Therapeutic challenges after successful thrombectomy in a patient with an antiphospholipid syndrome associated M1-occlusion: A case report

Abstract

Backround

Stroke is a frequent disorder in patients with an antiphospholipid syndrome (APS). Due to a high risk for further thromboembolic events, appropriate anticoagulation therapy in patients with an APS-associated stroke seems mandatory but drug eluting and duration is a matter of debate.

Case

A 48-year-old female patient presented with Broca’s aphasia and mild hemiparesis on the right side. Diagnostic work-up revealed left middle cerebral artery (MCA) occlusion yet without diffusion-weighted lesions. Due to a thrombocytopenia (67.00 g/l) systemic thrombolysis was not indicated and endovascular treatment was initiated 150 min after symptom onset. After successful clot retrieval, recurrent re-occlusions lead to the necessity of stent implantation and anticoagulation, respectively. On day 5 she developed a new severe right-sided hemiparesis. The magnetic resonance imaging (MRI) showed a subtotal restenosis of the left MCA despite the regular anticoagulation regime leading to a new left MCA ischaemic stroke. In the meantime, the unknown aetiology, the patients’ age and the thrombocytopenia let to further diagnostic workup. Elevated blood parameters such as lupus anticoagulant (LA)-1, LA-ratio, positive anti-nuclear antibody (ANA), p-anti-neutrophil cytoplasmic antibodies (ANCA), c-ANCA confirmed the diagnosis of APS.

Conclusion

This case report showed the feasibility of mechanical clot retrieval and stent implantation in patients with APS. Due to the elevated risk of in-stent thrombosis a prolonged therapy with glycoprotein (GP)IIb/IIIa receptor antagonists in the initial postoperative period and further anticoagulation with coumarin derivate might be needed.

Keywords

Antiphospholipid syndrome stroke thrombectomy stent

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References

Lim

. Antiphospholipid antibody syndrome. Hematology Am Soc Hematol Educ Program 2009; 2009: 233–239.

Lim

. Antiphospholipid syndrome. Hematology Am Soc Hematol Educ Program 2013; 2013: 675–680.

Cervera

Piette

J-C

Font

. Antiphospholipid syndrome: Clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients. Arthritis Rheum 2002; 46: 1019–1027.

Ruiz-Irastorza

Hunt

Khamashta

. A systematic review of secondary thromboprophylaxis in patients with antiphospholipid antibodies. Arthritis Rheum 2007; 57: 1487–1495.

Finazzi

Marchioli

Brancaccio

. A randomized clinical trial of high-intensity warfarin vs. conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS). J Thromb Haemost 2005; 3: 848–853.

Crowther

Ginsberg

Julian

. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N Engl J Med 2003; 349: 1133–1138.

Mokin

Khalessi

Mocco

. Endovascular treatment of acute ischemic stroke: The end or just the beginning? Neurosurg Focus 2014; 36: E5.

Berkhemer

Fransen

PSS

Beumer

. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 11–20.

Broussalis

Trinka

Wallner

. Thrombectomy in patients with large cerebral artery occlusion: A single-center experience with a new stent retriever. Vasc Endovascular Surg 2014; 48: 144–152.

10.

Hausegger

Hauser

Kau

. Mechanical thrombectomy with stent retrievers in acute ischemic stroke. Cardiovasc Intervent Radiol 2014; 37: 863–874.

11.

Broderick

Palesch

Demchuk

. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368: 893–903.

12.

Ciccone

Valvassori

Nichelatti

. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368: 904–913.

13.

Kidwell

Jahan

Gornbein

. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013; 368: 914–923.

14.

Goyal

Demchuk

Menon

. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 1019–1030.

15.

Abid

Frikha

Bahloul

. Acute myocardial infarction in young adults with antiphospholipid syndrome: Report of two cases and literature review. Pan Afr Med J 2011; 8: 13.

16.

Musuraca

Imperadore

Terraneo

. Successful treatment of post-exertion acute myocardial infarction by primary angioplasty and stenting in a patient with antiphospholipid antibody syndrome. Blood Coagul Fibrinolysis 2004; 15: 95–98.

17.

Badak

Güneri

Kirimli

. Primary stenting in a patient with acute myocardial infarction and primary antiphospholipid syndrome. J Invasive Cardiol 2002; 14: 194–197.

18.

Timurkaynak

Cemri

Ozdemir

. Primary angioplasty and stenting in a patient with primary antiphospholipid syndrome and thrombocytopenia. J Invasive Cardiol 2001; 13: 395–400.

19.

H-M

Lee

K-T

Chu

C-S

. Acute thrombosis after elective direct intracoronary stenting in primary antiphospholipid syndrome: A case report. Kaohsiung J Med Sci 2003; 19: 177–182.

20.

Mito

Miura

S-I

Takada

. A case of coronary artery disease with antiphospholipid syndrome that showed repeated stent thrombosis. J Cardiol Cases 2011; 4: e80–e86.

21.

Coster

van Dijk

Treurniet

FEE

. Successful intra-arterial thrombolysis beyond the accepted 6-hour time window in two young patients. J Neurol Sci 2010; 288: 182–185.

22.

Biceroglu

Ildizli Demirbas

Karaca

. Acute thrombotic occlusion of right coronary and left circumflex coronary arteries in a patient with antiphospholipid syndrome: Successful stent implantation. Case Rep Med 2010; 2010: 198594.

23.

Smukowska-Gorynia

Mularek-Kubzdela

Araszkiewicz

. Recurrent acute myocardial infarction as an initial manifestation of antiphospholipid syndrome: Treatment and management. Blood Coagul Fibrinolysis 2015; 26: 91–94.

24.

Okuma

Kitagawa

Yasuda

. Comparison between single antiplatelet therapy and combination of antiplatelet and anticoagulation therapy for secondary prevention in ischemic stroke patients with antiphospholipid syndrome. Int J Med Sci 2009; 7: 15–18.