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Washington University Experience | VASCULAR | Infarct - Embolic | 22A0 Case 22 History
Case 22 History ---- The decedent was a 60-year-old woman who presented with slurred speech, right sided paralysis, and right sided facial droop. Head CT demonstrated a left MCA/ACA stroke, a hyperdense left MCA sign, and no hemorrhage. She received tPA at 0901 hours. CT angiography revealed occlusion of the left internal carotid artery, just distal to the carotid bifurcation, with occlusion extending distally to the M1 segment (of the left MCA). There was no underlying stenosis of the associated vessels. Neuro-intervention was able to pass an intravascular device through her occlusion, but her clot migrated, resulting in occlusions within the M2 segment of left MCA, and the A2 segment (of the left ACA); the M2 occlusion was subsequently opened with complete perfusion anteriorly; there was more distal migration and fragmentation of the distal left posterior division embolus (leaving very small distal defects in parietal branches), but perfusion was restored to the entire MCA distribution due to collateral flow, The left A2 segment remained occluded, but the restored left MCA provided some pial collateral flow to the A2 territory. Nevertheless, she had residual aphasia and right hemiparesis. Carotid Angiography on 02/15 found complete occlusion of the right internal carotid artery just distal to the carotid bifurcation. ---- Intravascular devices have been reported to release fragments of hydrophilic polymeric coating that can occlude downstream vessels. Because there were several intravascular procedures in this patient’s course, it is difficult to determine precisely which of them may have generated emboli. However, anatomical association of such emboli with at least one histologically relatively less chronic infarct (right centrum semiovale), suggests that some of the procedure-related infarcts probably occurred in 02/2016. The associations of some other emboli with other regions of infarction appear to be less clearly causative, and may be coincidental. How these putative polymer-associated infarcts may have impacted the decedent’s clinical course, if at all, is unclear.
