Rescue Use of Tirofiban for Acute Carotid In-Stent Thrombosis

Carotid artery stenting is widely performed for extracranial carotid artery stenosis. In-stent thrombosis is a rare but potentially devastating complication. We present a case of acute in-stent thrombosis immediately following stent insertion and post-balloon dilatation in a 64-year-old male. Thrombosis was successfully treated by intravenous tirofiban, a glycoprotein IIb/IIIa receptor inhibitor.

Rescue Treatment with Intra-arterial Tirofiban Infusion and Emergent Carotid Stenting

Rapid arterial rethrombosis is associated with high-grade residual stenosis and usually occurs at the site of the initial occlusion, resulting in reocclusion of the recanalized artery. Platelets may play an active role in such rethrombosis after thrombolytic-induced clot lysis. Given that glycoprotein IIb/IIIa receptor blockers, like tirofiban, prevent thrombus formation by inhibiting the final common pathway of platelet aggregation, they may be helpful for treating rethrombosis after thrombolysis. A 64-year-old man presented with an acute ischemic stroke due to internal carotid artery (ICA) occlusion. The ICA was recanalized by intravenous thrombolysis but reoccluded shortly after recanalization. The reoccluded ICA was successfully recanalized using intra-arterial tirofiban. A carotid stent was subsequently inserted to relieve severe stenosis and to prevent recurrent stroke. Here, we report a case of rescue treatment of a successfully recanalized ICA by intra- arterial tirofiban. We suggest that rescue use of intra-arterial tirofiban may be effective and safe, especially in hemorrhage prone situations, due to the relatively lower dose of tirofiban compared with intravenous doses.

Lacunar Infarction in Type 2 Diabetes Is Associated with an Elevated Intracranial Arterial Pulsatility Index

PURPOSE: The arterial pulsatility index (PI) is measured by transcranial Doppler ultrasonography (TCD) and is postulated to reflect the vascular resistance distal to the artery being examined. An increased PI of the intracranial artery is often reported with diabetes mellitus (DM), old age, hypertension, intracranial hypertension, vascular dementia, and small artery disease. Microvascular complication of DM, which may contribute to cerebral infarction, involves the small perforating artery and may influence the PI of the proximal artery. MATERIALS AND METHODS: We performed a TCD examination in patients with type 2 DM with acute lacunar infarction (DML, n=35), type 2 DM without cerebral infarction (DMO, n=69), and in control cases with no DM or cerebral infarction (control group, n=41). We then compared the TCD findings among these groups. RESULTS: The PI was significantly higher in the DML and DMO groups than in the control group (1.05, 0.93, 0.73. respectively, for the right middle cerebral artery; 1.04, 0.90, 0.73, respectively, for the left middle cerebral artery; 0.97, 0.89, 0.70, respectively, for the basilar artery). The PI was also significantly higher in the DML group than in the DMO group for both middle cerebral arteries. The flow velocity was comparable among the three groups. CONCLUSION: The elevated PI of the intracranial arteries may reflect diabetic cerebral microvascular complications. The PI measurement using TCD may be a useful predictor of lacunar infarction in type 2 DM patients.

Increased Pulsatility Index in Acute Lacunar Infarction with Type II Diabetes

BACKGROUND: The pulsatility index (PI) measured by a transcranial Doppler (TCD) has been postulated to reflect the vascular resistance that is distal to the artery being examined. Therefore, pathologies of small perforating arteries may affect the PI of the proximal artery. Microangiopathy is a common vascular complication of diabetes mellitus (DM), which may contribute to the development of small infarctions involving the perforating artery, and may be reflected on the PI. METHODS: We enrolled patients with acute cerebral infarctions who were examined by TCD, MRI, and MRA and fulfilled the following criteria: 1)an infarction of less than 2 cm size involving a single perforating arterial territory; 2)no significant arterial stenosis on MRA; and 3)no cardioembolic sources. Patients were divided into either a group with DM, or without and TCD findings were compared. RESULTS: The DM group showed higher PI than non-DM (0.99 v.s. 0.85 for the right middle cerebral artery; 1.02 v.s. 0.85 for the left middle cerebral artery; and 0.94 v.s. 0.78 for the basilar artery). The mean flow velocity was comparable between the groups. Multivariate linear regression analysis revealed that the duration of DM was a significant predictor of elevated PI of the bilateral MCA and basilar artery and that age was another significant predictor in the case of basilar artery. CONCLUSIONS: The elevated PIs in DM patients suggest the possible role of diabetic microvascular complications in the development of the lacunar infarction. The PI measurement using TCD may be a useful marker of the lacunar infarction, especially in DM patients.

A Case of Congenital Neuromuscular Disease with Uniform Type 1 Fiber

Congenital neuromuscular disease with uniform type 1 fiber (CNMDU1) is a rare but distinct form of nonprogressive, congenital myopathy. CMNDU1 is characterized by a type 1 muscle fiber content of more than 99%. This condition has only been previously described in a few reports. The authors report an 11-year-old girl who exhibited delayed developmental milestones, proximal muscle weakness, and bilateral ptosis. Her serum creatine kinase level was normal but an electromyographic study showed myopathic changes. A biopsy specimen from the left deltoid muscle revealed a uniformity of type 1 fibers (greater than 99%) with a moderate variation in fiber size. This is the first case of CNMDU1 reported in Korea.