Multiple Vascular Territories Research Articles

Ischemic Stroke in Patients with Solid Gynecologic Tract Tumors and Coagulopathy

Aim: Patients with gynecological neoplasms often suffer ischemic stroke. This study aimed to clarify the underlying mechanisms of ischemic stroke in patients with gynecological tract tumors. Methods: We retrospectively reviewed 6 patients with gynecologic tumors and hypercoagulability who were being treated for acute ischemic stroke between 2006 and 2012. Diffusion-weighted magnetic resonance imaging (DW-MRI), cardiovascular risk factors including plasma D-dimer levels, and histologic examination of the patients' solid tumors were performed. All 6 patients underwent transesophageal echocardiography (TEE) for nonbacterial thrombotic endocarditis (NBTE) and paradoxical embolism. Results: All 6 patients showed elevated plasma D-dimer levels. In 1 patient, paradoxical embolism was diagnosed. In the remaining 5 patients, DW-MRI scans showed numerous lesions in multiple vascular territories, and in 4 of these 5 patients, TEE demonstrated vegetations on the mitral valve, leading to the diagnosis of NBTE. Interestingly, 2 of these 4 patients had benign uterine tumors, whereas the other 2 had ovarian cancer. Conclusions: NBTE was the main etiology for ischemic stroke in patients with gynecologic tract tumors and coagulopathy. Both malignant and benign tumors of the gynecologic tract can cause NBTE.

Cerebral arteriovenous malformation: Complex 3D hemodynamics and 3D blood flow alterations during staged embolization

Complex hemodynamics in cerebral arteriovenous malformations (AVM) are thought to play a key role in their pathophysiology. We applied 4D flow magnetic resonance imaging (MRI) for the detailed evaluation of AVM function at baseline and to investigate the impact of staged embolization on AVM hemodynamics in a patient with a Spetzler-Martin grade III AVM. The patient underwent three embolization procedures resulting in >50% nidal casting and obliteration of several arteriovenous fistulae. 4D flow MRI demonstrated highly complex 3D hemodynamics at baseline and revealed intricate arterial feeding, a large vascularized nidus with high variability in regional blood flow velocities, and clearly visible venous drainage with high flow velocities above 50 cm/s. 3D blood flow visualization and quantification during follow-up illustrated the systemic impact of focal embolization on cerebral hemodynamics resulting in compaction of the AVM, redistribution of blood flow velocities, and altered peak flow velocities and blood flow in multiple vascular territories. 4D flow MRI may offer a useful noninvasive tool to help to identify subtleties and nuances of the quantitative hemodynamic alterations in AVM vascular architecture as a supplement to established imaging modalities.

Aging, Aortic Arch Calcification, and Multiple Brain Infarcts Are Associated with Aortogenic Brain Embolism

Background: Mobile or ulcerated aortic plaques (MUAPs) on transesophageal echocardiography (TEE) can cause aortogenic brain embolism. Aortic arch calcification (AoAC) on chest X-ray represents systemic atherosclerosis. This study focused on AoAC on chest X-ray and its link with atheromatous aortic plaques (AAPs) on TEE in stroke patients. The aim of the present study was to assess the relationship between AoAC and AAPs in unexplained stroke patients. Methods: A total of 178 patients (mean age: 64 ± 15 years; 115 males) with ischemic stroke who underwent TEE were enrolled. The patients were classified based on TEE findings: (1) AAPs <4 mm; (2) AAPs ≥4 mm, and (3) MUAPs. The extent of AoAC on chest X-ray was divided into 4 grades (0-3). Clinical characteristics including AoAC were compared among the 3 groups. Multiple logistic regression analysis was performed to identify the independent factors associated with MUAPs. An original diagnostic criterion was defined as a potential indicator of MUAPs in unexplained stroke patients. Results: 104 (58%) patients had AAPs <4 mm, 46 (26%) had AAPs ≥4 mm, and 28 (16%) had MUAPs. Older age (OR: 1.14; 95% CI: 1.06-1.24; p = 0.001), AoAC (OR: 2.35; 95% CI: 1.30-4.24; p = 0.005), and multiple infarctions in multiple vascular territories (VTs) demonstrated on diffusion-weighted imaging (DWI) (OR: 2.58; 95% CI: 1.35-4.92; p = 0.004) were independently associated with MUAPs. The CAM score was defined as consisting of the degree of AoAC (0-3 points), age (≥70 years: 1 point), and DWI findings (multiple infarctions in 1 VT: 1 point; 2 VTs: 2 points; more than 3 VTs: 3 points). The prevalence of MUAPs was substantially increased in patients with medium risk (CAM score 3-4, OR: 7.68; 95% CI: 2.89-20.44; p < 0.001) and high risk (CAM score 5-7, OR: 20.63; 95% CI: 5.12-83.06; p < 0.001). Conclusions: Older age, advanced AoAC, and multiple infarctions in multiple VTs are associated with aortogenic brain embolism. The CAM score can be useful for the diagnosis of aortogenic brain embolism.

