Curr Top Neurol Psychiatr Relat Discip. Vol 18, No. 3, September 2010 51
Pospelova at al.
CASE REPORT
UDC 616.133-08
HIRUDOTHERAPY IN THE TREATMENT OF BILATERAL INTERNAL CAROTID
ARTERY OCCLUSION: CASE REPORT
HIRUDOTERAPIJA U TERAPIJI BILATERALNE KAROTIDNE OKLUZIVNE BOLESTI:
PRIKAZ SLUČAJA
Maria L. Pospelova1, Oleg D. Barnaulov2
Abstract: We present a case of a 67-year-old man, who had two ischemic strokes, fi rst with a right hemiparesis
and sensory aphasia, second with signs of brain stem damage. Magnetic resonance angiography and
ultrasonography confi rmed bilateral occlusion of internal carotid arteries. Computed tomography revealed
multiple ischemic lesions of the brain. Having had contraindications for aspirin due to duodenal ulcer, the
patient was initially and aft erwards regularly treated with hirudotherapy. His general medical condition
was later stable, while neurological defi cit almost completely improved. During the eleven-year follow-up,
the patient has had only one transient ischemic attack, otherwise without any complaints. Atherosclerotic
changes have been stable, as well as the parameters of platelet function.
Key words: hirudotherapy, internal carotid artery occlusion.
Sažetak: Prikazujemo slučaj muškarca starog 67 godina sa dva ishemijska moždana udara: prvi sa desnostranom
piramidnom slabošću i senzornom afazijom, drugi sa slikom oštećenja moždanog stabla. Magnetno-
rezonantnom anigiografi jom i ultrazvukom utvrđena je obostrana okluzija unutrašnjih karotidnih
arterija. Kompjuterizovanom tomografi jom utvrđene su multiple bilateralne ishemijske lezije mozga.
Obzirom da boluje od čira na dvanaestopalačnom crevu, kao i na to da odbija hirurški tretman, pacijent
je inicijalno, kasnije i hronično u redovnim seansama, lečen hirudoterapijom. Njegovo opšte zdravstveno
stanje u daljem toku praćenja bilo je stabilno, a neurološki defi cit se gotovo u potpunosti povukao. Tokom
11 godina redovnih neuroloških kontrola, pacijent je imao jedan tranzitorni ishemični atak, bez drugih
neuroloških tegoba. Aterosklerotske promene na krvnim sudovima su sve vreme stacionarne, kao i parametri
trombocitne funkcije.
Ključne reči: Hirudoterapija, okluzija unutrašnjih karotidnih arterija
1 Unit of Neurology, Institute of the Human Brain, Russian Academy of Sciences, Saint-Petersburg, Russia.
pospelovaml@mail.ru.
2 Institute of the Human Brain, Russian Academy of Sciences, Saint-Petersburg, Russia
Correspondence to: Maria L. Pospelova, MD, PhD, Unit of Neurology, Institute of the Human Brain, Russian
Academy of Sciences, Saint-Petersburg, Russia. E-mail: pospelovaml@mail.ru.
* Received: May 26, 2010; accepted: September 9, 2010.
52 Curr Top Neurol Psychiatr Relat Discip. Vol 18, No. 3, September 2010
Pospelova at al.
INTRODUCTION
Patients with stenoses and occlusions of internal
carotid arteries (ICA) and intracranial arteries are
classifi ed as having a high risk of stroke. Population-
based studies have showed that 30% -50% of
ischemic episodes, both permanent and temporary,
are complications of atherosclerotic plaques
(1). In asymptomatic ICA stenosis of 50-99%, the
risk of cerebral ischemia is 2 - 5.2% per year and
increases in symptomatic hemodynamically signifi
cant stenosis to 8.5% per year, while symptomatic
ICA occlusions bear risk of around 11% per
year (2,3).
Th e eff ects of hirudotherapy in the treatment of
patients with stenosis or occlusion of cerebral arteries
and internal carotid arteries have not been
studied.
CASE REPORT
We present a case of a 67-year-old man who had
an ischemic stroke with right hemiparesis and
sensory aphasia. Two months aft er the initial ischemic
event he was again medically observed,
complaining of being unstable, clumsy in the right
extremities, having diffi culty in word fi nding,
with general slowness of movements, and occasional
headaches. On physical examination, he had
sensory aphasia, nystagmus to the side, left facial
palsy and hypoesthesia of the left part of the face.
