Multiple Emboli Research Articles

Acute Obstructive Hydrocephalus and Acute Cerebellar Ischemic Stroke as a Complication of Takayasu Arteritis in a Young Male Patient: A Rare Case Report

Introduction: Takayasu arteritis is a rare type of vasculitis associated with various neurological manifestations. Multiple components, including thrombosis, embolism, stenosis, and vascular inflammation, are involved in the underlying pathophysiology. Case Presentation: A 21-year-old male patient presented with vomiting, difficulty speaking, disorientation, and seizures. On examination, pinpoint pupils and blood pressure discrepancies among four limbs were noted. Imaging findings supported the diagnosis of acute obstructive hydrocephalus, acute cerebellar infarction, and Takayasu arteritis. The patient was treated with IV antibiotics and steroids and underwent a ventriculoperitoneal shunt. Case discussion: Takayasu arteritis with cerebellar ischemia and obstructive hydrocephalus is quite a rare case. It presents with headache, dizziness, disorientation, and rarely with stroke. The diagnostic process includes computed tomography angiography (CTA) and imaging of the brain. It is mostly treated with pharmacological therapy; however, in some cases, surgery is required. Conclusion: This case highlights the rare but serious neurological adverse effects of Takayasu arteritis in young male patients, as well as the importance of interdisciplinary care. To prevent neurological degeneration, Takayasu arteritis patients must be identified and treated as soon as possible.

Клинический случай лечения пострадавшего с тяжелой сочетанной травмой с множественной жировой эмболией с преимущественным поражением головного мозга

Road traffic accidents occupy the first positions due to severe combined injuries of the population. One of the most dangerous and poorly diagnosed complications of the acute period of combined skeletal injury is the syndrome of fatty embolism with predominant brain damage. Despite the large number of proposed methods and treatments for this complication, the mortality rate remains very high at the moment. A clinical case of successful treatment of multiple fatty embolism of the microvascular bed of internal organs with predominant brain damage in a patient with severe concomitant trauma is presented. Despite the difficulties of diagnosis and treatment, a high percentage of disability, complications and mortality, and the difficulty of preventing this complication of fat embolism with a predominant manifestation in the form of cerebral fat embolism, a favorable outcome is possible for patients with concomitant trauma.Keywords: traffic accident, fractures of long bones, traumatic shock, polytrauma, fat embolism, cerebral fat embolism, intensive care.

Inferior Myocardial Infarction Recanalized by Multiple Embolization to Distal Branches

Inferior Myocardial Infarction Recanalized by Multiple Embolization to Distal Branches

Abstract 139: Super Distal Access using the Vecta46 Intermediate Catheter in Embolization of the MMA for cSDH

Introduction There is increasing literature to support the efficacy of middle meningeal artery (MMA) embolization in the treatment of chronic subdural hematomas (cSDH). Techniques for optimal embolization of the MMA are yet to be elucidated. We hypothesized utilization of a novel 046” intermediate catheter within the proximal MMA trunk carry procedural advantages for multiple pedicle embolizations and ease of navigation to distal MMA vasculature. Methods We retrospectively reviewed and analyzed a prospectively maintained IRB‐approved database of the senior authors. Results Twenty‐one (21) consecutive cases of Vecta46 utilization with MMA embolization were identified (2023), in patients 69±13 years (range 49‐83 years), 4 (19%) women. Four (19%) patients were on antiplatelet/anticoagulants. At presentation, recurrent cSDH in 9 patients (43%) were previously managed with burr holes (n=2, 22%), craniotomy (n=3, 33%), or without drainage (n=4, 44%). Average admission cSDH thickness was 8.8±1.6mm, midline shift of 3±0.7mm. Access was performed through a 5‐ or 6‐French arteriotomy. Both anterior and posterior MMA branches were embolized in 16 (76%) cases, and adjunctive coiling of the proximal MMA trunk was performed in all cases. Vecta46 was successfully placed in the proximal MMA trunk in all cases. There were no vessel irregularities, vasospasm, or dissection noted along the course of the MMA Vecta46 placement. No immediate procedural complications were noted and all cases achieved complete distal MMA occlusion. Figure 1: (A) Ophthalmic (black) and petrous (white) collaterals off the anterior and posterior MMA branches, respectively. (B) Contralateral (green) and falx (orange) penetration of the MMA branches. (C) Proximal coiling of the anterior and posterior MMA branches (black). Conclusion The Vecta46 intermediate catheter is a powerful tool for MMA embolization that allows the safe and effective placement of an intermediate catheter in the proximal MMA trunk. This allows for simple catheter exchange for multiple liquid embolic pedicle embolizations and significant support for navigating microcatheters to distal MMA branches.