Acute Ischemic Brain Lesions in Infective Endocarditis: Incidence, Related Factors, and Postoperative Outcome

Background: Acute brain infarction affects the timing and regimen of cardiac surgery in patients with infective endocarditis (IE). We aimed to identify preoperative brain MRI characteristics, incidence, and related factors for acute ischemic lesions in left-sided IE patients undergoing cardiac surgery. Furthermore, we investigated whether preoperative acute ischemic lesions are associated with postoperative neurological complications in IE patients. Methods: We retrospectively reviewed consecutive patients with a definite left-sided IE who underwent cardiac surgery in 6 university-affiliated hospitals from January 2004 to November 2011. Preoperative brain MRI evaluations were systematically performed on all patients without contraindications, regardless of neurological complications, with the aim of preventing perioperative complications. Patients were included if diffusion-weighted imaging and fluid-attenuated inversion recovery sequences were performed within 14 days after diagnosis. Associations between acute ischemic lesions and related factors were analyzed. Neurological complications within 30 days after surgery were evaluated for postoperative outcome analyses. Results: Of 139 consecutive patients with left-sided IE who underwent cardiac surgery, 85 patients were evaluated in this study. The mean age was 58 ± 16 years, and 22 patients (26%) were women. Preoperative MRI revealed acute ischemic lesions in 47 patients (55%), and 19 of these patients developed neurological symptoms. Among the patients with ischemic lesions, 24 (60%) had small lesions (<10 mm), 36 (77%) had multiple lesions, and 30 (64%) had lesions in multiple vascular territories. Compared to patients without ischemic lesions, patients with acute ischemic lesions were older and had significantly higher white blood cell counts and plasma C-reactive protein (CRP) levels, but lower hemoglobin levels. Logistic regression analyses showed that the white blood cell count and plasma CRP level were independently associated with acute ischemic lesions [adjusted OR per 1-SD increase were 2.21 (95% CI: 1.23-4.35) and 2.33 (95% CI: 1.27-4.96), respectively]. Three patients developed postoperative neurological complications, but preoperative acute ischemic lesions and postoperative complications were not associated. Conclusions: Preoperative MRI detected a high incidence of asymptomatic ischemic lesions in IE patients. Acute ischemic lesions were often small, multiple, and located in multiple vascular territories. Inflammatory reactions may play an important role in the development of ischemic lesions in IE patients.

