Stroke and Acute Coronary Syndrome from One Clot

A 54-year-old woman, active smoker, presented to the emergency department (ED) because of chest pain and shortness of breath. Both the blood test for myocardial enzymes and the electrocardiogram supported the diagnosis of acute coronary syndrome. During the clinical evaluation, an abrupt onset of neurological deficit (aphasia and right hemiplegia) occurred and the consultant neurologist graded it as severe National Institutes of Health Stroke Scale (NIHSS score = 14). An unenhanced brain computed tomography (CT) scan was performed and the findings were unremarkable. Therefore, the patient underwent an advanced neuroimaging study, including CT angiography (CTA) and CT perfusion (CPT). CTA of the neck and intracranial vessels was followed by a CTA for the whole aorta to rule out aortic dissection. The CTA had shown some hypodense filling defects in the right sinus of Valsalva (SOV) close to the aortic wall in the aortic arch close to the emergence of the brachiocephalic trunk and left common carotid artery with tomographic features of clots (Fig 1A). The clot in the right SOV was occluding the ostium and the main stem of the right coronary artery with reopening at a branching site (Fig 1B). Intracranial CTA shown a left distal M1 and M2 middle cerebral artery (MCA) occlusion (Fig 1C). Intravenous thrombolysis was performed and the patient had a good functional outcome at 24 hours and 3 months (final modified Rankin scale score = 0). Anticoagulant treatment with low-molecular-weight heparin (LMWH) was started after 24 hours from the symptom's onset. The follow-up CTA assessed the resolution of the hypodense filling defects in the aortic arch and the persistence of the right SOV thrombosis with right coronary artery occlusion (Fig 2A). Brain magnetic resonance imaging (MRI) with MR angiography showed the recanalization of the left MCA and the final small ischemia in the MCA territory (Fig 2B, C). The main thrombophilic trigger was a lung cancer with histopathologic diagnosis of carcinoid tumor (Fig 2D). Carcinoid tumors are rare causes of vascular disorders1 and SOV thrombosis is an even rarer cause of coronary artery obstruction.2 A stroke or peripheral vascular ischemia by artery-to-artery embolism and the simultaneous occurrence of both vascular events was a challenge both for diagnostic and therapeutic strategies. None. M.Z. and R.P. designed the study. R.P. contributed to the acquisition and analysis of data. M.Z. and R.P. drafted the text and preparing the figures. The authors declared no conflict of interest.