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Free-floating thrombus (FFT) of the cervicocranial arteries is a rare neurovascular condition. Up to now, there is no standardized definition for FFT. Therefore, FFT is occasionally mistaken for intraluminal thrombus (ILT) or smooth mural thrombus. The most precise and ideal definition of FFT would be a long-extended intraarterial thrombus that is attached to the arterial wall with its one end, while its other end is surrounded by blood flow and moves freely with the cardiac cycle. FFT usually manifests as an ischemic stroke, thus it is considered as an emergency case. Herein, we report a rare case of symptomatic FFT in the left vertebral artery extending from V0 to V2 segments in a middle-aged smoker, who presented with multiple embolic strokes in different territories of posterior circulation and was successfully treated medically. This case sheds light on the challenges of the clinical approach of FFT in the vertebral artery and it is an attempt to draw attention to the necessity of conducting a large-scale study to find out the ideal approach to manage such conditions.

Background Severe acute respiratory syndrome coronavirus (SARS-CoV-2) due to novel coronavirus disease 2019 (COVID-19) has led to an unprecedented worldwide pandemic with diverse respiratory symptoms as well as systemic manifestations and complications. The neurological manifestations of COVID-19 include, but are not limited to, headache, cerebrovascular disease, and skeletal muscle injury. Case report Herein, we present a case of stroke with large vessel occlusion in a middle-aged man, who recently recovered from severe SARS-CoV-2 infection. This patient is not known to have any medical illness or surgical history and has no cerebrovascular risk factors. Moreover, the patient underwent extensive investigations, including neuroimaging, cardiac and laboratory work-up with no evidence of stroke etiology. Conclusion The mechanism of cerebrovascular events in the setting of COVID-19 is still uncertain and probably multi-factorial. The prevailing hypothesis is a strong thrombotic tendency, which may even be prolonged after complete recovery. In our patient's case, hypercoagulability in the context of viral infection is the most likely mechanism for the stroke. Further studies are needed to find out the exact pathogenesis of thromboembolic events in the setting of COVID-19 infection as well as the efficacy, safety, dosage, and duration of anticoagulants in such conditions.

Ali Alhashim, Kawther Hadhiah, Hassan Al-Dandan, Mugbil Aljaman, Majed Alabdali, Mohammed Alshurem, Danah Aljaafari, Mustafa AlQarni Neurology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, 34212, Saudi ArabiaCorrespondence: Ali Alhashim, Neurology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, 34212, Saudi Arabia, Tel +966509444833, Email ahalhashem@iau.edu.saBackground: Spontaneous simultaneous bilateral basal ganglia hemorrhage (SSBBGH) is an extremely rare condition with only a few published case reports and series. However, there is no systematic review that has been published yet.Objective: The study aims to conduct a systematic review on spontaneous simultaneous bilateral basal ganglion bleeding and a descriptive statistical analysis of collected data on epidemiology, clinical features, etiology, therapeutic approach and prognosis. This review aims to be a clinical reference for busy clinicians when they are faced with such a rare condition.Methodology: This review has been carried out in accordance with recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.Results: Review of 60 cases showed that SSBBGH affected predominantly male patients (70%) with an average age of 50.8 ± 15.33 years and the male-to-female ratio was 2.5:1. The female patients tend to be older with an average age of 54.22 ± 16.67 years. Location of SSBBGHwas more common in the putamen (90% vs 10% non-putaminal). SSBBGH posed a significant mortality rate (33.33%). Among patients who survived, only 40.6% (13/32 report) have had favorable outcomes (mRS ≤ 2) and the remaining 59.4% (19/32) ended up with poor functional status (mRS ≥ 3-5). The most common implicated etiologies were hypertension followed by alcohol intoxication.Conclusion: SSBBGH is a rare clinical entity with significant morbidity and mortality. Systemic approach can lead to early recognition of etiology and prompt treatment. Hypertension and the putamen are the most common etiology and location of SSBBGH, respectively. History of hypertension and age can help narrow differential diagnosis and limit unnecessary testing or intervention.Keywords: bilateral basal ganglia bleeding, bilateral basal ganglia hemorrhage, non-traumatic, simultaneous

BACKGROUND COVID-19 is an acute respiratory disease caused by the SARS-CoV-2 virus, which was discovered in 2019. The high transmission and seriousness of COVID-19 necessitated the development of an effective vaccine to control spread of the disease. Multiple vaccines have been granted emergency use authorization (EUA) by the U.S. Food and Drug Administration, namely, the Pfizer-BioNTech, Moderna (mRNA), and the JohnsonJohnson/Janssen (vector) vaccines. As these novel vaccines have been used, adverse effects have been reported, ranging from mild myalgia to severe anaphylaxis and thrombotic events. Thrombotic consequences raised suspicion for the development of cerebral venous sinus thrombosis (CVST), which is a severe condition associated with occlusion of venous sinuses and disruption of the venous system flow. CASE REPORT A 28-year-old healthy woman presented with a 2-week history of persistent and progressive headache 4 days after receiving an mRNA COVID-19 vaccine (Pfizer-BioNTech). Cerebral computed tomography (CT) and CT venography confirmed the presence of extensive thrombus involving the left transverse and sigmoid sinus as well as the internal jugular vein. Furthermore, other than recent the COVID-19 vaccination, there were no precipitant risk factors in her clinical history or in the detailed laboratory work-up. CONCLUSIONS Headache associated with red flags following administration of any COVID-19 vaccine should prompt urgent neuroimaging to rule out secondary causes and determine the appropriate management. Our patient lacked the typical profile of CVST commonly seen following administration of the Oxford-Astrazeneca vaccine. The findings of low platelet count may indicate the peculiar pathophysiology of a thrombotic event associated with with the Pfizer vaccine.

Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.