Plateletpheresis: Nonoperative Management of Symptomatic Carotid Thrombosis in a Patient with Reactive Thrombocytosis.

BACKGROUND: The most common pathology associated with an intraluminal carotid thrombus is underlying atherosclerosis. In rare cases, it may be associated with thrombocytosis. Currently there are no clear recommendations for the treatment of ischemic stroke associated with thrombocytosis. Our present case illustrates the use of plateletpheresis for the acute management of thrombocytosis complicated by an internal carotid artery thrombus resulting in a right middle cerebral artery stroke.

CASE DESCRIPTION: A 55-year-old female who presented with symptoms of acute, transient left hemiparesis and a National Institutes of Health Stroke Scale (NIHSS) score of 1. Initial head computed tomography (CT) scan was nonrevealing. Laboratory results revealed a mild hypochromic anemia and a platelet count of 1014 × 103 /mL. The patient was not a candidate for thrombolytic therapy due to the time window. Soon after admission, she experienced acute worsening of symptoms, with an NIHSS score of 18. CT angiography of the head and neck showed acute ischemic infarction involving the right middle cerebral artery territory with a nonocclusive intraluminal thrombus within the right carotid bulb. Aspirin 325 mg and intravenous heparin infusion were initiated. After a thorough workup, reactive thrombocytosis secondary to iron deficiency anemia was diagnosed. Plateletpheresis was started, and after 1 cycle the platelet count stabilized at 400 × 103 /mL. Complete thrombus resolution was confirmed on follow-up CT angiography on day 10 after admission without the need for surgical revascularization.

CONCLUSIONS: The role for plateletpheresis in treating secondary thrombocytosis is not well established. In cases with extreme thrombocytosis, immediate surgical thrombectomy may be contraindicated owing to a high risk of rethrombosis. Urgent cytoreduction with correction of the putative mechanism for thrombocytosis should be undertaken to provide optimal management.