EMBOLUS TO NEW TERRITORY (ENT) IN A LARGE VESSEL DISEASE MIMICKING CARDIOEMBOLIC INFARCTION – A CASE REPORT
1 Department of Neurology, College of Medicine, The Catholic University of Korea
2 Department of Radiology, College of Medicine, The Catholic University of Korea
Background & Significance Pseudo-steno-occlusion of the proximal ICA is rare in an acute stroke patient with atrial fibrillation. Here we report a case with early recurrent stroke during the acute stage of a cardioembolic infarction at first encountered as a large artery stroke. Case An 83-year-old woman came to the ER for right hemiparesis. She had mild motor aphasia with right hemiparesis (upper MRC grade III, lower IV). In the TOF MRA, severe stenosis of the left proximal ICA with severe stenosis of the M2 inferior branch of the left MCA was found. In the diffusion images, multifocal embolic infarctions were found in the left MCA territory. The initial electrocardiogram (ECG) was normal. She was given aspirin and clopidogrel for the prevention of recurrent stroke and the preparation for carotid stenting. On hospital day 3, sudden tachycardia was detected, and ECG showed atrial fibrillation with a rapid ventricular response. To find any abnormal findings such as cerebral edema or hemorrhagic transformation, we planned a follow-up CT scan. On hospital day 4, however, she was found as a drowsy mental status with left hemiplegia. The follow-up CT angiography revealed right MCA occlusion and we performed endovascular suction thrombectomy and the left CCA angiography. At the second pass, the right MCA was fully recanalized (modified TICI grade 3) and the previously stenosed left proximal ICA was slightly regressed and the intraluminal filling defect was found. After switching to edoxaban for the secondary prevention of the cardioembolic stroke, she was discharged home at modified Rankin scale 2.
Cardioembolic stroke due to atrial fibrillation may cause intraluminal thrombosis mimicking large vessel steno-occlusive disease. The clinical course and the meticulous evaluation for any possible cause for cardioembolic stroke are important for the prevention of recurrent stroke during an acute stage.