Emergent Carotid Embolectomy with TCD Intra-op Monitoring to Treat Growing Internal Carotid Artery (ICA) Thrombus Actively Embolizing to the Middle Cerebral Artery (MCA)
Jacob B Watson, Kaled Diab, Ponraj Chinnadurai, Zsolt Garami, Nora Kovacs, Lilla Juhasz, Linda Le
Houston Methodist Hospital, Houston, TX
OBJECTIVES: The objective of this case is to demonstrate the technical details and successful outcome of emergent open surgical treatment with TCD intra-op monitoring of an enlarging acute thrombus in the proximal ICA actively embolizing to the MCA and presenting as evolving stroke.
METHODS: A 36-year-old female with past medical history of stroke (with minor residual sensory deficits), essential thrombocythemia (platelets 1326k this admission), anemia, type 2 diabetes, hyperlipidemia, uterine fibroids, and polysubstance abuse presented with headache, lightheadedness, visual changes, and eye pain. Initial NIHSS 1. CTA neck showed a small intraluminal mural thrombus in the posterior medial wall of right ICA at the carotid bulb. MRI brain showed several recent strokes and subacute strokes in the right frontal/parietal lobes and basal ganglia. The following day, she developed left hemiplegia, right facial droop, left gaze preference, and right neglect. Repeat transcranial doppler (TCD) showed active embolization to the right MCA which was correlating in real-time with her worsening neurological symptoms. NIHSS had progressed to 21 within a few hours. Repeat CTA neck showed a rapid increase in size of the right ICA mural thrombus. CT Perfusion showed small area of infarct with large penumbra. Vascular surgery was consulted for emergent surgical intervention due to her stroke in evolution. After multidisciplinary discussion, the decision was made to perform a carotid embolectomy with TCD monitoring.
RESULTS: Successful removal of the proximal internal carotid artery thrombus and repair with patch angioplasty with a positive outcome and technical success.
CONCLUSIONS:
Growing internal carotid artery thrombus associated with active embolization to the MCA presents as a stroke in evolution. This video shows an open surgical approach with real-time TCD monitoring that treats this serious condition. 
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