An 80-year-old man presented to the emergency department (ED) with persistent left-sided hemiplegia and neglect. His past medical history was significant for atrial fibrillation, congestive heart failure, and prior right middle cerebral artery stroke. A computed tomography angiogram of the head and neck obtained in the ED revealed a large saddle thrombus of the supra-aortic arch vessels (A). The origins of the innominate and left common carotid arteries were occluded, with the tail of the thrombus extending up to the left carotid bulb and an embolic occlusive thrombus in the right carotid siphon extending into the right middle cerebral artery including the M1 and M2 segments. Magnetic resonance imaging of the brain revealed several punctate embolic infracts involving the left corona radiata and left perirolandic vertebral region (B and C, right) with extension of his prior right middle cerebral artery infarct (B and C, left). This was consistent with multifocal embolic ischemic stroke secondary to the saddle thromboembolus.
Surgical and nonsurgical options were discussed with the family. Surgery would have included bilateral carotid cutdowns with thrombectomy of both common carotid arteries. However, the procedure would not change the clot in the right middle cerebral artery. The family elected to proceed with nonsurgical anticoagulation management with immediate heparinization and bridge to long-term warfarin treatment. He was discharged on day 5 to home with occupational and physical therapy. Four days later, he was readmitted to the ED for respiratory distress and unresponsiveness with a concern of an acute neurologic emergency. Again, continued anticoagulation management was recommended after imaging showed decreased thrombus burden. The patient was discharged from the hospital on the fourth day with no complications during the following 2 months. The patient consented to the publication of this report.
Discussion
There are multiple reports involving saddle thromboembolism of the lower aorta vessels and carotid artery bifurcations.1, 2, 3 However, a saddle thromboembolism of the supra-aortic arch vessels, especially one of this magnitude, is very rare and not well reported in the literature. Management of a saddle thromboembolism has traditionally included open vs endoluminal thrombectomy, endovascular stent deployment, and thrombolytic therapy.1, 2, 3, 4
Footnotes
Author conflict of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
Supplementary data
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References
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