Lysis of a thrombus in the internal carotid artery by a glycoprotein IIb/IIIa receptor antagonist

History: A 55-year-old man was admitted with acute right-sided arm and leg paralysis and motor aphasia, which were regressing at time of admission. He was known to have had several episodes of abnormal motor function in the r ight arm resulting from transitory cerebral ischaemic attacks. He was a hea vy smoker. Investigations: Cranial computed tomography (CCT) excluded acute bleeding a nd there was no evidence of a stroke. Duplex sonography showed a filiform s tenosis at the origin of the left internal carotid artery (ICA) with an ech o-poor structure in the distal lumen. Subsequent angiography demonstrated a n inoperable thrombus adherent to the filiform left ICA stenosis and extend ing to the base of the skull. Diagnosis, treatment and course: The neurological symptoms regressed over 2 4 hours, confirming the diagnosis of prolonged ischaemic neurological defic it. CCT having excluded bleeding, but significant left ICA stenosis by a th rombus having been demonstrated, treatment with acetyl salicylic acid (aspi rin) and heparin was initiated. After the described angiographic confirmati on of a thrombus adherent to the filiform stenosis, treatment with Tirofiba n, a glycoprotein (GP) IIb/IIIa receptor antagonist, was begun and the thro mbus completely dissolved. The filiform ICA stenosis was then treated surgi cally. Conclusion: This case demonstrates complete lysis of a long thrombus in the ICA by Tirofiban, making a primarily inoperable stenosis amenable to surgi cal intervention. It is not yet clear whether administration of CP IIa/IIIb receptor antagonists provides a therapeutic option in the treatment of int racranial arterial thromboses.