Recurrent Strokes due to Transient Vasospasms of the Extracranial Internal Carotid Artery
In July 1999, a previously healthy 34-year-old female patient was admitted to our hospital for the first time with an acute left-sided brachiofacial hemiparesis. She reported that similar symptoms had occurred several times in the previous 10 years but had regressed spontaneously. Aside from regular nicotine consumption, she had no other cardiovascular risk factors. In addition, she had no history of migraine headaches.\nMagnetic resonance imaging (MRI) showed an internal middle cerebral artery (MCA) territory watershed infarct, probably of hemodynamic origin. Duplex sonography on admission revealed proximal occlusions of both ICAs and retrograde flow in both supratrochlear arteries (STA). Three days later, a digital subtraction angiography showed a recanalization of the left ICA and a persistent occlusion of the right ICA at the origin, which subsequently never recanalized. On axial T1-weighted fat-suppressed images, the presence of intramural hematomas and thus arterial dissections as a cause of the bilateral ICA occlusions could be ruled out. A cerebrospinal fluid analysis was unremarkable.\nUnder the assumption of vascular spasms, the patient was treated with the calcium antagonist nimodipine (240 mg/day) and was heparinized with an aim for a partial thromboplastin time of >60 s. Despite this treatment, a transient occlusion of the left ICA, confirmed with repeated ultrasound and magnetic resonance angiography (MRA), occurred again during this first admission. The patient was discharged receiving nimodipine, and an oral anticoagulation with phenprocoumon was begun.\nIn February 2004, she was readmitted due to a short episode with paresis of the right hand and aphasia. While MRI including diffusion-weighted imaging showed no new infarction, an initial occlusion and subsequent reopening of the left ICA was documented with ultrasound and MRA. During the course of this admission, oral anticoagulation was discontinued and the patient was discharged with Aspirin and nimodipine.\nIn March 2010, February 2011 and May 2011, the patient experienced recurrent episodes with transient right-sided hemiparesis and aphasia. In all three instances, MRI revealed new small infarcts in the left MCA territory. Extensive laboratory investigations were performed twice (including virology, bacteriology and tests for thrombophilia and vasculitis), but revealed no pathological results. Likewise, 2 chest X-rays and an ultrasound of the abdomen were normal.\nSimilar to the findings in 2004, MRA and ultrasound repeatedly revealed an initial occlusion and subsequent reopening of the left ICA (fig. , fig. ) without nimodipine administration. During the episodes of left ICA occlusion, a reduced pulsatility in the left MCA, a collateralization via the posterior communicating arteries and a retrograde flow within the ipsilateral STA were observed with ultrasound. After recanalization, ultrasound showed an antegrade flow within the ipsilateral STA and a completely normalized MCA flow.\nSince May 2011, the patient has had no further ischemic symptoms. A coincidence with smoking was presumed during the first stays, but attacks appeared also after she quit smoking.