Successful Recanalization by Intravenous Thrombolysis in a Patient With Calcified Cerebral Emboli With Major Vessel Occlusion: A Case Report

TL;DR

A patient with calcified cerebral emboli and major vessel occlusion showed successful recanalization after intravenous thrombolysis.

Contribution

Demonstrates that intravenous thrombolysis can be effective for calcified cerebral emboli with major vessel occlusion.

Findings

Intravenous thrombolysis led to symptom improvement and recanalization of the right M2 branches.

Calcification in the brain sulcus was associated with a missed diagnosis of arterial occlusion.

Follow-up imaging showed distal migration of calcification following treatment.

Abstract

A 69-year-old man, with a history of left superficial temporal artery-middle cerebral artery bypass due to cerebral infarction by left internal carotid artery occlusion, was hospitalized with acute right hemispatial neglect and left hemiparesis. Diffusion-weighted imaging showed a high-intensity lesion in the right insular cortex. Although there seemed to be no arterial occlusion in magnetic resonance angiography (MRA), non-contrast computed tomography (CT) on admission showed calcification in the right Sylvian fissure. As hyperacute ischemic stroke within 4.5 hours after onset, we used an intravenous recombinant tissue plasminogen activator, and his symptoms improved. Follow-up MRA revealed recanalization of the right M2 branches with distal migration of calcification. Although calcification was identified on non-contrast CT in the initial assessment, the diagnosis of middle cerebral artery occlusion was missed. Therefore, arterial occlusion should be considered when calcification is observed in the brain sulcus. This case also illustrated that intravenous thrombolysis may be effective even in calcified cerebral emboli with major vessel occlusion.

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