Background and Purpose: Fibrocartilaginous embolism from the nucleus pulposus has been reported as a rare cause of spinal cord ischemia. We were unable to find previous reports of embolism from this source to cerebral arteries.Case Description: A previously healthy 17-year-old girl fell during a basketball game. Left hemiparesis and unresponsiveness developed followed by signs of right uncal herniation and death over a 3-day period. There was no evidence of neck, head, or spine trauma, and cardiac evaluation was normal. Neuropathological examination showed extensive ischemic infarction of the right middle cerebral artery territory, brain edema, and herniation. Complete embolic occlusion of the right middle cerebral artery by fibrocartilaginous material, consistent with nucleus pulposus, was documented. Small, terminal coronary artery branches also showed embolism by the same material and limited areas of myocardial infarction.Conclusions: Acute cerebral embolism after minor trauma in a young patient may be rarely due to fibrocartilaginous embolism from the nucleus pulposus. The pathogenesis of this problem remains poorly understood, but systemic embolism appeared to have occurred in this case. (Stroke 1993;24:738-740 when she fell, apparently with brief loss of consciousness. Two to 3 hours later, she presented with progressive weakness of the left side of her body along with decrease in the level of consciousness and was then admitted to a rural hospital. Three days later, after she failed to regain consciousness, transfer to the National University Hospital in Bogotai, Colombia, was obtained. Review of systems, past medical history, and family history were unremarkable. On admission, physical examination disclosed a well-nourished girl who was afebrile with a blood pressure of 120/70 mm Hg, a pulse of 75 beats per minute, and respirations at 26 breaths per minute. There were no skin lesions and no evidence of head, neck, or spine trauma. Cardiopulmonary examination was normal, as was the remainder of her physical examination. Neurological examination showed a comatose patient responding to painful stimulation with decerebrate rigidity. The right pupil was dilated and fixed with complete right oculomotor paralysis. A left hemiplegia was present with spontaneous bilateral Babinski's sign. The patient was diagnosed as having suffered from the possible rupture of an intracranial aneurysm. A number of laboratory tests were noncontributory. Computerized tomography of the brain could not be obtained. Cardiorespiratory arrest ensued promptly, and she died after unsuccessful resuscitation maneuvers.Postmortem examination showed an extensive ischemic infarction in the territory of the right middle cerebral artery caused by embolism and total occlusion of the initial segment of the artery (Figure 1). On sectioning the stem of the right middle cerebral artery was totally occluded, extending beyond the origin of its first branches. 1,875 g. Flattening of the convolutions and bilateral uncal herniation, more severe on the r...

We report the results of transcranial ultrasound monitoring in three patients with intracranial arterial stenosis of the middle cerebral artery treated with the only drug-eluting balloon certificated for intracranial use in highly symptomatic intracranial arterial stenosis, ELUTAX “3” (AR Baltic Medical). We performed transcranial Doppler ultrasounds 24 h, 72 h, 10 days, 15 days and 30 days after the angioplasty, thereby measuring mean flow velocity (MFV) in the maximum stenosis area in patients with symptomatic steno-occlusive disease of the middle cerebral artery treated with ELUTAX “3”. Two patients were treated during mechanical thrombectomy (MT) due to acute ischemic stroke and one patient was treated on elective basis due to symptomatic pre-occlusive stenosis, with recurrent transient ischemic attacks (TIAs) refractory to medical therapy. In Case 1, the first transcranial Doppler ultrasounds evidenced MFV of 348 cm/s, with progressive MFV reduction until 15 days post-treatment, with MFV of 177 cm/s. In Case 2, 24 h after angioplasty had an MFV of 258 cm/s, decreasing to 103 cm/s at 30 days. Case 3 had an MFV of 436 cm/s before angioplasty that immediately decreased after the procedure to 364 cm/s, with a final MFV of 260 cm/s at 30 days. We have recorded a progressive MFV reduction in intracranial arterial stenosis, with better outcomes in patients treated during MT. In our experience, the use of ELUTAX “3” for the treatment of symptomatic intracranial arterial stenosis achieves a progressive improvement of stenosis, evident in the first weeks, to a higher extent in cases of occlusive thrombosis. More studies are needed to provide more information about this device.

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▶Fig. 4 Carotid duplex with color. Left ICA is occluded from the beginning by hypoechoic heterogeneous material, with absence of flow inside.