Key result
In two patients with acute ischemic stroke from complex aortic arch plaques, one showed complete thrombus resolution after IV alteplase, highlighting these plaques as a stroke risk factor.
Why the study?
Limited data are available for the off-label use of intravenous thrombolysis and mechanical thrombectomy in the presence of aortic arch thrombus in acute ischemic strokes.
Case Report (n=2)
Complex aortic arch plaques with floating thrombi are an important risk factor for acute ischemic stroke, and IV thrombolysis may be considered in eligible patients to resolve the thrombus.
Complex aortic plaques may cause stroke; leaves open optimal antithrombotic strategies in Level 5 data.
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.
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Ali et al. (2021) conducted a case report in Acute thromboembolic ischemic stroke (n=2). IV tissue plasminogen activator (TPA) was evaluated on Clinical and radiological outcome (thrombus resolution and survival). In two patients with acute ischemic stroke from complex aortic arch plaques, one showed complete thrombus resolution after IV alteplase, highlighting these plaques as a stroke risk factor.
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