Multi-valve Libman-Sacks's endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up.

We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up.

Perfect storm: a clinical case of multisite (brain, coronary, renal and spleen) embolism in patient with atrial fibrillation

Nonvalvular atrial fibrillation (AF) is the most common cause of arterial thromboembolism, especially of ischemic stroke. Other than stroke AF-associated embolic events are usually underestimated but at least similarly important. We present a rare case of simultaneous multiple embolism in a 70 years old women with permanent AF.

Perfect storm: a clinical case of multisite (brain, coronary, renal and spleen) embolism in patient with atrial fibrillation

Nonvalvular atrial fibrillation (AF) is the most common cause of arterial thromboembolism, especially of ischemic stroke. Other than stroke AF-associated embolic events are usually underestimated but at least similarly important. We present a rare case of simultaneous multiple embolism in a 70 years old women with permanent AF.

Multiple Emboli Caused by Mechanical Mitral Valve Thrombosis: A Case Report

We present the case of a 51-year-old woman with a history of atrial fibrillation and rheumatic heart disease who underwent a prosthetic mitral valve replacement two years ago. Despite receiving anticoagulant therapy, this patient experienced embolisms, including embolic strokes and a coronary embolus, over a month. Following a cardiology evaluation, it was determined that mechanical valve thrombosis was the primary source of embolism, and embolisms ceased following a replacement. This case report illustrates the difficulty in diagnosing prosthetic valve thrombosis as a source of multiple emboli in patients receiving adequate anticoagulant therapy, a rare but potentially fatal complication of mechanical valve replacement.

A fatal case of fulminant group: a streptococcal infection in a neonate

BackgroundFulminant hemolytic streptococcal infection is a condition of sudden onset and rapidly progressing septic shock caused by Streptococcus pyogenes. It causes beta (complete) hemolysis. Although type A Streptococcus occurs more frequently, all streptococci that cause beta-hemolysis are eligible as causes. This report describes a rare autopsy case of fulminant group A streptococcal infection in a neonate.Case presentationA 16-day-old girl, 3300 g, born by spontaneous delivery at 41 weeks 1 day, experienced a 1-day history of low-grade fever, malaise, and a few hours of cyanosis and anuria, prompting her parents to bring her to the hospital. Her eldest brother, who lived with her, had been infected with Streptococcus approximately one month earlier, and had been treated with ten days of antibiotics. The infant died three hours after presentation. Autopsy findings indicated her to be 52 cm in length, weighing 3585 g, with medium build and normal nutrition. Her lungs were slightly oligemic with decreased volumes. The liver and kidneys were mildly enlarged. The spleen was markedly enlarged. The adrenal glands showed diffuse cortical hemorrhage (Fig. 1). There was some thymic atrophy (thymus weight 7.4 g, < 1 SD below the mean). Histopathological findings included chronic and neutrophilic infiltration of the tonsils and multiple septic emboli containing cocci in the lungs. Perivascular inflammatory cell infiltrates were observed in the lungs, myocardium, kidneys, adrenal glands, brain, meninges, and liver, with micro-necrotic changes in the kidneys and liver. Fibrin thrombi were observed in multiple renal glomeruli. Hemophagocytosis by macrophages was observed in the spleen, liver, lymph nodes, bone marrow, and adrenal glands. Immunostaining showed positive results for group A Streptococcus antibody in the tonsils, with bacterial masses. Blood cultures were positive for group A Streptococcus pyogenes.ConclusionsBecause of the lower respiratory tract infection and suspected sibling transmission, in addition to the adrenal hemorrhages, a diagnosis of fulminant sepsis with group A Streptococcus pyogenes with associated Waterhouse–Friderichsen syndrome was made.

