Ulcerative plaques in Bovine aortic arch : Etiology of multi-territory ischemic stroke

초록

Introduction: Multi-territory ischemic stroke can be caused by proximal vascular lesion. Case Presentation: A 73-year-old male patient presented with a series of ischemic strokes over the last 3 months. He had history of hypertension, diabetes mellitus and stable angina. Initially, the brain magnetic resonance image revealed multiple tiny diffusion restrictions in the left cerebral hemisphere and right cerebellum. Sequential tests showed he had a severe stenosis of left proximal internal carotid artery of 76.7% NASCET. He also had Bovine aortic arch, a common origin of the brachiocephalic trunk and left common carotid artery, with the brachiocephalic artery outpouching aneurysm. He was successfully treated with the carotid endarterectomy of the left proximal ICA (ICA) with dual antiplatelet therapy. However, 2 month later, he had the recurrent stroke in the right posterior cerebral artery (PCA) and right middle cerebral artery (MCA) territories. One month later, he had another recurrent stroke in the left MCA territory plus left PCA territory. Based on his medical history, cerebral embolism of cardiac origin was strongly suspected. Follow-up transesophageal echocardiography test was therefore performed and we found 7mm ulcerative plaques at greater curvature of aortic arch. A multidisciplinary team including cardiovascular surgeons, cardiologists, radiologists and neurologists met. As antiplatelet therapy was not sufficient to prevent recurrent infarction, the partial debranching hybrid stent graft was chosen. The left subclavian artery to left common carotid artery bypass was performed first, followed 1 month later by a successful brachiocephalic trunk stent graft to treat brachiocephalic aneurysm. Finally, the bovine aortic arch was removed and no further ischemic events have manifested after the treatment. Discussion: Ulcerated plaques in the bovine aortic arch is the embolic source that can be surgically eradicated.