Dilated Left Atrium Is Associated with Multiple Vascular Territory Strokes (P04.082)

Dilated Left Atrium Is Associated with Multiple Vascular Territory Strokes (P04.082)

Abstract TP219: Implantation With Reveal XT After Cryptogenic Stroke Is A Useful Tool To Detect Previously Undiagnosed Atrial Fibrillation

Cryptogenic strokes are those ischemic cerebral events with no clear etiology, many of which have embolic characteristics. It is hypothesized that many of these emboli are due to undiagnosed and asymptomatic atrial fibrillation (AF). 1 Our study selected patients with cryptogenic strokes for implantation with the Reveal XT insertable cardiac monitor with the hope of detecting AF in these patients. Methods: Patients with ischemic strokes had MRI or CT performed to visualize the infarct. A neurologist determined as to whether the infarct was lacunar, and due to small vessel disease, or if it was an embolic appearing stroke based on the infarct’s size and location (cortical, wedge shaped infarct, multiple vascular territories, watershed territory). If the infarct appeared embolic, and the patient had no history of AF, a full stroke workup was initiated consisting of fasting lipid panel, bilateral carotid dopplers, MRA or CTA of the head, Transesophageal Echocardiogram (TEE), continuous telemetry and hypercoagualable labs if age of the patient was &lt;50). If the stroke was in the posterior circulation, a CTA or MRA of the neck replaced the bilateral carotid dopplers. Patients who had an embolic appearing stroke with a negative TEE, no episodes of AF on cardiac telemetry, MRA or CTA negative for a focal area of stenosis, and carotid Doppler examinations showing less than 50% ipsilateral stenosis were diagnosed as having a cryptogenic stroke. These patients were then offered implantation with the Reveal XT with follow up by a cardiac electrophysiologist who would adjudicate any triggered episodes of atrial fibrillation. Results: Following this protocol, 22 patients were successfully implanted with the Reveal XT device. Of these patients, 9 were discovered to have AF, or 41% yield. Once diagnosed with atrial fibrillation, these patients were then placed on appropriate anticoagulation therapy. Conclusion: Based on the above results, the Reveal XT insertable cardiac monitor is useful in detecting AF in patients with embolic appearing cryptogenic strokes with otherwise negative workup, and can ultimately change the patient’s therapeutic regimen. Footnotes 1 Finsterer J, (June, 2010) “Management of Cryptogenic Stroke” Acta Neurol Belg . 110(2):135–47.

Abstract TMP13: Baseline DWMRI Characteristics In Patients With Cryptogenic Stroke And Patent Foramen Ovale: Results From The Closure I Trial

Background: Cryptogenic stroke may have several etiologies including paradoxical embolism through a patent foramen ovale (PFO). A cardiac source of embolism may be suggested by multiple infarcts, sometimes hemorrhagic, in different vascular distributions or a cortical wedge shaped infarct. We report the baseline diffusion weighted MRI (DWMRI) characteristics in patients with cryptogenic stroke and a patent foramen ovale (PFO) from the CLOSURE I trial. Methods: CLOSURE I compared device closure versus medical therapy for secondary prevention in patients with cryptogenic TIA or stroke and a PFO. Of 909 patients randomized, 562 patients demonstrated acute infarcts on baseline DWMRI and are included in this analysis. Multivariate proportional hazard Cox regression compared imaging subgroups with remaining randomized patients Results: Single infarcts were found in 62% of patients. Of these, 61% were anterior circulation, 30% posterior, and 8.5% were of uncertain territory. Of the anterior circulation infarcts, 40% were cortical, 36% subcortical, and 24% affected both the cortical and subcortical regions. Of the posterior circulation infarcts, 45% were thalamic or cerebellar. Of 562 patients, 18.5% had a single subcortical lesion &lt;1.5cm in diameter and met the radiological definition of an acute lacunar infarct. Multiple infarcts were found in 38%. Infarcts in a single vascular territory were found in 23%, often in the anterior circulation (66%). Infarcts in multiple vascular territories were found in 15%. Hemorrhagic infarction was present in 9%. Adjusting for patient characteristics, no significant difference in 2 year rate of TIA, stroke or death was found compared to remaining randomized patients. Discussion: The specificity of infarct patterns for embolism in patients with cryptogenic stroke and a PFO is uncertain. We found no significant relationship between lacunar or subcortical infarction and the risk of recurrent TIA or stroke. Baseline infarct patterns on DWMRI in patients with cryptogenic stroke and PFO may not be useful in predicting recurrent stroke risk or determining best prevention therapy.

