It was April 25, 2016 when a-25-year old woman was brought to emergency room in Shohada Tajrish hospital with sudden onset aphasia and right sided hemiparesis. She was a Persian teacher from Kashan. She has had these symptoms from 2 days ago. She had no significant past medical history or family history of cerebrovascular disease or risk factors for atherosclerotic stroke or history of blunt cervical trauma. She had no significant drug history such as anti-conception drugs.
On physical examination, right sided reduction in muscle tone and force as well as aphasia was observed but she was conscious and oriented to time and place.
Upon admission, Standard work-up for stroke in young patients was performed. Admission examination showed resting blood pressure 115/75 mmHg, heart rate 80 pulses/min, SpO2 97%, respiratory rate 15 breaths/min, body temperature heat 37  C. A 12-lead electrocardiogram showed no obvious abnormalities. Initial Brain CT examination was not significant. Brain magnetic resonance imaging (MRI) revealed infarct in left temporal and periventricular areas as well as hemorrhage in the left basal ganglia in the left middle cerebellar artery (MCA) territory. Brain magnetic resonance angiography (MRA) showed obstruction on terminal branches of MCA. Transthoracic echocardiography showed no obvious intracardiac thrombus or atrial or ventricular shunts.
Carotid duplex ultrasonography showed an iso-echogenic thrombus ranged about 5 mm x 10 mm partially attached to arterial wall of the right internal carotid artery which had been floating in accordance with the heartbeat.
Thereafter, she then had a CT angiogram (CTA, multidetector, 16 slices) which confirmed the presence of intraluminal thrombus within the right internal carotid artery. (Fig 1, Fig. 2)
Anticoagulation therapy (intravenous heparin) was administered at his initial review. Based on the recommendation of our Multidisciplinary team (MDT) she underwent an urgent operation.
After general anesthesia, through classic endarterectomy incision right common carotid artery as well as its bifurcation was exposed. After exposure, common carotid as well as external and internal carotid arteries were controlled using a vessel loop with extreme care about 1 cm away from the site of thrombus. Intravenous heparin 80 u/kg was administered 3 min before clamping. First, the internal carotid artery was clamped to avoid thrombus embolization. Next, the common carotid artery and the external carotid artery were clamped and vertical arteriotomy was done respectively. Through arteriotomy we let the thrombus to get out and to be suctioned. Then the vascular shunt was replaced through common carotid to internal carotid artery. The clamping time was only about 120 s. The remaining thrombus was detached from the intima and sent to histopathologic examination. Thereafter, artery was irrigated by heparinized saline and arteriorrhaphy was done at the end. the surgery was done by Dr. A.Afsharfard, Professor of General and Vascular Surgery in Shohada hospital.
Histopathology results confirmed thrombotic material. To explore the etiology of her problem various lab tests were done. Results of evaluations of protein C, protein S, antithrombin III, C-reactive protein, anticardiolipin antibody were normal, but the level of lupus anticoagulant antibody was markedly elevated at 87.5 units (normal range, 20-39 units).
She was discharged from hospital after an uneventful recovery showing gradual improvement and complete resolution of symptoms in follow-up post-operative visits.