Acute carotid T occlusion in a young patient: cryptogenic origin?

A 32-year-old man without previous medical problems had acute global aphasia and right-sided hemiplegia (National Institutes of Health Stroke Scale [NIHSS] score 16 points) shortly after carrying a heavy mirror. Smoking (8 pack-years) was his only vascular risk factor. Computed tomographic angiography demonstrated a left carotid T occlusion (occlusion of the carotid artery, middle and anterior cerebral artery). Ninety minutes after symptom onset, intravenous thrombolysis was initiated with 80 mg recombinant tissue-type plasminogen activator, but successful reperfusion (Thrombolysis in Cerebral Infarction scale 3) was achieved only after thrombectomy with a Solitaire Stent (puncture 236 minutes and reperfusion 263 minutes after symptom onset). The thrombus was 20 mm long. Immediately after the intervention, his symptoms started to improve, and head MRI on the day after showed a residual 3.5 cm×1.5 cm×1.5 cm lesion in the left-sided basal ganglia on diffusion weighted imaging and that the recanalized carotid T stayed open (Figure 1). Secondary prevention with aspirin 100 mg/d and atorvastatin 40 mg/d was initiated. The sudden onset of physical straining and the large thrombus were suspicious for a cardioembolic source. Admission and follow-up ECG, 24-hour ECG recordings, and transesophageal echocardiography were normal. The only abnormalities of ancillary investigations were borderline-elevated high-sensitivity troponin T (hs troponin T; 0.015 μg/L; normal value 3-fold elevated creatine kinase levels (750 U/L; normal value