Therapy of hypoperfusion and embolism from severe MCA stenosis with antithrombotic medication

Background and purpose: Hemodynamic ischemia in patients with large artery stenosis usually necessitates an increase of the perfusion pressure whereas an embolic pathology may be adequately handled by the administration of antithrombotic drugs. We present a patient in whom both pathologies were successfully treated by antiplatelet drugs.

Summary of case: A 48-year-old woman presented with a recurrent symptomatic severe left middle cerebral artery stenosis. MRI depicted left-hemispheric ischemic infarcts in the deep and subcortical white matter and in the cortical border-zone. Cerebrovascular reserve in the distribution territory of the stenosed artery as assessed by TCD after carbon dioxide stimulation revealed an exhausted reserve capacity. One-hour TCD monitoring detected 64 microembolic signals distal to the arterial stenosis.

Results: 24 hours after the initiation of dual antiplatelet medication with Aspirin 500 and Clopidogrel 300, which was continued by daily Aspirin 100mg and Clopidogrel 75mg for further 3 months, no microembolic signal was detected and cerebrovascular reserve had normalized accompanied by a cessation of ischemic symptoms.

Conclusion: We propose that in the presence of acute symptomatic large artery stenosis both, hemodynamic and embolic pathology may be adequately managed by antithrombotic therapy.