Ali Liaquat, Safan Abeer, Kamran Sadat, Akhtar Naveed, Elalamy Osama
Neurology, Hamad General Hospital, Doha, QAT.
Neurology, Hamad Medical Corporation, Doha, QAT.
Cureus. 2021 Aug 7;13(8):e16977. doi: 10.7759/cureus.16977. eCollection 2021 Aug.
Atherosclerosis is a systemic pathologic process, may involve aorta and is important cause of systemic embolization. The risk of embolism is increased for mobile and complex aortic plaques that are >4 mm thick. The most common manifestations are stroke, transient ischemic attack (TIA) and peripheral embolization. Imaging modalities used include transesophageal echocardiogram (TEE), CT angiography and magnetic resonance angiography (MRA). The mainstays of medical treatment are antiplatelets and statin. The role of anticoagulation is reserved for plaques with thrombotic component. There were two patients who presented with large acute ischemic stroke with high grade, floating aortic arch thrombus and complex aortic arch plaques. In one of cases, after 10-day follow-up CT aortic angiography showed completely resolved thrombus after being treated with IV tissue plasminogen activator (TPA) followed by low molecular weight heparin (LMWH). The risk of embolism depends on size of aortic plaques and mobility. TEE is modality of choice for thoracic aortic plaques. Aortic plaques >4 mm are independent predictors of recurrent ischemic stroke. There are limited data available for off-label use of intravenous thrombolysis and mechanical thrombectomy (MT) in presence of aortic arch thrombus in acute ischemic strokes. These two case reports help in recognition of aortic arch complex plaques as independent risk factor for recurrent stroke. The right patients may consider about the use of intravenous alteplase and MT performed via trans-brachial access after excluding aortic dissection and aneurysm. In future, multicenter, randomized controlled trials will be required for safety of IV TPA and MT.
动脉粥样硬化是一种全身性病理过程，可能累及主动脉，是全身性栓塞的重要原因。厚度>4 mm的可移动性复杂主动脉斑块会增加栓塞风险。最常见的表现是中风、短暂性脑缺血发作（TIA）和外周栓塞。使用的影像学检查方法包括经食管超声心动图（TEE）、CT血管造影和磁共振血管造影（MRA）。药物治疗的主要手段是抗血小板药物和他汀类药物。抗凝治疗仅适用于有血栓形成成分的斑块。有两名患者出现大型急性缺血性中风，伴有高度、漂浮的主动脉弓血栓和复杂的主动脉弓斑块。在其中一例中，经过10天的随访，CT主动脉血管造影显示，在接受静脉注射组织纤溶酶原激活剂（TPA）随后使用低分子量肝素（LMWH）治疗后，血栓完全溶解。栓塞风险取决于主动脉斑块的大小和可移动性。TEE是检查胸主动脉斑块的首选方法。厚度>4 mm的主动脉斑块是复发性缺血性中风的独立预测因素。对于急性缺血性中风伴有主动脉弓血栓时静脉溶栓和机械取栓（MT）的超说明书使用，可用数据有限。这两例病例报告有助于认识到主动脉弓复杂斑块是复发性中风的独立危险因素。在排除主动脉夹层和动脉瘤后，合适的患者可考虑使用静脉注射阿替普酶和经肱动脉途径进行MT。未来，需要进行多中心随机对照试验来评估静脉注射TPA和MT的安全性。
