Recurrence of embolism post intravenous thrombolysis on an asymptomatic bilateral carotid stenosis

Abstract

Atherosclerosis is the most common cause of stroke and patients with stroke due to large-vessel atherosclerosis are at the highest risk of recurrent stroke. Carotid endarterectomy (CEA) is a secondary prevention method for reducing the risk of stroke, but endovascular therapy has developed rapidly in recent years. The long-term therapeutic efficacy of endovascular stenting for carotid artery stenosis has been shown not to be inferior to CEA. We present the case of a 61-year-old female, smoker, dyslipidemic, hypertensive, therapeutically neglected, who suddenly developed right hemiplegia accompanied by central facial palsy and motor aphasia. The inclusion criteria allowed the initiation of intravenous thrombolytic therapy. At 2 and 24 hours after thrombolysis the evolution was favorable with the almost complete recovery of motor and speech production deficits. At 48 hours after thrombolysis, the patient experienced rapid decompensation and worsening, with recurrence of hemiplegia on the same side and motor aphasia. Cervical echoDoppler and cerebro-cervical CT angiography (CTA) revealed a complete right internal carotid artery (ICA) and quantified the degree of left ICA stenosis asymptomatic up to that time. The case was a challenge in terms of subsequent secondary prevention. Although most studies dealt with endarterectomy as a treatment for tight carotid stenosis, in the here reported case this was not possible, so we had to resort to angioplasty with placement of a self-expandable stent in the left ICA.