Rambam Health Care Campus has gained a great deal of experience in treating strokes, with a focus on those that require invasive intervention through cerebral catheterization. However, a phenomenon presented at Rambam in recent days managed to surprise the doctors, especially in light of the fact that not one, but two such patients were rushed to Rambam within two days. The phenomenon is so rare that the Director of Rambam's Department of Vascular Surgery and Transplantation had never seen it before. December 27, 2020 – Surachat Pinthong, a 27-year-old from Thailand who works in agriculture in the Jordan Valley, came to Rambam Health Care Campus recently, suffering from advanced stroke symptoms. In order to decide on the treatment, Pinthong, like any stroke patient, underwent a series of tests aimed at accurately diagnosing the problem and its location. Imaging showed that he was suffering from a rare, congenital condition often referred to as a Carotid Web, (a thin, linear membrane that develops as a web-like formation in a carotid artery), in the area where the artery splits in the neck. Over time, this defect—which is probably caused by an excess production of connective tissue—causes a disruption in the normal blood flow to the brain, enabling the formation of blood clots and endangering the patient by increasing the possibility of brain embolisms. “In this strategic spot leading to the brain, a large, 2cm x 2cm blood clot formed,” recalls Dr. Eytan Abergel, Director of the Invasive Neuroradiology Unit (brain catheterization) at Rambam. "This huge clot had already begun to crumble and small clots that separated from moved through the artery to the brain and created another blockage there." With the clock ticking, Rambam doctors were faced with a difficult challenge – in order to treat the cerebral blockage, the second blockage created in the carotid artery also had to be treated, as it would otherwise continue to disintegrate and endanger the patient's life. "This was a difficult problem," explains Dr. Abergel. "The tools I work with for cerebral catheterization are tiny, 2 mm in diameter, and are not intended to treat such large clots. We understood that a combination of forces was needed here." Dr. Karram, who was involved in the treatment of the young patient, was called to the catheterization room. First, Dr. Abergel inserted the tiny catheters into the patient's arteries, bypassing the huge clot from the side, moving upwards to the blockage created in the brain, and carefully removing it with the help of Dr. Eran Meirovich, an attending physician in the Department of Neurosurgery. Following the complex procedure, once the tests showed that the blood flow to the other side of the brain improved, Dr. Karram began the second phase – the operation to remove the clot from the carotid artery while the patient was lying on the catheterization table. With the help of Dr. Samer Diab, a physician in the Department of Vascular Surgery and Transplantation, Dr. Karram opened the artery and removed the clot and the membrane that allowed the carotid web to form, completely eradicating the danger that hovered over Pinthong's life. "Surgery in the catheterization room is not a routine matter," says Dr. Karram, "but here, the complexity of the case left no choice; it was necessary to combine two therapeutic and expert approaches from different fields to save the patient’s life. Within minutes it was clear the procedure was successful and blood flow resumed. We are definitely pleased with the results." Two days before Pinthong's arrival, a man in his 40s arrived at Rambam suffering from similar symptoms. In his case, the circumstances were less urgent and he was treated differently, but it was an unusual coincidence to have two of these types of cases so close together. "In 25 years of working at Rambam, I have not seen such a case, "notes Dr. Karram, "and within two days, there were two of them. It is such a rare phenomenon that you just have to look for it in the patient. Our two patients did not match the medical profile of stroke patients, and we tried to understand what happened. During testing, we discovered the same carotid web, but you also need to know what to look for," he says, adding, "when young people without other risk factors have a stroke, this pathology should be suspected. It is possible that due to the rarity of findings and lack of awareness, some cases are missed. Without proper treatment, the patient remains at high risk for stroke recurrence." A few days after the dramatic treatment, Pinthong is resting in in his bed in the Department of Vascular Surgery and Transplantation with a smile on his face. He does not speak Hebrew or English and communication with him is done mainly through Google Translate or via Facebook with his sister in Thailand, who is also a doctor. By the means at his disposal, he and the friend accompanying him express gratitude to the staff and understand the magnitude of the miracle they have experienced. "Due to quick, comprehensive treatment and the fact that he is a young person, Pinthong came out of the incident unscathed," a Rambam staff member explains. "In case of stroke symptoms, one must not hesitate for a moment and must be evacuated to the hospital. Every moment is important and can save lives." In the photos: Dr. Tony Karram, Dr. Eytan Abergel and Surachat Pinthong. Photography courtesy of Rambam Medical Campus.
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