Abstract WP220: Determinants for Cryptogenic Stroke: Clinico-radiologic Findings

Background: Cryptogenic stroke accounts for 30-40% of all strokes. Aortic arch atheroma(AAA), patent foramen ovale(PFO) and paroxysmal atrial fibrillation(PAF) are common causes which require different treatment strategies. However not all patients could undergo extensive work-ups. We investigated clinico-radiological characteristics of these 3 common causes of cryptogenic stroke to find a model helping decision-making. Method: We enrolled 194 patients with cryptogenic stroke at the time of admission. After performing extensive work-ups including electrocardiography, transthoracic or transesophageal echocardiography, transcranial right-to-left shunt test, coronary computed tomography angiography or cardiac telemetry, patients were allocated into 3 groups; (1) AAA(n=25), (2) PFO(n=94), and (3) PAF(n=75). Vascular risk factors and findings on diffusion-weighted image were analyzed. Results: Clinico-radiologic features were different. Patients with PFO were younger (mean, 56.1[PFO] vs. 73.9[AAA] vs. 70.6[PAF] years; p &lt;0.001) and hypertension was less common ( p &lt;0.001). Smoking was more common in AAA group ( p =0.018). PAF-related strokes had higher NIHSS ( p &lt;0.001) and a larger lesion (≥20mm, 81.1%[A-fib] vs. 16.0%[AAA] vs. 46.2%[PFO]; p &lt;0.001). By contrast, AAA-related strokes showed small but multiple lesions scattered in multiple vascular territories ( p &lt;0.001). Patients with PFO had subcortical lesions ( p =0.029) in posterior circulation ( p =0.004). Multivariate regression analysis revealed that age, NIHSS, hypertension, multiple(≥3) lesions and involvement of multiple vascular territories could differentiate 3 groups (R 2 =0.6581). We calculated probability for 3 groups and performed external validation. Conclusion: Patients with cryptogenic stroke showed distinct features which may provide clues for stroke mechanisms. Our data suggested that etiologic work-ups for cryptogenic stroke could be guided by these features.

Coiling Occlusion of the Vertebral Artery for a Patient with Recurrent Posterior Circulation TIAs

Recurrent posterior circulation infarcts frequently involve multiple vascular territories, suggesting an embolic source. We describe a patient with left vertebral artery occlusion who had recurrent transient ischaemic attacks due to cerebral embolization originating from the occluded vertebral artery in spite of optimal anticoagulant and antithrombotic treatment. This was successfully managed by coiling occlusion of the vertebral artery with no recurrence of symptoms over one year of follow-up. To our knowledge, this is the first report of coiling occlusion in the treatment of recurrent vertebral artery embolization.

Stroke and Cancer

The importance of cancer-associated hypercoagulability as a possible stroke etiology in patients with cancer has received relatively little attention to date. A recent study has suggested that cancer-associated hypercoagulation may be of special importance in the absence of conventional stroke mechanisms. We identified patients with ischemic stroke sequentially admitted to our stroke center with the additional diagnosis of active and malignant cancer from 2002 to 2011. By using our prospectively collected stroke, MRI, and laboratory data banks, the etiology and risk factors of stroke, types of cancer, deep vein thrombosis/pulmonary embolism, d-dimer levels, and diffusion-weighted imaging lesion patterns were compared to an age- and sex-matched control group. Patients with cancer with a conventional stroke etiology and patients with an unidentified and/or cancer-associated stroke etiology were analyzed separately. One hundred forty patients with cancer and 140 control subjects were included. Unidentified stroke (P<0.001) and infarction in multiple vascular territories (P<0.001) were significantly more frequent and d-dimer levels significantly higher (P<0.05) in patients with cancer. Vice versa, risk factors such as hypertension (P<0.05) and hyperlipidemia (P<0.01) were more prevalent in control subjects. Deep vein thrombosis and pulmonary embolism were more frequent (P<0.01) and d-dimer levels higher (P<0.01) in the patients with unidentified and/or cancer-associated stroke etiology compared to the patients with cancer with a conventional stroke etiology. Lung and pancreatic cancer were significantly overrepresented and d-dimer levels higher in these patients compared with other patients with cancer (P<0.01). Our data confirm the concept of cancer-associated hypercoagulation as a widely underestimated important stroke risk factor in patients with cancer, especially in those with severely elevated d-dimer levels and in the absence of conventional risk factors.

