. The thrombus was removed successfully by endovascular thrombectomy with recanalization of carotid-Sylvian occlusion. Our literature search yielded seven reported cases of aortic thrombus due to cocaine use revealed by lower limb ischemia (3 patients), renal infarction (1 patient), abdominal pain (1 patient), bowel ischemia (1 patient), and lower limb ischemia with renal infarction (1 patient). CONCLUSION: Aortic thrombus should be suspected in patients without overt cardiovascular risk factors but with a recent history of cocaine use who presents with acute ischemic stroke.

Second-dose intravenous thrombolysis with tenecteplase in alteplase-resistant medium-vessel-occlusion strokes: A retrospective and comparative study.

INTRODUCTION: In intracranial medium-vessel occlusions (MeVOs), intravenous thrombolysis (IVT) shows inconsistent effectiveness and endovascular interventions remains unproven. We evaluated a new therapeutic strategy based on a second IVT using tenecteplase for MeVOs without early recanalization post-alteplase. PATIENTS AND METHODS: This retrospective, comparative study included consecutively low bleeding risk MeVO patients treated with alteplase 0.9 mg/kg at two stroke centers. One center used a conventional single-IVT approach; the other applied a dual-IVT strategy, incorporating a 1-h post-alteplase MRI and additional tenecteplase, 0.25 mg/kg, if occlusion persisted. Primary outcomes were 24-h successful recanalization for efficacy and symptomatic intracranial hemorrhage (sICH) for safety. Secondary outcomes included 3-month excellent outcomes (modified Rankin Scale score of 0-1). Comparisons were conducted in the overall cohort and a propensity score-matched subgroup. RESULTS: Among 146 patients in the dual-IVT group, 103 failed to achieve recanalization at 1 h and of these 96 met all eligible criteria and received additional tenecteplase. Successful recanalization at 24 h was higher in the 146 dual-IVT cohort patients than in the 148 single-IVT cohort patients (84% vs 61%, p < 0.0001), with similar sICH rate (3 vs 2, p = 0.68). Dual-IVT strategy was an independent predictor of 24-h successful recanalization (OR, 2.7 [95% CI, 1.52-4.88]; p < 0.001). Dual-IVT cohort patients achieved higher rates of excellent outcome (69% vs 44%, p < 0.0001). Propensity score matching analyses supported all these associations. CONCLUSION: In this retrospective study, a dual-IVT strategy in selected MeVO patients was associated with higher odds of 24-h recanalization, with no safety concerns. However, potential center-level confounding and biases seriously limit these findings' interpretation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05809921.