Symptomatic free-floating thrombus in the vertebral artery: a case description
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PROVIDER: S-EPMC10240024 | biostudies-literature | 2023 Mar
REPOSITORIES: biostudies-literature
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Project description:BackgroundCarotid 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 summaryThis 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.ConclusionWe innovatively report a successful ultrasound-guided EVT for CFFT. Ultrasound assistance can provide quick and effective guidance and may guide tailored aspirations during EVT.
| S-EPMC9519131 | biostudies-literature
Project description:We report an incident of detection of a free-floating thrombus in the left ventricle (LV) using intraoperative two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) during proximal coronary artery bypass graft anastomosis. A 58-year-old man presented to us with a 6-month history of chest pain without any history suggestive of myocardial infarction or transient ischemic attacks. His preoperative echocardiography revealed the systolic dysfunction of LV, mild hypokinesia of basal and mid-anterior wall, and the absence of an aneurysm. He was scheduled for on-pump coronary artery bypass surgery. On intraoperative TEE before establishing cardiopulmonary bypass (CPB), a small immobile mass was found attached to LV apical area. After completion of distal coronary artery grafting, when the aortic cross-clamp was removed, the heart was filled partially and beating spontaneously. TEE examination using 2D mode revealed a free-floating mass in the LV, which was suspected to be a thrombus. Additional navigation using biplane and 3D modes confirmed the presence of the thrombus and distinguished it from papillary muscles and artifact. The surgeon opened the left atrium after re-establishing electromechanical quiescence and removed a thrombus measuring 1.5 cm Χ 1 cm from the LV. The LV mass in the apical region was no longer seen after discontinuation of CPB. Accurate TEE-detection and timely removal of the thrombus averted disastrous embolic complications. Intraoperative 2D and recent biplane and 3D echocardiography modes are useful monitoring tools during the conduct of CPB.
| S-EPMC4881683 | biostudies-literature
Project description:ObjectiveTo compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis.MethodsVIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant.ResultsThree patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1-4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14-1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05).ConclusionsStenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk.Isrctncom identifierISRCTN95212240.Classification of evidenceThis study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.
| S-EPMC5606920 | biostudies-literature
Project description: Not available
| S-EPMC3816168 | biostudies-literature
Project description:Free-floating right heart thrombus (RHT) is an extreme medical emergency in the context of acute massive pulmonary embolism (PE). Despite the advances in early diagnosis, the management is still very debatable due to lack of consensus. We reported the case of a 66-year-old male, with a history of moderate renal dysfunction and dilated cardiomyopathy, who presented to the emergency department for acute dyspnea. His angiographic magnetic resonance imaging revealed bilateral extensive PE. Transthoracic echocardiography showed RHT with moderate right ventricular dysfunction and pulmonary hypertension. Venous Doppler of the lower extremities noted the presence of a floating clot in the right common femoral vein. The patient was managed successfully by thrombolytic therapy with tenecteplase. To the best of our knowledge, this is the first case report of RHT and PE from Lebanon. Published cases from Middle Eastern countries are scarse.
| S-EPMC5989551 | biostudies-literature
Project description:Thrombus migration is a well-known clinical condition that occurs before mechanical thrombectomy and after intravenous thrombolysis in patients with anterior circulation strokes. Although thrombus migration from the vertebral artery (VA) can result in life-threatening basilar artery (BA) occlusion, its occurrence in the posterior circulation has rarely been discussed. Two patients with secondary BA occlusion caused by spontaneous thrombus migration from the VA are presented. A 60-year-old man with a left cerebellar infarction secondary to ipsilateral VA occlusion was admitted to our hospital 8 hours after onset, with a National Institute of Health Stroke Scale (NIHSS) score of 4. The patient became comatose 3.5 hours after arrival owing to subsequent BA occlusion. He was successfully treated with mechanical thrombectomy. A 74-year-old man with right cerebellar infarction secondary to ipsilateral VA occlusion was admitted to our hospital 26 hours after onset, with an NIHSS score of 3. He became comatose 1 hour after arrival owing to BA occlusion and was treated with thrombectomy, followed by internal and external decompression. Despite the mild symptoms of VA occlusion and consequently delayed admission to the hospital, stroke physicians should be aware that spontaneous thrombus migration from the VA to the BA can result in a life-threatening presentation.
| S-EPMC11399790 | biostudies-literature
Project description:BackgroundCarotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.MethodsWe prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.ResultsWe enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.ConclusionsThe majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.
| S-EPMC10359789 | biostudies-literature
Project description:Carotid free-floating thrombus (FFT) is very rarely diagnosed in patients with acute ischemic stroke. It is a real clinical emergency due to the significant risk of death associated with thromboembolic complications. Herein, we present three patients with ischemic stroke caused by carotid FFT after less than 20 days from administration of mRNA vaccine BNT162b1 (Pfizer/BioNTech) for Severe Acute Respiratory Syndrome-CoronaVirus 2 (SARS-CoV-2). To our knowledge, these are the first cases reporting carotid FTT following SARS-CoV-2 vaccination.
| S-EPMC9362674 | biostudies-literature
Project description:BackgroundA floating thrombus in an ascending aorta with normal morphology is very rare, but when it does occur, it may induce a systemic embolism or fatal stroke. The pathophysiological mechanisms of aortic mural thrombi remain unclear, and there is no consensus regarding therapeutic recommendations.Case presentationWe report a 49-year-old male who presented with chest discomfort for 5 days and was admitted to our emergency unit. A contrast-enhanced computed tomography angiography (CTA) surprisingly demonstrated a large filling defect suggestive of a thrombus in his otherwise healthy distal ascending aorta. Surgical resection of the mass and attachment site was performed. Histological examination confirmed that the mass was a thrombus, but the cause of the thrombus formation was unknown.Conclusionsfloating aortic thrombi are rare, and they are prone to break off, thus carrying a potential risk for embolic events with catastrophic consequences. Surgical resection, both of the aortic thrombus and attachment site, as well as postoperative anticoagulant administration, are standard treatments.
| S-EPMC7724786 | biostudies-literature
Project description:Background and Purpose: Drug-eluting stents generally have superior performance to bare metal stents in the treatment of vertebral artery stenosis (VAS). This prospective, multicenter, and single-arm clinical trial was initiated to assess in-stent restenosis (ISR) and midterm outcome after rapamycin-eluting stent placement in patients with symptomatic extracranial VAS. Methods: The subjects underwent angiographic follow-up at 6 months and final clinical follow-up at 12 months. The primary efficacy endpoint was ISR at 6 months. Secondary endpoints included technical success, target lesion-related transient ischemic attack (TIA), stroke, or death, and all-cause TIA, stroke, or death during the 12-month follow-up period. Results: A total of 104 stents were implanted in the 101 patients and 83 patients (82.2%) completed angiographic follow-up at 6 months. The technical success rate was 86.1% (87/101); mean in-stent stenosis rate was 25.1 ± 17.1% and ISR rate was 5.9% (95% CI: 0.8-10.9%). All the patients with ISR were completely asymptomatic and no stent fractures were observed during angiographic follow-up. At the 12-month clinical follow-up, target lesion-related TIA, stroke, or death had occurred in two (2.0%) patients and all-cause TIA, stroke, or death had occurred in six (6.1%) patients. Conclusion: The placement of rapamycin-eluting stents in patients with symptomatic extracranial VAS yields favorable ISR results and showed a trend of favorable safety outcomes including low rates of perioperative complications and late stroke. However, further study is needed to establish the long-term clinical benefits of this stent in the treatment of VA disease.
| S-EPMC8662782 | biostudies-literature