Cerebrovascular EvaluationCerebrovascular EvaluationINTERNAL CAROTID ARTERY THROMBUS INTERNAL CAROTID ARTERY THROMBUS

Sickle Cell DiseaseSickle Cell Disease

Watson Smith, RDMS, RVTWatson Smith, RDMS, RVT

From the D. E. Strandness, Jr. Vascular Laboratory From the D. E. Strandness, Jr. Vascular Laboratory and and

The Division of Vascular Surgery, The Division of Vascular Surgery, Department of Surgery, Department of Surgery,

University of Washington, Seattle, WAUniversity of Washington, Seattle, WA

Background-Background-What is Sickle Cell Disease?What is Sickle Cell Disease?

• Inherited blood disorderInherited blood disorder

• Abnormal hemoglobin S- RBCs become crescent shapedAbnormal hemoglobin S- RBCs become crescent shaped

• RBCs carry less O2- get stuck in small vesselsRBCs carry less O2- get stuck in small vessels

• Pain crisisPain crisis

• Treated with RBC exchange transfusionsTreated with RBC exchange transfusions

• Bone marrow Tx.Bone marrow Tx.

Sickle Cell and Thrombus-Sickle Cell and Thrombus-Poorly UnderstoodPoorly Understood

• Can lead to large vessel intimal hyperplasiaCan lead to large vessel intimal hyperplasia

• Sickle cells can adhere to endotheliumSickle cells can adhere to endothelium

• Superimposed thrombosis- most frequent cause of stroke Superimposed thrombosis- most frequent cause of stroke in Sickle cell patientsin Sickle cell patients

Day 1Day 1

31 year old male with Sickle Cell Anemia and Hx. of 31 year old male with Sickle Cell Anemia and Hx. of Renal Tx. presents to ED Renal Tx. presents to ED

• Recently hospitalized for sickle cell crisisRecently hospitalized for sickle cell crisis

• Right side weakness and decreased sensationRight side weakness and decreased sensation

• Head CT- No acute intracranial abnormality. Head CT- No acute intracranial abnormality.

Day 1Day 1MRAMRA

Non Contrast MRA- Left lacunar infarcts Non Contrast MRA- Left lacunar infarcts

>50% stenosis left ICA- atherosclerotic plaque vs. artifact.>50% stenosis left ICA- atherosclerotic plaque vs. artifact.

Day 1Day 1Initial Carotid Duplex ExamInitial Carotid Duplex Exam

Day 1Day 1Initial Carotid Duplex ExamInitial Carotid Duplex Exam

Day 1Day 1Other Duplex FindingsOther Duplex Findings

• Everything else normal in carotid and vertebral arteriesEverything else normal in carotid and vertebral arteries

• TCD exam normal- no collaterals, stenosis or Doppler TCD exam normal- no collaterals, stenosis or Doppler emboliemboli

Day 1Day 1Therapies and StrategiesTherapies and Strategies

• Heparin drip, ASAHeparin drip, ASA

• Vascular consult- 2Vascular consult- 2ndnd MRA with Gadolinium to confirm MRA with Gadolinium to confirm diagnoses diagnoses

• Hematology consult- possible transfusionHematology consult- possible transfusion

Day 2Day 2

• No new Sxs. No new Sxs. Improved strength in right upper extremity Improved strength in right upper extremity

• 3rd MRA3rd MRA- findings concerning for ongoing - findings concerning for ongoing embolic embolic phenomena.phenomena.

• No Doppler emboli on repeat TCDNo Doppler emboli on repeat TCD

• No intervention or surgeryNo intervention or surgery. Given the location and nature . Given the location and nature of the thrombus, the operation itself presents a significant of the thrombus, the operation itself presents a significant risk of generating emboli risk of generating emboli

Day 2 Day 2 22ndnd Duplex exam Duplex examCarotid ImagesCarotid Images

• Day 2 carotid imageDay 2 carotid image

Days 3 and 4Days 3 and 4• Sxs. continue to improveSxs. continue to improve

• TCD exams remain normalTCD exams remain normal

• anticoagulatedanticoagulated

• RBC Exchange transfusion plannedRBC Exchange transfusion planned

Day 5Day 5

• New onset of right upper extremity weakness, New onset of right upper extremity weakness, dysarthria. Aphasiadysarthria. Aphasia

• CT no hemorrhage and no obvious new infarct CT no hemorrhage and no obvious new infarct

• MRI New foci of acute infarcts in the left temporal and left MRI New foci of acute infarcts in the left temporal and left frontal lobe frontal lobe

• Now scheduled for surgical exploration Now scheduled for surgical exploration

• pre op Duplex exam was orderedpre op Duplex exam was ordered

Day 5Day 5 Duplex ExamDuplex Exam

• The thrombus was gone! The surgery was cancelledThe thrombus was gone! The surgery was cancelled

The patient did OK!The patient did OK!

• RBC Exchange transfusion completedRBC Exchange transfusion completed

• Speech therapy- Sxs. slowly improving Speech therapy- Sxs. slowly improving

• AnticoagualtedAnticoagualted

• Follow ups planned with hematology and vascular surgeryFollow ups planned with hematology and vascular surgery

1 Year Later1 Year Later

• Seen in ED with Neck painSeen in ED with Neck pain

• Carotid imageCarotid image

Discussion, ConclusionsDiscussion, Conclusions

• Duplex US gold standard for carotid bifurcations lesionsDuplex US gold standard for carotid bifurcations lesions

• Importance of extracranial evaluations for TCD examsImportance of extracranial evaluations for TCD exams

• Emboli monitoring with TCD had limitationsEmboli monitoring with TCD had limitations

• Sickle cell disease is a unique processSickle cell disease is a unique process