Introduction: Anatomical variants of the aortic arch, such as the bovine aortic arch, are commonly considered benign. However, this case demonstrates that such configurations may pose a higher thrombogenic risk than normally considered, especially in patients with recurrent cerebrovascular events despite antithrombotic therapy.
Description: A 65-year-old female with history of a recent right middle cerebral artery (M1) occlusion stroke medically treated with dual antiplatelet therapy (DAPT), presented to the emergency department as a stroke alert after a witnessed fall at home. CTA of the head revealed an acute left M1 occlusion, for which she underwent mechanical thrombectomy (TICI 3). Also seen CTA imaging was a thrombus within the aortic arch with bovine aortic arch anatomy. No cardioembolic source of her stroke was identified on echocardiography. No surgical intervention was performed and she was managed medically with anticoagulation by heparin gtt. Due to high-risk for hemorrhagic conversion, DAPT was discontinued.
Discussion: This case underscores the potential thrombogenicity of a bovine aortic arch, particularly in patients with recurrent embolic strokes and no other identifiable embolic sources. The patient also underwent a hypercoagulable workup and did not reveal any pro-thrombotic conditions, which highlights the potential thrombogenicity of a bovine aortic arch, likely due to turbulent blood flow and thrombus formation at the arch vessel origins. Recognition of this variant as a potential embolic source may inform secondary prevention strategies in cryptogenic stroke patients.
Clinicians should consider the thrombogenic potential of a bovine aortic arch, especially in patients presenting with recurrent embolic strokes without a clear etiology. This case highlights the importance of thorough vascular imaging and consideration of anatomical variants in the diagnostic evaluation and management of stroke patients.
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