Clues to Occult Cancer in Patients with Ischemic Stroke

BackgroundWe hypothesized that hidden malignancy could be detected in patients with cryptogenic stroke without active cancer when they showed the distinctive characteristics of cancer-related stroke.Methods and FindingsAmong 2,562 consecutive patients with acute ischemic stroke, patients with cryptogenic stroke were analyzed and categorized into two groups according to the presence of active cancer: cryptogenic stroke with active cancer (cancer-related stroke, CA-stroke) group and without active cancer (CR-stroke) group. Patients with active lung cancer without stroke were also recruited for comparison purposes (CA-control). Clinical factors, lesion patterns on diffusion-weighted MRI (DWI), and laboratory findings were analyzed among groups. A total of 348 patients with cryptogenic stroke were enrolled in this study. Among them, 71 (20.4%) patients had active cancer at the time of stroke. The D-dimer levels were significantly higher in patients with CA-stroke than those with CR-stroke or CA-control (both p<0.001). Regarding lesion patterns, patients with CA-stroke mostly had multiple lesions in multiple vascular territories, while more than 80% of patients with CR-stroke had single/multiple lesions in a single vascular territory (P<0.001). D-dimer levels (OR 1.11 per 1 µg/mL increase; 95% CI 1.06–1.15; P<0.001) and DWI lesion patterns (OR 7.13; 95% CI 3.42–14.87; P<0.001) were independently associated with CA-stroke. Workup for hidden malignancy was performed during hospitalization in 10 patients who showed elevated D-dimer levels and multiple infarcts involving multiple vascular territories but had no known cancer, and it revealed hidden malignancies in all the patients.ConclusionPatients with CA-stroke have distinctive D-dimer levels and lesion patterns. These characteristics can serve as clues to occult cancer in patients with cryptogenic stroke.

Temporal trends in the incidence and recurrence of hospitalised atherothrombotic disease in an Australian population, 2000–07: data linkage study

ObjectivesTo examine temporal trends in the incidence and recurrence of hospitalised coronary heart disease (CHD), cerebrovascular disease (CeVD) and peripheral arterial disease (PAD) separately and combined, and by the history...

Characterization of the Infarct Pattern Caused by Vulnerable Aortic Arch Atheroma: DWI and Multidetector Row CT Study