Mild pyramidal palsy of the right side of the body
was evident, as well as the presence of pathological
cerebellar signs. He had had hypertension for
17 years, ischemic heart disease (acute cardiac infarction
two years before the stroke) and duodenal
ulcer.
On computed tomography, multiple bilateral ischemic
lesions of the brain were observed. Magnetic
resonance angiography and duplex scan of
cervical arteries confi rmed the occlusions of both
internal carotid arteries and a stenosis of the left
vertebral artery of more than 60%. Lipidogram
and coagulogram were normal. Th e parameters
of functional thrombocyte activity were changed
dramatically: discocytes 72%, disco-echinocytes
21.5%, total number of active thrombocytes 30%,
number of aggregated thrombocytes 26.5%, number
of small aggregates 18%, number of medium
and large aggregates 0.8. He scored 0.45 on Zung
anxiety scale (4), and 19 on Beck’s depression inventory
(BDI), indicating a mild depression (5).
Th e patient was off ered extra-intracarotid anastomosis,
which he refused. Aspirin treatment being
contraindicated, twelve sessions of hirudutherapy
were carried out. During the treatment the patient
was taking dypiridamole and antihypertensives.
Aft er hirudotherapy the patient noticed that
the headaches became less frequent and stability
when walking improved. His arterial pressure stabilized.
Th ere were no signifi cant changes in neurological
status, and the depression parameters
improved (17 points on BDI).
Th e parameters of functional platelet activity partially
normalized: number of discocytes increased
to 92% and normalized, number of disco-echinocytes
decreased to 13.5% and normalized, total
number of active thrombocytes decreased to
22.5%, number of aggregated thrombocytes decreased
to 9%, number of small aggregates normalized
at the ratio of 0.2%, number of medium
and large aggregates also returned to normal. On
the ultrasound follow- up study cerebral blood
fl ow was compensated without any signs of progression.
Further on, the patient has been under medical
observation for 10 years. Th e courses of hirudotherapy
have been carried out almost regularly in
the regimen of two times a month, with a threemonth
break in the summer. Th e patient has not
been taking any drugs apart from dypiridamole
and enalapril. For the last 9 years, he has had only
one transitory ischemic attack. Th e patient has
been neurologically stable with mild right-sided
hemiparesis and his headaches got milder.
Ultrasonographic studies of cervical arteries have
been performed annually so far, showing no progression
of atherosclerotic plaques. Platelet functional
activity normalized completely by the third
course of hirudotherapy.
Curr Top Neurol Psychiatr Relat Discip. Vol 18, No. 3, September 2010 53
Pospelova at al.
CONCLUSION
Bilateral occlusions of the cervical arteries bear rather
pessimistic prognosis concerning outcome
and repeated ischemic events. Standardized treatment
is non-specifi c and includes treatment of
the risk factors and prevention of stroke (6). We
successfully treated hypertension in our patient
with regular cardiological follow up. Due to his
contraindications we used dypiridamole and hirudotherapy
as a preventive treatment, with regular
controls of coagulation and platelet function parameters.
Th is approach proved eff ective concerning
the patient’s long-term general medical condition
and neurological state.
Despite its well known potential therapeutical effects,
hirudotherapy has not been studied in controlled
clinical trials. We proved its benefi cial effects
on platelet parameters in a small study, however
further research is required. Th e case reported
above gives practical evidence of possible positive
long-term therapeutical eff ects of hirudotherapy,
supporting our enthusiasm on this issue.
Financial Disclosure: Th e authors have nothing
to report
REFERENCES
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2. Inzitari D, Eliasziw M, Gates P, Sharpe BL, Chan
RK, Meldrum HE, Barnett HJ. Th e causes and risk of
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3. Zung WW. A self-rating depression scale. Arch
Gen Psychiatry. 1965;12:63-70.
4. Beck AT, Ward CH, Mendelson M, Mock J,
Erbaugh J. An inventory for measuring depression.
Arch Gen Psychiatry. 1961;4:561-571.
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Furlan A, Goldstein LB, et al. Stroke Council of the
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American Stroke Association. Stroke 2003; 34:1056-
1083.

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