AJR 2001; 176:1603
© American Roentgen Ray Society
Fragmentation of an Intracerebral Embolus After IV Tissue Plasminogen Activator Treatment
Mihran Artinian and
Viken Babikian
Harvard Medical School Boston, MA 02115
Boston University School of Medicine Boston, MA 02118-2526
A 49-year-old man was admitted to the hospital for evaluation of right
lower extremity caludication. He had no history of cerebrovascular disease,
and findings of the neurologic examination were normal. Approximately 2 hr
after undergoing aortic arch aortography, the patient developed a sudden
neurologic deficit, and at examination was found to have a global aphasia with
mild right-sided weakness in his face and arm. The patient's vital signs were
stable. A brain CT scan obtained 1 hr later showed an area of low attenuation
in the left insular cortex as well as a calcific plaque or clot in the left
middle cerebral artery M1 segment (Fig.
1A). Brain infarction was diagnosed. IV tissue plasminogen
activator was administered according to the National Institute of Neurological
Disorders and Stroke protocol
[1] within 2 hr of onset of
symptoms.
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Fig. 1A. —49-year-old man with global aphasia and sudden onset of right
arm and facial weakness. Unenhanced brain CT scan obtained 1 hr after onset of
stroke symptoms shows calcific plaque or clot (arrow) in left middle
cerebral artery distal M1 segment. No other emboli are seen in middle cerebral
artery branches.
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A follow-up brain CT scan obtained 20 hr after onset of stroke symptoms
revealed fragmentation of the original plaque or clot into at least two
smaller emboli with distal migration (Figs.
1C and
1D). There was also hemorrhagic
transformation of the infarcted area (Figs.
1B and
1C). Further examination of the
patient on angiography showed neither stenosis nor occlusion of the left
middle cerebral artery M1 segment. A 60% stenosis of the left internal carotid
artery origin was detected. The neurologic deficit improved during the
subsequent days with a gradual recovery of speech and a complete resolution of
the weakness. At discharge, the patient was taking only aspirin.
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Fig. 1C. —49-year-old man with global aphasia and sudden onset of right
arm and facial weakness. Unenhanced brain CT scans show evidence of
hemorrhagic transformation. M1 segment embolus is no longer visible, but its
fragments can now be seen in operculofrontal (arrow, C) and
insular (arrow, D) branches of middle cerebral artery.
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Fig. 1D. —49-year-old-man with global aphasia and sudden onset of right
arm and facial weakness. Unenhanced brain CT scans show evidence of
hemorrhagic transformation. M1 segment embolus is no longer visible, but its
fragments can now be seen in operculofrontal (arrow, C) and
insular (arrow, D) branches of middle cerebral artery.
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Fig. 1B. —49-year-old man with global aphasia and sudden onset of right
arm and facial weakness. Follow-up unenhanced CT scan obtained 20 hr after
onset of stroke more clearly shows low-attenuation area in left frontal and
insular cortex.
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Emboli that occlude intracranial arteries and cause brain ischemia are
usually difficult to monitor clinically in patients. Follow-up angiographic
studies suggest acute occlusions of the principal brain arteries spontaneously
resolve within days after the onset of symptoms. Pathologic examination of the
brain, which often takes place weeks after the stroke, can show occlusions of
distal arterioles. Clot lysis and arterial patency can be revealed on
angiography during intraarterial thrombolysis
[2]. A favorable prognosis is
associated with early reestablishment of flow to the ischemic brain.
Our patient is an example of a case of early fragmentation and distal
migration of an embolus. These events occurred in association with IV tissue
plasminogen activator administration and subsequent gradual improvement of the
neurologic deficit. These brain CT findings may be of interest to physicians
caring for patients with acute stroke.
References
-
National Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke.
N Engl J Med
1995;333:1581
-1587[Abstract/Free Full Text]
-
del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent
M. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct
arterial delivery in acute middle cerebral artery stroke.
Stroke
1998;29:4
-11[Abstract/Free Full Text]
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