Background: Aortic arch atheroma (AAA) has been accepted as a possible embolic source in patients with ischemic stroke, especially cryptogenic stroke. However, despite its well-known role as a risk factor for stroke, research focused on the mechanism or characteristics of stroke caused by AAA is insufficient. In this study, we aimed to evaluate clinical and radiological characteristics including lesion pattern on DWI in acute stroke patients associated with vulnerable AAA detected by multidetector row computed tomography (MDCT). Methods: From September 2008 through May 2011, patients who presented with acute ischemic stroke and underwent MDCT were found in a prospective stroke registry. Patients without evident stroke etiology were included and classified by presence of vulnerable AAA. Vulnerable AAA was defined as (i) at least 6 mm thick adjacent to the aortic wall; (ii) ulcerated plaque, or (iii) soft plaque. Soft plaque was defined as the presence of clearly visualized area of hypoattenuation (<80 Hounsfield units) suggestive of thrombus. The patients without vulnerable AAA were classified as no/simple AAA group. The characteristics of diffusion-weighted MRI (DWI) lesions were analyzed in terms of the number and size of the lesions, and the involved vascular territories. Results: A total of 63 cryptogenic stroke patients were included in this study. Vulnerable AAA was observed in 15 (23.8%) patients. The patients with vulnerable AAA were older than those with no/simple AAA (p = 0.026). DWI analysis revealed that the vulnerable AAA group had a greater chance of having multiple and small lesions in multiple vascular territories that were mainly located in cortical and border-zone regions than the no/simple AAA group. Multiple logistic regression analysis showed that age (odds ratio 1.17; 95% confidence interval 1.02–1.34) and multiple small lesions in multiple vascular territories (odds ratio 33.18; 95% confidence interval 4.26–258.45) were independently associated with vulnerable AAA. Conclusion: Vulnerable AAA is independently associated with a DWI pattern characterized by multiple small scattered lesions in multiple vascular territories in conjunction with age. It may help determine stroke mechanism quickly and easily, and provide more information about the pathomechanism of vulnerable AAA-related stroke.

Facial Numbness: An Early Clinical Sign in Cerebral Mucormycosis (P01.254)

Objective: To describe a case of isolated facial numbness as the first symptom of cerebral mucormycosis. Background Rhino-orbital-cerebral mucormycosis is a relatively rare entity. It is classically seen in diabetics with ketoacidosis, as the fungi have a reductase that allows growth in high glucose and acidic conditions. The syndrome typically has a prodrome consisting of purulent nasal discharge, perinasal or periorbital cellulitis, and vision changes. A rare and late complication of the disease is invasion of the intracranial vessels (typically by local invasion of the cavernous sinus), which can lead to cerebral infarcts. The disease has a very high mortality and early recognition is imperative to prevent serious complications and death. Design/Methods: Case report. Results: The patient was a 64 year old male with uncontrolled diabetes and HIV who was admitted to a community hospital with complaints of severe lethargy and unilateral facial numbness. He was treated for diabetic ketoacidosis and urinary tract infection. Several days later he developed hemiparesis and was found to have acute anterior cerebral artery infarct. Following clinical deterioration and transfer to a tertiary stroke center, he was found to have multiple additional vascular territory infarcts. Post-mortem studies revealed extensive mucormycosis involving intracranial vessels. Conclusions: Unless recognized and treated early, cerebral mucormycosis is invariably fatal. The early clues to diagnosis in this case were presence of diabetic ketoacidosis, facial numbness, and sinusitis present on imaging. In this setting, ENT consultation for exploration of sinuses should be considered. Disclosure: Dr. Miller has nothing to disclose. Dr. Kittner has nothing to disclose.

Pentraxin-3 as a Marker of Advanced Atherosclerosis Results from the Bruneck, ARMY and ARFY Studies

ObjectivePentraxins like C-reactive protein are key components of the innate immune system. Recently, pentraxin-3 (PTX3) has been proposed to be a specific marker of vascular inflammation, yet its association with atherosclerosis is still unclear.Methods and ResultsPTX3 serum levels were measured in three independent studies of 132 young men (ARMY Study), 205 young women (ARFY Study) and 562 individuals 55 to 94 years old (Bruneck Study). In contrast to C-reactive protein, PTX3 showed little relationships with classic vascular risk factors and pro-inflammatory conditions. In the population based Bruneck Study, PTX3 level was independently associated with prevalent cardiovascular diseases (multivariable odds ratio [95%CI] 3.09 [1.65–5.79]; P<0.001). Moreover, PTX3 level correlated with the severity of carotid and femoral atherosclerosis and was highest in individuals with multiple vascular territories affected. In contrast, there was no association with elevated intima-media thickness, a precursor lesion of atherosclerosis, in any of the three populations investigated.ConclusionsLevel of PTX3 is independently associated with atherosclerosis and manifest cardiovascular disease but not early vessel pathology. Unlike C-reactive protein, PTX3 is not a component of the classic acute phase response (systemic inflammation) but appears to be more specific for vascular inflammation.