Complicated infectious endocarditis in a patient with human immunodeficiency virus: A case report

INTRODUCTION: Infectious endocarditis (IE) in injecting drug patients with human immunodeficiency virus (HIV) is manifested predominantly by damage to the tricuspid valve (TV). The pathogen of the disease is Staphylococcus aureus. The IE peculiarities of the TV in this category of patients are multiple septic emboli in the small circulation, which may result from flotation vegetations, and predominance of pulmonary symptomatology over cardiac phenomena.&#x0D; CASE PRESENTATION: A 30-year-old female HIV-infected injecting drug user was dynamically monitored for the laboratory-confirmed IE development by transthoracic echocardiography during a year. The patient was twice admitted to the intensive care unit in a serious condition with purulent-septic complications in the lungs in the form of bilateral polysegmental destructive (septic) pneumonia confirmed by X-ray and multispiral computed tomography. After intensive therapy, the patient refused further ARV treatment and consultations with a cardiac surgeon. A clinical follow-up demonstrated IE of the TV and right-sided lower lobe pneumonia in an HIV-infected drug-dependent patient after a cesarean section. Immunodeficiency without appropriate ARV therapy had a negative impact on the course of the disease. According to transthoracic echocardiography, an increase in TV vegetations from 7 mm to 16 mm and regurgitation were observed, whereas left ventricular ejection fraction decreased from 60% to 47% during the follow-up. Complications of cesarean section, immunodeficiency, and absence of ARV therapy could be the trigger factors of the IE development. Injection drug use with possible violations of asepsis and circulation of microorganisms of the causative agents in the blood contributed to the rapid development of the disease and was a determining factor of the infectious process in the TV.&#x0D; CONCLUSIONS: Echocardiography remains the primary radiological diagnostic method for examining HIV-infected drug-dependent patients with fever and/or after medical manipulations. However, this group of patients more frequently clinically manifests the disease with bright pulmonary pathology. Therefore, radiological methods should necessarily be a priority during the diagnostic search. The sources of septic embolism in the small circulation in IE may be loose and floating TV vegetations.

COVID-19-related multiple inflammatory syndrome-C and pulmonary embolism in Aicardi-Goutries syndrome.

COVID-19-related multiple inflammatory syndrome-C and pulmonary embolism in Aicardi-Goutries syndrome.

An Unusual Case of an Ascending Aortic Thrombus: A Case Report

Ascending aortic ulcerated plaques and thrombi are rare, with an incidence rate of 0.45% [ 1 Sabetai M, Conway A, Hallward G, Bapat V. Ascending aorta thrombus adjacent to a cholesterol-rich plaque as the source of multiple emboli. Interact Cardiovasc Thorac Surg. 2013;16(3):389–90. Google Scholar , 2 Wang B, Ma D, Cao D, Man X. Huge thrombus in the ascending aorta: a case report and literature review. J Cardiothorac Surg. 2019;14(1):157. Google Scholar ]. Presentation is variable but may result in devastating complications including thromboembolism [ 1 Sabetai M, Conway A, Hallward G, Bapat V. Ascending aorta thrombus adjacent to a cholesterol-rich plaque as the source of multiple emboli. Interact Cardiovasc Thorac Surg. 2013;16(3):389–90. Google Scholar , 2 Wang B, Ma D, Cao D, Man X. Huge thrombus in the ascending aorta: a case report and literature review. J Cardiothorac Surg. 2019;14(1):157. Google Scholar ].

Lymphatic Embolization for the Management of Post-operative Chyle Leaks Following Solid Tumor Resection in Pediatric Patients

Chyle leaks are a common post-operative complication following solid-tumor resection in pediatric patients. Current treatments for persistent chyle leaks are limited, leading many patients to experience prolonged hospitalization, nutritional deficits and/or delays in cancer therapies. Lymphatic embolization is an emerging treatment option for chyle leaks, however, limited reports exist of its use in pediatric populations. We conducted a retrospective review of pediatric patients (<18) who underwent lymphangiogram with intent for lymphatic embolization for the management of chyle leaks following solid-tumor resection between 2017 and 2022. Seven patients underwent a total of 11 attempted lymphatic embolization procedures after current standard of care treatments failed to resolve the leak. Lymphangiograms identified a chyle leak in 6 of 7 patients and embolization had a technical success rate of 73%. The complication rate was 9% and complications were limited to one episode of inadvertent gastric wall perforation that did not result in a gastric leak. Lymphatic embolization was ultimately associated with chyle leak resolution in 100% of patients within a median of 24 days, however, repeat embolization was required in 5 of 7 patients (83%). Lymphatic embolization appears to be a safe and effective treatment for persistent chyle leaks in pediatric patients, leads to a direction reduction in chyle output, and has high rates of technical and clinical success. Complete resolution of the chyle leak may require multiple embolization procedures. Further work is needed to determine whether earlier intervention may offer benefit for the management of pediatric chyle leaks. IV.

Multi-modality imaging assessment of microbubbles and cerebral emboli in left ventricular pulsed field ablation.

