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A 54-year-old male with a history of transient ischemic attack (TIA) presented with two episodes of acute ischemic stroke. The first episode, in 2006, was successfully treated with intravenous tissue plasminogen activator (IV TPA), intra-arterial TPA, and mechanical thrombectomy. The second episode occurred after a brief interruption of aspirin therapy and was managed conservatively due to delayed presentation. Despite dual antiplatelet therapy (DAPT), the patient developed a persistent M1 occlusion with subsequent thrombus formation. Subsequent investigations, including transcranial Doppler (TCD) and cerebral angiography, failed to identify a clear embolic source. The patient underwent carotid endarterectomy (CEA), which revealed focal shelf-like projections of fibrotic intima without atherosclerotic changes. Since the procedure, the patient has remained stroke-free.
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Pathophysiology of Thrombus Formation: What are the potential mechanisms underlying thrombus formation in this patient, given the absence of significant atherosclerosis and negative embolic workup? Could a hypercoagulable state or endothelial dysfunction play a role?
Pathophysiology of Thrombus Formation: What are the potential mechanisms underlying thrombus formation in this patient, given the absence of significant atherosclerosis and negative embolic workup? Could a hypercoagulable state or endothelial dysfunction play a role?
Role of Antiplatelet Therapy: How should the long-term antiplatelet therapy strategy be optimized for this patient? Should lifelong DAPT be considered, or might a single antiplatelet agent be sufficient? What are the risks and benefits of each approach? What is the role of anticoagulation?
Role of Antiplatelet Therapy: How should the long-term antiplatelet therapy strategy be optimized for this patient? Should lifelong DAPT be considered, or might a single antiplatelet agent be sufficient? What are the risks and benefits of each approach? What is the role of anticoagulation?
Surveillance and Prevention: What surveillance strategies should be implemented to monitor for recurrent stroke or vascular events? Should regular carotid ultrasound or MRI be considered? What lifestyle modifications or medical therapies might help reduce the risk of future events?
Surveillance and Prevention: What surveillance strategies should be implemented to monitor for recurrent stroke or vascular events? Should regular carotid ultrasound or MRI be considered? What lifestyle modifications or medical therapies might help reduce the risk of future events?
Differential Diagnosis: What other conditions could potentially explain the patient's recurrent stroke events? Should genetic testing for thrombophilia or other vascular disorders be considered?
Differential Diagnosis: What other conditions could potentially explain the patient's recurrent stroke events? Should genetic testing for thrombophilia or other vascular disorders be considered?
Ethical Considerations: Given the patient's history of stroke and the potential risks and benefits of long-term antiplatelet therapy, how should shared decision-making be approached to ensure patient autonomy and optimal outcomes?
Ethical Considerations: Given the patient's history of stroke and the potential risks and benefits of long-term antiplatelet therapy, how should shared decision-making be approached to ensure patient autonomy and optimal outcomes?