Abstract 3401: Characterization of the Infarct Pattern Caused By Complex Aortic Arch Atheroma: DWI and Multi-detector Row CT study

Background: Aortic arch atheroma (AAA) has been accepted as a possbile embolic source in patients with ischemic stroke, especially cryptogenic stroke. In this study, we aimed to evaluate clinical and radiological characteristics including lesion pattern on DWI in acute stroke patients associated with complex AAA detected by multidetector row computed tomography (MDCT). Methods: Form September 2008 through May 2011, patients who were presented with acute ischemic stroke and underwent MDCT were found in a prospective stroke registry. Patients without evident stroke etiology were included and classified by presence of complex AAA. Complex AAA was defined as at least 6 mm thick adjacent to the aortic wall, ulcerated plaque, or vulnerable plaque. The characteristics of DWI lesions were analyzed in terms of the number and size of the lesions, and the involved vascular territories Results: A total of 62 cryptogenic stroke patients were included in this study. The complex AAA was observed in 14 (22.6%) patients. The patients with complex AAA were older than those with no/simple AAA. There were no differences between groups in terms of vascular risk factors, laboratory findings, and pre-stroke medication. DWI analysis revealed that complex AAA group had a more chance to have multiple and small lesions in multiple vascular territories that mainly located in cortical and border-zone regions than no/simple AAA group ( Figure ). Multiple logistric regression analysis showed that age (OR 1.17; 95% CI 1.02-1.40) and multiple small lesions in multiple vascular territories (OR 31.32; 95% CI 3.99-245.67) were independently associated with the complex AAA. Conclusion: The results of DWI pattern analysis indicate that complex AAA demonstrated by MDCT is associated with multiple small scattered lesions in multiple vascular territories. Figure . Summation map of all patient’ diffusion-weighted imaging in patients with complex aortic arch atheroma. The majority of lesions are small and located in cortical and border-zone regions.

Recurrent Transient Ischemic Attacks in a 48-Year-Old Patient With an Undiagnosed Ebstein's Anomaly: A Case Report

Ebstein ’ s anomaly is a rare congenital malformation of the heart characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialisation of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet. Its presentation depends on the severity of the anomaly. Mild forms are often undiagnosed until adulthood due to its benign course. Importantly, interatrial communications are present in 80% of the patients with EA through which a paradoxical embolism may occur whenever a right-to-left shunt exists. The authors describe a case of a 47-year-old white man that presented with acute recurrent transitory ischemic brain attacks and progressive exertional dyspnea. A brain CT scan revealed infarcts in multiple vascular territories. Echocardiographic studies revealed an Ebstein ’ s anomaly with a right-to-left shunt through an interatrial communication and severe right heart failure. Doppler study of the cervical and extremities ’ vessels was negative for a possible thrombotic source. A diagnosis of transient ischemic attacks presumably secondary to paradoxical embolism with unknown source was established. The patient was successfully submitted to heart surgery and improvement of symptoms and heart function was observed. At follow-up he remains well and without further neurological events. doi:10.4021/jmc439w

Recurrent Transient Ischemic Attacks in a 48-Year-Old Patient With an Undiagnosed Ebstein’s Anomaly: A Case Report

Ebstein’s anomaly is a rare congenital malformation of the heart characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialisation of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet. Its presentation depends on the severity of the anomaly. Mild forms are often undiagnosed until adulthood due to its benign course. Importantly, interatrial communications are present in 80% of the patients with EA through which a paradoxical embolism may occur whenever a right-to-left shunt exists. The authors describe a case of a 47-year-old white man that presented with acute recurrent transitory ischemic brain attacks and progressive exertional dyspnea. A brain CT scan revealed infarcts in multiple vascular territories. Echocardiographic studies revealed an Ebstein’s anomaly with a right-to-left shunt through an interatrial communication and severe right heart failure. Doppler study of the cervical and extremities’ vessels was negative for a possible thrombotic source. A diagnosis of transient ischemic attacks presumably secondary to paradoxical embolism with unknown source was established. The patient was successfully submitted to heart surgery and improvement of symptoms and heart function was observed. At follow-up he remains well and without further neurological events. J Med Cases. 2012;3(1):54-59 doi: https://doi.org/10.4021/jmc439w

