Cerebral Thrombo-Angiitis Obliterans in a Patient with Marijuana Use

A 50-year-old man with past medical history significant for hypertension, cigarette smoking (1.5 packs for 30 years), marijuana use (inhalational use daily for 25 years), alcohol use and previous stroke presented with acute onset left sided hemiparesis. The patient did not report any history of claudication in the past but reported left upper and lower extremities feeling cooler as compared to the right side for over a year. On laboratory investigations, C-reactive protein was 2.63 mg/dl, erythrocyte sedimentation rate was 26 mm/hour, ANCA was positive (1:160), lipid profile (triglycerides, and total cholesterol) was within normal limits except for low HDL cholesterol level (22 mg/dl). MRI brain demonstrated multiple areas of restricted diffusion within the right frontal lobe and the right frontal parietal cortical junction (Figure 1) consistent with acute multifocal infarcts in the distal right middle cerebral artery distribution. A catheter-based diagnostic cerebral angiogram was performed which demonstrated occlusion of the right internal carotid artery 3–4 cm above the bifurcation [Figure 2(A)] along with high-grade stenosis of the right superficial temporal artery [Figure 2(B)] on the right common carotid artery and selective right external carotid injections, respectively. There was moderate severity of stenosis noted in the cavernous segment of the left internal carotid artery with slight dilation in the pre-stenotic segment [Figure 3(A)]. The right middle and anterior cerebral arteries were noted to have collateral reconstitution via the left anterior communicating artery [Figure 3(B)]. There was occlusion of the left internal jugular vein at its origin from the left sigmoid sinus with anterior supplemental drainage via pterygoid venous plexus and retromandibular vein [Figure 4(A) and (B), on left internal carotid injection during the venous phase. There was evidence of large vessel disease with focal stenosis of the left subclavian artery in the vicinity of thyrocervical trunk (Figure 5) and complete occlusion of the left vertebral artery from its origin (Figure 5). Distal branches of the right posterior cerebral artery were prominent and had filling via cortical anastomoses between the right posterior pericallosal artery and parietal cortical branches [Figure 6(A) and (B)]. Abdominal aortic run-off was performed which demonstrated significant peripheral vascular disease with occlusion of the right deep femoral artery at its origin and high-grade stenosis of superficial femoral artery, in addition to moderate stenosis of the left deep femoral artery and caliber diminution of the left superficial femoral artery (Figure 7). Angiographic findings were hence suggestive of diffuse medium and large-sized arterial disease in extracranial and intracranial arteries, subclavian and femoral arteries. Possible differentials included premature atherosclerosis and cerebral variant of thromboangiitis obliterans or systemic vasculitis. However, cerebral thromboangiitis obliterans was most likely due to longstanding history of cigarette and marijuana use and diffuse steno occlusive disease in multiple arterial beds and involvement of veins, and inconclusive vasculitis workup.