Trombose venosa cerebral e o uso de anticoncepcionais orais: Uma revisão integrativa

O objetivo do estudo foi relacionar as pesquisas sobre trombose venosa cerebral com o uso de anticoncepcionais orais combinados. Trata-se de uma revisão integrativa da literatura realizada através das bases de dados: LILACS, Scielo, Periódicos Capes, Medline PubMed, Cochrane Library e Science Direct, utilizando os descritores: “contraceptive agents”, “intracranial embolism thrombosis”, "thrombosis" “intracranial thrombosis”. Para a seleção de artigos foi utilizado o operador booleano “AND” entre os descritores. A pergunta norteadora, elaborada através da metodologia de PICO (Paciente, Intervenção, Controle, Outcome), foi: "Os anticoncepcionais orais desencadeiam a trombose venosa cerebral?”. Nos resultados foram encontrados 47 artigos, sendo 35 excluídos por não apresentarem relação entre trombose venosa cerebral e anticoncepcionais orais. Dessa forma, foram selecionados 12 artigos para compor essa revisão. No estudo pode-se concluir que, o risco dos eventos trombóticos venosos, em usuárias de anticoncepcionais orais combinados, está aumentado. Isto posto, é importante enfatizar o uso racional desses medicamentos, assim como a compreensão para o diagnóstico precoce da trombose venosa cerebral.

Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery

Background: Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past. Case Description: A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit. Conclusion: Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.

Intentional subintimal carotid stenting of internal carotid dissection in a patient with acute ischaemic stroke

Carotid artery dissection is a common cause of juvenile stroke. Endovascular treatment of acute stroke due to carotid dissection can be challenging, and endoluminal crossing of the dissection is sometimes impossible. We describe a case of intentional subintimal recanalisation of a cervical carotid dissection followed by intracranial thrombectomy and stenting. We report the case of a young woman with severe acute ischaemic stroke due to carotid artery dissection and intracranial embolism. After failure of endoluminal crossing of the dissected segment, intentional subintimal crossing with re-entry distally to the dissection was achieved and a stent was deployed. Then, middle cerebral artery thrombectomy was performed achieving good recanalisation. Acute thrombus formed in the bulged segment of the carotid stent and was managed with additional stent placement. The patient had a good clinical recovery. In selected cases, after failure of conventional techniques, subintimal recanalisation of carotid dissections may be performed.

“Malignant” Carotid Artery Dissection

Purpose:Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation.Patients and Methods:We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness. The first patient had a carotid occlusion through which a catheter could not be passed, so intracranial thrombolysis was achieved through a microcatheter navigated through the posterior circulation. Surgical intimectomy and thrombectomy of the dissected ICA was then carried out using an intraoperative Fogarty arterial embolectomy catheter passed up the dissected ICA, followed by endovascular stenting of the reopened cervical ICA. The second patient underwent intracranial microsurgical embolectomy and, after an unsuccessful attempt of stenting the dissected and severely narrowed cervical ICA, surgical reopening again with a Fogarty catheter. Both patients suffered basal ganglionic infarcts but most of the middle cerebral artery territories were preserved and the patients made satisfactory recoveries.Conclusion:“Malignant” carotid artery dissection causing occlusion or near occlusion with intracranial embolism is an important cause of severe and life-threatening hemispheric ischemia. Treatment should include aggressive endovascular and microsurgical interventions when the hemisphere is at risk.