Increased lipoprotein(a) is associated with polyvascular disease in patients undergoing coronary artery bypass graft

ObjectiveWe sought to identify clinical and biochemical predictors of disease in multiple vascular territories, in patients with established coronary heart disease. MethodsA total of 470 patients (329 men, 141 female) who had undergone coronary artery bypass grafting (CABG) were enrolled in this prospective study. Polyvascular disease was defined on the presence of existing symptomatic or asymptomatic carotid artery stenosis and/or peripheral artery disease, which is present in 32.1% of patients (n=151). ResultsClinical and laboratory features independently associated with the presence of polyvascular disease included age ≥65 years, male sex, hypertension, former or current smoker, low BMI, and high Lp(a). Lp(a) was the only biochemical marker that had an independent association with polyvascular disease (OR=1.01 per 1mg/dl increase; 95% CI, 1.00–1.01). The fourth quartile of Lp(a) has significant associations with the risk of two or more vascular territories involvement (OR=1.866; 95% CI, 1.056–3.297), and three vascular territories involvement (OR=4.240; 95% CI, 1.405–12.798). There was a significant trend towards patients with the highest quartile of Lp(a) that has association with more advanced polyvascular disease (test for trend: p=0.008 for involvement of three vascular territories). ConclusionHigh Lp(a) was independently associated with polyvascular disease in patients who undergo CABG, which is suggestive of an indirect evidence of the pathophysiologic function of Lp(a) in polyvascular disease.

Secondary infarction in single or in multiple vascular territories: two different entities following subarachnoid hemorrhage?

The pathogenesis of secondary infarctions (SI) after aneurysmal subarachnoid hemorrhage (SAH) is poorly understood. To assess whether SI in single (SSI) or multiple (MSI) vascular territories represent different disease entities, we compared clinical profiles of patients with these patterns of SI. CT/MRI-examinations of 448 patients were reviewed for new infarctions within 28 days after SAH, and categorized into SSI or MSI. Only patients with adequate follow-up imaging excluding any new infarctions were included for analysis (269 patients). Procedure-related infarctions were excluded. Odds ratios (ORs) with corresponding 95% confidence intervals (CI) were calculated for patients with SSI or MSI versus patients without SI to analyze differences in demographic characteristics, vascular risk factors, disease-related characteristics and treatment modalities. Thirty-six patients had SSI, 53 MSI and 180 no SI. ORs in MSI-patients were >1.5 times higher compared with ORs in SSI-patients for multiple vascular risk factors [MSI:5.4 (2.3–13) versus SSI:1.2 (0.5–2.8)], poor clinical condition on admission [MSI:4.6 (2.4–8.9) versus SSI:2.4 (1.1–5.2)], initial loss of consciousness [MSI:2.6 (1.3–5.3) versus SSI:1.1 (0.5–2.3)] and large amounts of intraventricular blood [MSI:2.9 (1.4–5.8) versus SSI:1.5 (0.7–3.2)]. In multivariate analysis ORs remained higher in MSI for presence of multiple vascular risk factors [MSI:1.9 (1.2–2.9) versus SSI:1.1 (0.8–1.7)] and initial loss of consciousness [MSI:3.0 (1.0–8.9) versus SSI:1.6 (0.6–4.0)]. Our findings suggest that SSI and MSI after SAH are not distinct disease entities. MSI was related to the same characteristics as SSI but to a larger extent, specifically to the presence of multiple vascular risk factors, initial loss of consciousness, larger amounts of intraventricular blood, and poor clinical status on admission.