Pulsed field ablation (PFA) may have a superior safety profile compared to other technologies, but it has the potential to cause gaseous microbubbles (MB), which may be associated with cerebral emboli. Limited relative safety data has been published regarding PFA in the left ventricle (LV). Healthy and chronic myocardial infarction (MI) swine underwent PFA (monopolar, biphasic, 25 Amps) in the LV using an irrigated focal catheter under intra-cardiac echocardiography (ICE) guidance for MB monitoring. Two control swine received air MBs through the lumen of the ablation catheter. Swine underwent brain MRI before and after PFA (or control air MB injection). Gross pathology and histology of brains with abnormal MRI findings were performed. Four healthy and 5 chronic MI swine underwent 124 left ventricular PFA applications. No PFA-related MB formation was noted on ICE. Both control swine developed multiple acute emboli in the thalamus and caudate on DWI, ADC, and FLAIR brain MRI images in response to air MB injection. Of the 9 PFA swine, there were no abnormalities on ADC or FLAIR images. There was one hyperintense focus in the left putamen on the DWI trace image, but the absence of ADC or FLAIR affirmation suggested it was artifact. Gross pathology and histopathology of this region did not detect any abnormalities. Focal monopolar biphasic PFA of both healthy and chronically infarcted left ventricular myocardium does not generate any MB or cerebral emboli observable on ICE and brain MRI.

Amniotic fluid embolism causing multiorgan embolisms and reinforces the need for point-of-care ultrasound.

Pregnant patients are at risk of several possible complications during the peripartum period. Amniotic fluid embolism (AFE) is a peripartum complication with high mortality and morbidity. The sudden entry of amniotic fluid into the maternal circulation causes a rapid and dramatic sequence of clinical events called AFE. The reported incidence of AFE after a cesarean section is around 19%, and after a normal delivery, it is 11%. AFE causing multiple embolisms is not reported in the literature, nor is the use of point-of-care ultrasound (POCUS) in the diagnosis of AFE. We report a case of AFE causing pulmonary and ovarian embolisms. A 34-year-old pregnant lady had an elective lower section cesarean section (LSCS) for transverse lying and placenta previa under combined spinal and epidural anesthesia. She was gravida 3 para 2 and had regular antenatal check-ups, and she presented for her LSCS at 36 weeks of gestation. Immediately after delivery of the fetus, the patient had convulsions, cardiac arrest, and disseminated intravascular coagulopathy (DIC). Immediately, cardiopulmonary resuscitation started, and the team achieved a return of spontaneous circulation (ROSC) in 3 minutes. DIC was corrected with blood and blood products during this maneuver, and POCUS of the inferior vena cava and heart showed multiple small particles floating, thus confirming the diagnosis of AFE in this patient. The patient was transferred to the intensive care unit (ICU), intubated, and ventilated, necessitating a vasopressor infusion. Computed tomographic pulmonary angiography (CTPA) showed pulmonary embolism and ovarian vein embolism, which were managed with heparin infusion. She was hemodynamically stable and weaned from vasopressors, and the ventilator was then extubated on day 13 of ICU admission. She remained awake and in stable condition. The patient was transferred to the ward and subsequently discharged to go home on the 20th-day post-delivery. AFE can be quickly diagnosed using clinical manifestations and POCUS, and it can be managed early for better patient outcomes. POCUS will show multiple smaller and a few larger amniotic fluid emboli in the heart and vena cava. These larger AFE emboli can migrate and cause multiple embolisms, requiring systemic anticoagulation.

A Clinical Case of the Progress of Infective Endocarditis in an HIV-Infected Patient without Antiretroviral Therapy Complicated by Repeated Episodes of Septic Destructive Pneumonia (Clinical Example)

Infectious endocarditis (IE) in HIV-infected users of injecting drug is manifested by a predominant lesion of the tricuspid valve (TV), and the causative agent of the disease is Staphylococcus aureus. A feature of the course of IE TV in this category of patients are multiple septic embolisms in the small circulatory circle, the source of which may be floating vegetation and the predominance of pulmonary symptoms over cardiac.

