Cerebral Thrombo-Angiitis Obliterans in a Patient with Marijuana Use

Abstract

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-stenFigure 1. MRI brain demonstrating foci of restricted diffusion within the right frontal lobe (a) and the right
frontal parietal cortical junction (B) on DWI sequence.
otic 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 caliberdiminution 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