Case Report
Open Access
Floating Carotid Thrombus Treated By
Endoluminal Stent Reconstruction with
Anticoagulation: A Case Report
Devendra Singh Bisht1*, Anupam Jindal2
1Consultant Interventional Cardiologist, Mayo Healthcare, Punjab, India.
2Director and neurosurgeon, Mayo Healthcare, Punjab, India.
2Director and neurosurgeon, Mayo Healthcare, Punjab, India.
*Corresponding author: Devendra Singh Bisht, Consultant cardiologist, Mayo Healthcare, Sector 69, Mohali, Punjab, India, Tel: +918427464246;
Email:
@
Received: January 1, 2018; Accepted: January 31, 2018; Published: March 02, 2018
Citation: Devendra Singh B, Anupam J (2018) Floating Carotid Thrombus Treated By Endoluminal Stent Reconstruction with Anticoagulation: A Case Report. J Clin Trial Cardiol 5(2): 1-2. DOI: 10.15226/2374-6882/5/1/00149
Abstract
We present case of a 44 year-old male with ischemic stroke
caused by thrombo-embolism from floating thrombus most probably
caused by an atherosclerotic plaque rupture. Thrombus was detected
during ultrasound imaging of carotid vessels. Computed tomography
angiography of neck vessels confirmed the presence of atherosclerotic
plaque rupture with evidence of thrombus in proximal internal
carotid. After discussion with the neurosurgical team, our case was
treated with anticoagulation and Endoluminal stent reconstruction of
ruptured carotid plaque.
Keywords: carotid artery disease; cerebrovascular accident;
Keywords: carotid artery disease; cerebrovascular accident;
Introduction
Floating thrombus (FT) is usually detected in the cardiac
chambers or in the pulmonary circulation, [1, 2] but their presence
in the carotid circulation is a rare diagnosis. Their presence
is thought to be related with atherosclerotic plaque rupture,
[3] or other conditions like trauma, dissection, aneurysm, and
hyper coagulability or cocaine usage [4-8]. FT is almost always
symptomatic. The treatment of floating internal carotid artery
(ICA) thrombus is based on expert opinions. It can be treated
with conservative management alone (anticoagulation and/or
ant platelet therapy), carotid endarterectomy (CEA), or carotid
artery stenting (CAS) [3, 5].
Here, we present a case of a symptomatic floating ICA thrombus, which was discovered by ultrasound and was treated successfully with CAS.
Here, we present a case of a symptomatic floating ICA thrombus, which was discovered by ultrasound and was treated successfully with CAS.
Case Report
A 44 year-old diabetic, right-handed man presented with
sudden onset dysarthria, plegia of the right arm, and severe
paresis of the right leg. He also had history of fall prior to
developing weakness. He didn’t complain of any abdominal
or chest symptoms, and there was no history of headache,
nausea, vomiting, bladder-bowel incontinence or abnormal
body movements. The past, personal and family history was
noncontributory. On general physical examination patient was
Figure 1: longitudinal ultrasound images of the left internal carotid artery
demonstrate floating thrombus within the lumen (arrow).
After discussion with neurosurgery team and patient’s family;
End luminal stent reconstruction of symptomatic, ruptured
carotid plaque was decided in addition to anticoagulation and
ant platelet therapy. The patient remained clinically stable, and
uncomplicated left ICA angioplasty with 7-9 x 40 mm RX Acculink
stent (Abbott Vascular, Santa Clara, CA, USA) was done [Figure
2]. Afterwards patient was kept on Aspirin and Warfarin with
international normalized ration (INR) target of 2-3. Patient was
transferred to inpatient stroke rehabilitation unit for physical
therapy, where he continued to make improvements.
Figure 2: Common carotid artery injections before (A, left) and after (B,
right) carotid stenting, displaying preoperative floating thrombus (arrow)
and postoperative endoluminal reconstruction of the vessel.
Discussion
FT is a rare entity with variable incidence rate based on
imaging modality used for diagnosis. Arning and Herrmann [9]
reported an incidence of 0.05% in a retrospective study based
on ultrasound, whereas Buchan et al [10] reported an incidence
as high as 1.45% based on angiograms. Atherosclerosis with
ruptured atherosclerotic plaque is reported to be the most
important factor in the etio-pathogenesis of FT. Carotid stenos
is with altered flow dynamics across the site of stenos is further
increases the risk of developing FT. Acute ischemic stroke is the
most common presentation of FT. [10] Transient ischemic attacks
(TIA) may be the likely clinical manifestations of developing FT.
Due to availability, CTA of neck vessels appears to be the most
common imaging modality used for the diagnosis. American
heart association also recommends CTA as the preferred modality
for imaging the vasculature in acute stroke or TIA. We diagnosed
our case in duplex ultrasound of neck vessels, which was further
confirmed by CTA of neck vessels.
FT in the extra-cranial carotid circulation portends on therapeutic dilemma. Randomized trials on anticoagulation by heparin or heparinoids in the setting of acute ischemic stroke failed to demonstrate mortality or morbidly benefit. However, anecdotal evidence favors heparin therapy in certain conditions of hypercoagulable states, extra-cranial arterial dissection and intra-luminal arterial thrombus, to prevent stroke recurrence. [11, 12] Aspirin dosing need to be individualized according to indication and bleeding risk. In the stroke of stoke, low doses (50mg daily) are adequate for some patients, while other requires higher doses (160-325 mg per day) [13, 14]. We have kept our patient on both ant platelet and anticoagulant considering arterial dissection and superimposed thrombosis.
FT can be treated medically, carotid end-arterectomy or endovascular stenting [3, 5]. Till date no randomized control trial exists to support surgical (CAS, CEA or carotid bypass) versus medical management (anti-platelets and or anticoagulation). Our patient was treated both with LMWH and CAS. He experienced a favorable outcome with no recurrence of neurological deficit over 3 months of follow up.
FT in the extra-cranial carotid circulation portends on therapeutic dilemma. Randomized trials on anticoagulation by heparin or heparinoids in the setting of acute ischemic stroke failed to demonstrate mortality or morbidly benefit. However, anecdotal evidence favors heparin therapy in certain conditions of hypercoagulable states, extra-cranial arterial dissection and intra-luminal arterial thrombus, to prevent stroke recurrence. [11, 12] Aspirin dosing need to be individualized according to indication and bleeding risk. In the stroke of stoke, low doses (50mg daily) are adequate for some patients, while other requires higher doses (160-325 mg per day) [13, 14]. We have kept our patient on both ant platelet and anticoagulant considering arterial dissection and superimposed thrombosis.
FT can be treated medically, carotid end-arterectomy or endovascular stenting [3, 5]. Till date no randomized control trial exists to support surgical (CAS, CEA or carotid bypass) versus medical management (anti-platelets and or anticoagulation). Our patient was treated both with LMWH and CAS. He experienced a favorable outcome with no recurrence of neurological deficit over 3 months of follow up.
Conclusions
We describe a middle aged man with an ischemic stroke due
to FT on ulcerated plaque. This article highlights the concept that
plaque morphology may be equally important in causing stroke
as the stenos are severity. Selected patient with ischemic stroke
may benefit from combined treatment of anticoagulation and
endovascular intervention.
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