Vertebral-Venous fistulas: Single center experience and practical treatment approach

Vertebral-venous fistulas (VVFs) are rare. Scarce literature exists to guide our understanding and management. We report our experience and propose a classification based on flow, feeder number, and involvement of accessible veins. Additionally, we include a practical treatment approach. Retrospective chart and imaging review of cerebrovascular arteriovenous fistulas treated in our center between July 2013 and April 2022. We reviewed patient demographics, presentation, imaging, treatment strategies, and outcomes. Nine patients with VVFs were identified, six were females. Ages ranged between 38-83 years. There were six high-flow and three low-flow. Most VVFs originated at the level of V3. Additional feeders from the internal carotid artery, external carotid artery, and/or subclavian artery were present in four cases (two were high-flow). Four cases had multiple arterial feeders. All cases were symptomatic. Origin was spontaneous in eight and iatrogenic in one case. Most common presenting symptoms were pain (7) and pulsatile tinnitus (4). Neurological deficits were present in two cases (1 high- and 1 low-flow). Four cases were treated with vertebral artery segmental sacrifice alone, three required multiple transarterial embolizations with or without VA sacrifice, one case had single transvenous approach, and one was treated with single targeted transarterial embolization. One patient had a minor transient neurological complication. No treatment-related mortality was seen. Treatment of high-flow and symptomatic low-flow VVFs is feasible and safe. Our classification and treatment approach might help guide patient selection and choice of endovascular approach. However, our approach warrants further validation with a larger number of patients.

Choledochoscope-guided treatment of pulmonary embolism caused by ventricular myxoma

A 33-year male patient presented with a 6-month history of cough and shortness of breath upon physical activity. Echocardiography demonstrated right ventricular space-occupying lesions. Contrast-enhanced computed tomography of the chest showed multiple emboli in the pulmonary artery and its branches. Right ventricle tumor (myxoma) resection, tricuspid valve replacement, and clearance of the pulmonary artery thrombus were performed under cardiopulmonary bypass. Minimally invasive forceps and balloon urinary catheters were used to clear the thrombus. Clearance was confirmed by direct visualization using a choledochoscope. The patient recovered well and was discharged. The patient was prescribed oral warfarin 3 mg/day, and the international normalized ratio for prothrombin time was maintained between 2.0 and 3.0. Pre-discharge echocardiogram showed no lesion in the right ventricle or pulmonary arteries. The 6-month follow-up echocardiography indicated that the tricuspid valve was functioning well and showed no thrombus in the pulmonary artery.

"Multidisciplinary Team Management of a Pregnant Woman With Newly Diagnosed Multiple Pulmonary Embolisms and Foetal Compromise, When to Deliver?"

Thromboembolic disease, including pulmonary embolism (PE) is the leading cause of direct maternal mortality in the UK (UKOSS, [1]). In women with diabetes, there is usually an increase in resistance to insulin within the placenta and taking corticosteroids often causes an increase in insulin requirements. A sudden reduction at term is an indication of a failing placenta and increases the risk of sudden stillbirth, requiring an expedited delivery.

Abstract Number ‐ 78: An Unusual Cause Of Progressive Visual Loss – Vein Of Galen Malformation

Introduction Vein of Galen Malformations (VOGM) are rare vascular conditions resulting from anomalous vascular shunts between primitive choroidal vessels and the Markowski Prosencephalic Vein (MPV). They comprise only 1% of all intracranial vascular malformations with a high mortality rate up to 76.7% if untreated. In this case report, we aim to bring awareness of this condition as a cause of progressive visual loss with the objective of making it relevant in our medical community. Methods We discuss the case of a truck driver who progressively and slowly lost his vision as a consequence of a VOGM. Results In this case report we present a 49‐year‐old man with a past medical history of hypertension and renal insufficiency who initially presented to his ophthalmologist for progressive vision loss accompanied by headaches. Bilateral papilledema was seen on examination as well as near complete vision loss on the right eye and 20/40 visual acuity on the left eye. He was referred to neurosurgery for suspicion of elevated intracranial pressure. CT angiogram demonstrated multiple areas of fistualization to the VOGM, including branches from the meningeal hypophyseal divisions, bilateral distal PICA divisions, and the thalamic striate divisions. A multisession endovascular treatment with multiple embolizations was pursued. Initially, the patient underwent a transarterial embolization of the left middle meningeal artery (MMA) and left occipital artery (OA) followed by embolization of the 4 branches of the right MMA. Then, he underwent embolization of 8 large feeding branches and three weeks later, transvenous coiling of the MPV was done. Post‐embolization angiograms showed progressive decrease in the size of the malformation, the degree of the shunt and, and in cortical venous reflux with near normalization of the capillary and venous phases timing in the left and right hemispheres. Although, the patient did not recover from prior visual deficits, his symptoms remained stable. Conclusions It is important to keep this unusual cause of progressive vision loss within the differential diagnosis. The earlier this diagnosis is made, the quicker patients can receive treatment preventing long term deficits, morbidity and mortality.