Background and aims: Aortic arch atheromatosis and thrombus is a risk factor for recurrent stroke. Results: A 51-year-old woman presented with a transient episode of aphasia. Clinical examination, neurosonologic examination and transthoracic echocardiography were all normal. MRI showed minor cortical infarcts in the left MCA territory. She was started on aspirin and five days later, she developed aphasia, right hemianopsia and right hemiplegia. Trancranial Doppler confirmed occlusion of the left MCA and urgent CT showed only the known minor infarction. Since mechanical thrombectomy (MT) was not available, we proceeded to off-label intravenous thrombolysis (IVT), resulting within 24h to near-complete reversal of the deficit. CT angiography revealed an aortic arch floating thrombus (AAT-image). The patient was discharged on acenocoumarol and 40 days later the thrombus had completely dissolved. Conclusion: This is the second case of IVT in a setting of stroke attributed to AAT, and the first case of early recurrent stroke treated safely and effectively with IVT, in presence of AAT. If imaging of the aortic arch is not performed, infarctions associated with aortic arch atheromatosis may be mischaracterized as ESUS. Safety of MT and IVT in presence of AAT is unknown but both treatments may be considered in disabling strokes. Patients with small infarcts and mild/no deficits after an initial stroke might be considered for IVT in case of early recurrence.
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