Letter to the editor Positional occlusion of the internal carotid artery by thrombus plugging causing transient ischemic attack Dear editor, Hypoperfusion transient ischemic attack (TIA) occurs in association with hemodynamically significant stenosis (1). We report a case with TIA repeatedly provoked by head position causing occlusion of the internal carotid artery (ICA) possibly due to intraluminal thrombus. A 68-year-old man with hypertension and diabetes visited our hospital with recurrent episodes of right-side weakness and dysarthria for three-months. These symptoms were easily provoked by looking up with the head bent back. Conventional angiography showed a severe stenosis of the left proximal ICA, with a round contrast-filling defect indicative of an
Correspondence: Keun-Hwa Jung*, Department of Neurology, Seoul National University Hospital, 101, Daehangno, Jongno-gu, Seoul, 110-744, South Korea. E-mail: [email protected] Conflict of interest: None declared. DOI: 10.1111/ijs.12349
intraluminal thrombus (Fig. 1a). Diamox single-photon-emission computed tomography showed a decreased basal perfusion and reduced vascular reserve in the left frontoparietotemporal area. Transcranial Doppler monitoring was performed during changes in neck position. With neck extension, the left middle cerebral artery flow was dampened, and the mean flow velocity was substantially decreased from 32 cm/s to 20 cm/s. For carotid stenting, the MO.MA Ultra (Medtronic, Seoul, Korea), a proximal cerebral protection device, was navigated into the left external carotid artery (ECA). Total proximal carotid flow arrest was induced with balloon occlusion of the common carotid artery and proximal ECA (Fig. 1b). Stenting of the left proximal ICA was performed without procedural complication (Fig. 1c). The recurrent TIA provoked by neck extension resolved afterward. Hypoperfusion TIA provoked by head position has been reported to arise in the vertebrobasilar system, where positional blood flow compromise occurs because of anatomical characteristics (2). Meanwhile, only two cases of positional TIA in the cervical carotid artery system have been reported (3,4). We propose that the mechanism of positional carotid ischemia in this case was a mobile thrombus plugging that compromised left ICA flow. The
high risk of procedural embolism during carotid stenting was overcome by the proximal cerebral protection device (5). Han-Gil Jeong1,2, Keun-Hwa Jung1,2*, and Jae-Kyu Roh1,2 1 Department of Neurology, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea 2 Program in Neuroscience, Neuroscience Research Institute, Seoul National University Medical Research Center, College of Medicine, Seoul National University, Seoul, South Korea
References 1 Klijn CJ, Kappelle LJ, Tulleken CA, van Gijn J. Symptomatic carotid artery occlusion a reappraisal of hemodynamic factors. Stroke 1997; 28:2084–93. 2 Kuether TA, Nesbit GM, Clark WM, Barnwell SL. Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency. Neurosurgery 1997; 41:427–33. 3 Sebastian J, Derksen C, Khan K, Saqqur M. Hemodynamic assessment of cervical internal carotid artery stenosis during head manipulation: case report. J Stroke Cerebrovasc Dis 2011; 20:479–81. 4 Nehls DG, Marano SR, Spetzler RF. Positional intermittent occlusion of the internal carotid artery. J Neurosurg 1985; 62:435–7. 5 Ansel GM, Hopkins LN, Jaff MR et al. Safety and effectiveness of the INVATEC MO. MA® proximal cerebral protection device during carotid artery stenting: results from the ARMOUR pivotal trial. Catheter Cardiovasc Interv 2010; 76:1–8.
Fig. 1 (a) Severe left proximal internal carotid artery stenosis with intraluminal thrombus (black arrow). (b) Total proximal carotid flow arrest is induced by balloon occlusion of the external carotid artery (long arrow) and the common carotid artery (short arrow). (c) Poststenting angiography.
E34
Vol 9, October 2014, E34
© 2014 World Stroke Organization
Correspondence: Keun-Hwa Jung*, Department of Neurology, Seoul National University Hospital, 101, Daehangno, Jongno-gu, Seoul, 110-744, South Korea. E-mail: [email protected] Conflict of interest: None declared. DOI: 10.1111/ijs.12349
intraluminal thrombus (Fig. 1a). Diamox single-photon-emission computed tomography showed a decreased basal perfusion and reduced vascular reserve in the left frontoparietotemporal area. Transcranial Doppler monitoring was performed during changes in neck position. With neck extension, the left middle cerebral artery flow was dampened, and the mean flow velocity was substantially decreased from 32 cm/s to 20 cm/s. For carotid stenting, the MO.MA Ultra (Medtronic, Seoul, Korea), a proximal cerebral protection device, was navigated into the left external carotid artery (ECA). Total proximal carotid flow arrest was induced with balloon occlusion of the common carotid artery and proximal ECA (Fig. 1b). Stenting of the left proximal ICA was performed without procedural complication (Fig. 1c). The recurrent TIA provoked by neck extension resolved afterward. Hypoperfusion TIA provoked by head position has been reported to arise in the vertebrobasilar system, where positional blood flow compromise occurs because of anatomical characteristics (2). Meanwhile, only two cases of positional TIA in the cervical carotid artery system have been reported (3,4). We propose that the mechanism of positional carotid ischemia in this case was a mobile thrombus plugging that compromised left ICA flow. The
high risk of procedural embolism during carotid stenting was overcome by the proximal cerebral protection device (5). Han-Gil Jeong1,2, Keun-Hwa Jung1,2*, and Jae-Kyu Roh1,2 1 Department of Neurology, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea 2 Program in Neuroscience, Neuroscience Research Institute, Seoul National University Medical Research Center, College of Medicine, Seoul National University, Seoul, South Korea
References 1 Klijn CJ, Kappelle LJ, Tulleken CA, van Gijn J. Symptomatic carotid artery occlusion a reappraisal of hemodynamic factors. Stroke 1997; 28:2084–93. 2 Kuether TA, Nesbit GM, Clark WM, Barnwell SL. Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency. Neurosurgery 1997; 41:427–33. 3 Sebastian J, Derksen C, Khan K, Saqqur M. Hemodynamic assessment of cervical internal carotid artery stenosis during head manipulation: case report. J Stroke Cerebrovasc Dis 2011; 20:479–81. 4 Nehls DG, Marano SR, Spetzler RF. Positional intermittent occlusion of the internal carotid artery. J Neurosurg 1985; 62:435–7. 5 Ansel GM, Hopkins LN, Jaff MR et al. Safety and effectiveness of the INVATEC MO. MA® proximal cerebral protection device during carotid artery stenting: results from the ARMOUR pivotal trial. Catheter Cardiovasc Interv 2010; 76:1–8.
Fig. 1 (a) Severe left proximal internal carotid artery stenosis with intraluminal thrombus (black arrow). (b) Total proximal carotid flow arrest is induced by balloon occlusion of the external carotid artery (long arrow) and the common carotid artery (short arrow). (c) Poststenting angiography.
E34
Vol 9, October 2014, E34
© 2014 World Stroke Organization
