London, United Kingdom 2013 30 Interesting and challenging cases Recurrent stroke in young cannabis user A.F. Santos1, M. Rodrigues2, J. Fernandes3, J. Rocha4, R. Maré5, C. Ferreira6 Neurology Department, Hospital de Braga, Braga, PORTUGAL1, Neurology Department, Hos-pital de Braga, Braga, PORTUGAL2, Neuroradiology Department, Hospital de Braga, Braga, POR-TUGAL3, Neuroradiology Department, Hospital de Braga, Braga, PORTUGAL4, Neurology Depart-ment, Hospital de Braga, Braga, PORTUGAL5, Neurology Department, Hospital de Braga, Braga, PORTUGAL6 Background: Drug misuse is a known risk factor for cerebrovascular disease, especially among young people. Cannabis is the most widely consumed illicit drug worldwide, but has only occasion-ally been associated with ischemic vascular events. Vasospasm, hypotension, arrhythmias, and vas-culitis have been proposed as potential mechanisms. Case report: A 27-year-old man, heavy cannabis user, was admitted in August 2006 with recent left basal ganglia infarct. His urine tested positive for cannabinoid. Laboratory studies, carotid and ver-tebral ultrasound, transesophageal echocardiogram (TEE) and holter were normal. CSF analysis: 14 cells (75% lymphocytes). Transcranial Doppler (TCD): left M1 MCA occlusion, confirmed by angi-ography. CNS vasculitis was suspected and prednisone was started. In February 2007: left hemicho-rea; right lenticulostriate infarct on CT scan. Urine: positive for cannabinoid. Laboratory studies (including MELAS, Fabry, CADASIL), CSF: normal. TCD with bubble test and TEE suggested the hypothesis of small patent foramen ovale (PFO). Brain MRI: multiple infarcts; brain MRI angiogra-phy: “stop” signal in M1. Hipocoagulation was started. In August 2008: abrupt onset of a left hemi-paresis. Urine: positive for cannabinoid. Laboratory studies, CSF, carotid and vertebral ultrasound, echocardiogram, holter: normal. Brain MRI: multiple recent ischemic lesions in the right carotid ter-ritory, old lesions bilaterally. Brain MRI angiography: diffuse irregularities of the anterior and poste-rior circulation; MCA peripheral branches occlusion. Aspirin and prednisolone were restarted, with no repetition of cerebrovascular events. Discussion: We believe that the recurrent strokes in our patient were associated with the chronic use of cannabis, being vasculitis the most likely mechanism. Toxicological screening for cannabinoid metabolites should be done in young stroke patients with no apparent vascular risk factors or evi-dence E-Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854 609 of dissection. 29 Interesting and challenging cases Antiplatelet therapy in floating thrombus L. Rubio Flores1, J.C. Rodríguez-Carrillo2, G. Reig Roselló3, A. Ximénez Carrillo4, J.A. Vivancos Mora5 Stroke Unit. La Princesa Universitary Hospital. Instituto de Investigación Sanitaria Princesa., Madrid, SPAIN1, Stroke Unit. La Princesa Universitary Hospital. Instituto de Investigación Sani-taria Princesa., Madrid, SPAIN2, Stroke Unit. La Princesa Universitary Hospital. Instituto de Inves-tigación Sanitaria Princesa., Madrid, SPAIN3, Stroke Unit. La Princesa Universitary Hospital. In-stituto de Investigación Sanitaria Princesa., Madrid, SPAIN4, Stroke Unit. La Princesa Universitary Hospital. Instituto de Investigación Sanitaria Princesa., Madrid, SPAIN5 Background: The floating thrombus within the carotid artery (CFT) is a rare cause of cerebral in-farcts. The management of these cases constitutes a challenge. Method: We report a case of a patient with a left MCA stroke caused by a CFT. Results: A 78 year-old man was admitted to our hospital because of a 2-day weakness in the right leg. His past medical history included hypertension, dysli-pemia, ex-smoker, non-Hodgkin Lymphoma in remission, frontal basal cell carcinoma removed in 2009 and chronic renal failure secondary to right renal artery stenosis. Neurological examination revealed NIHSS 3 with mild paresis of the right leg, severe hypoesthesia and sensitive extinction on the right side. Routine laboratory testing showed mild renal failure and hyperkalemia. The ECG showed sinus rhythm without atrial fibrillation. CT revealed an acute infarct of the left frontoparietal cortex and a chronic lacunar infarct in the left caudate nucleus. At 3 days after admission the patient suddenly began with aphasia and severe right hemiparesis NIHSS 18. In-hospital Stroke Code was activated. We asked for a new CT and CTA which showed atheromatous plaques with calcifications and a filling defect related to non-occlusive CFT located in the distal bifurcation of the internal ca-rotid. It also demonstrated a subacute infarct in left frontoparietal cortex and an acute infarct in the left internal carotid territory with a significant penumbral area. Intravenous tPA, intraarterial pro-cedures and anticoagulation were not considered due to the recent cerebral infarct and the lack of great-vessel occlusion. The patient was conduced to the Stroke Unit and started on clopidogrel. Af-ter few days he improved rapidly and was discharged with a NIHSS of 2. A CTA performed 10 days later showed almost complete dissolution of the CFT. Conclusions: We noted that the FT is frequent-ly associated with early stroke recurrence. We highlighted the good outcome of antiplatelet therapy in a high-risk patient.
Karger_ESC London_2013
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