Recurrent Cerebral Infarction Caused by Mobile Aortic Arch Thrombus Refractory to Warfarin Therapy
A 61-year-old male was presented with sudden onset of left upper and lower extremities weakness and aphasia on July 8, 2010. He has a medical history of hypertension and diabetes mellitus and had been taking medication and insulin therapy for three years. Brain MRI revealed newly developed cerebral infarction by occlusion of the right middle cerebral artery (MCA). Chest radiography, echocardiography, and transthoracic echocardiography did not show any abnormalities. Laboratory test for hypercoagulability and lipid profile at admission was normal: low-density lipoprotein 116 mg/dL (reference, 0 to 130 mg/dL), total cholesterol 197 mg/dL (reference, 0 to 200 mg/dL), and homocysteine 7.45 µmol/L (reference, 5.08 to 15.39 µmol/L). However, TEE demonstrated echogenic finger-like thrombi with rocking motion (9.6 and 8 mm) on the top of the aortic arch (just proximal to the subclavian artery) with minimal atherosclerotic wall. Chest CT showed multiple ulcerations with intramural hematoma ().\nWe diagnosed embolic cerebral infarction originating from the aortic arch thrombi. The patient was initially treated with intravenous unfractionated heparin for 5 days. Because the location of the aortic arch thrombus did not allow surgical treatment, the patient was treated with 5 mg warfarin, initially, with an internationalized ratio (INR) between 2 and 3. Three days after onset, a rehabilitation program began at the bedside. Training for passive range of motion exercise, rolling and sitting was conducted at bedside. After transferring to the ward, gait training, strengthening exercises of left side muscles and balance training were performed. At the first discharge, 35 days from onset, he had fair grade of weakness in the left proximal upper and lower extremities and poor+grade in the left distal upper and lower extremities, according to the manual muscle test and grade II spasticity by Modified Ashworth Scale (MAS) in the left upper and lower extremities. He was able to walk indoors independently using a straight cane and plastic ankle-foot orthosis (AFO). The Korean-Modified Barthel Index (K-MBI) was 90 points and the Korean-National Institutes of Health Stroke Scale (K-NIHSS) was 5 points. The prescribed warfarin of 4 mg and INR was 2.5.\nOn November 8, 2010, the patient was admitted again with progressive weakness of the left extremities and dysarthria. He showed poor grade in the left proximal upper extremities and distal lower extremities. He was not able to walk or sit up by himself. Brain MRI revealed new developed anterior cerebral arterial infarction, and MR angiography conveyed obstruction of distal anterior cerebral artery (). He was treated with increased doses of warfarin by up to 5 mg and comprehensive rehabilitation was initiated. At the second discharge, onset after 25 days, it was examined that the left proximal and distal upper extremities were fair grade, the muscles of the left hip and knee were poor+, ankle was poor, and left extremities had spasticity with grade II by MAS. He was able to walk using a straight cane and plastic AFO under minimal assistance. K-MBI was 68 points and K-NISS was 7 points. He was hospitalized again on April 15, 2011 due to weaknesses in the left extremities and dysarthria, while maintaining 5 mg of warfarin with INR at 2. Left upper and proximal lower extremities were poor grade, and ankle dorsiflexor was trace grade. Brain MRI disclosed the recurrence of cerebral infarction of the right MCA territory. He was unable to walk and showed depression symptoms due to stroke recurrence. He and his wife wanted to be discharged after an acute phase treatment, 10 days after onset, and maintain 3 mg of warfarin (INR 3.14) medication at the outpatient clinic. At the third discharge, it was examined that the muscle strength of his left upper and lower extremities was poor grade; he was able to walk 30 m indoor using a quadricane and AFO under moderate assistance. K-MBI was 60 point. On January 2, 2012, he was unfortunately re-admitted to the stroke unit again with progressive weakness of left extremities and aphasia. He was again diagnosed with right MCA infarction. Brain MR angiography revealed occlusion in the M1 area of the right MCA territory. TEE showed one hypermobile aortic arch thrombus of approximately 3 mm in size at the top of the aortic arch, which was more decreased compared with the last study (2 mobile thrombus, 9.6 and 8 mm). He was treated with anticoagulation and comprehensive rehabilitation again. Also, he was prescribed 4 mg of warfarin (INR 2.61) and 100 mg of aspirin for additional thrombus control, along with 40 mg of atorvastatin. At the fourth discharge after rehabilitation therapy, 30 days after onset, the strength of muscles in the upper left extremity were trace grade, the muscles of hip were poor, knees were trace, ankles were trace, and the spasticity in the left upper and lower extremities was grade III by MAS. He needed at least minimal assistance for daily activities, including sitting up and standing up. He was able to walk 10 m with the help of a quadricane and AFO under a moderate degree of assistance. K-MBI was 47 points and K-NIHSS was 8 points.