An Unusual Cause of Stroke-the Importance of Saline Contrast Echocardiography (original) (raw)

Lesson of the month 2: A rare presentation of stroke: diagnosis made on magnetic resonance imaging

Clinical medicine (London, England), 2018

Bilateral thalamic infarcts are uncommon posterior circulation strokes. The artery of Percheron (AOP) is a rare anatomical variant involving a singular arterial supply to both thalami and occlusion leads to bilateral thalamic infarction.We report the case of a 71-year-old man who presented with decreased consciousness (fluctuating Glasgow Coma Scale score of 5-7). He had a background of atrial fibrillation and was anticoagulated with dabigatran, a novel oral anticoagulant. Computed tomography (CT) scan showed a mildly reduced attenuation in the region of the left thamalus.Subsequent diffusion-weighted magnetic resonance imaging (MRI) showed acute brainstem infarction, extending into the thalamus bilaterally, likely due to AOP occlusion. Bilateral thalamic infarcts due to AOP occlusion may not be recognised on initial CT scan and are more readily seen using diffusion-weighted MRI, which is the most beneficial imaging modality to aid in early diagnosis and treatment.

An Unusual Cause of Cardioembolic Stroke

The Neurologist, 2008

Background: Isolated left ventricular noncompaction (ILVNC) is a rare congenital condition that is the result of an intrauterine developmental arrest, which stops the compaction of the loose myocardial fiber meshwork of the left ventricle. This condition is recognized by an excessively prominent trabecular meshwork and deep intertrabecular recesses of the left ventricle. Although these intertrabecular recesses are prone to thrombus formation, with resulting embolic sequelae, the literature describes only 1 adult case of a stroke caused by ILVNC. Case Report: We describe a case of cerebral cardioembolism in a 33-year-old man due to ILVNC. Because of echocardiography (ECHO) findings in this case, cardiac magnetic resonance imaging (cMRI) was performed, which allowed a definite diagnosis to be obtained. Conclusion: This case should highlight the importance of performing cMRI especially in younger patients with embolic stroke, if the ECHO suggests a suspected myocardial disorder.

Livedo and ischemic strokes: diagnostic hints of a rare condition

Neurological Sciences, 2013

Sneddon's syndrome (SS) is a rare condition characterized by the combination of ischemic strokes and cutaneous livedo , defined as the ''persistent, not reversible with rewarming, violaceous, reticular or mottled pattern of the skin of trunk, arms or legs, consisting of regular unbroken circles (livedo reticularis) or irregular-broken circles (livedo racemosa)''. Other well-defined neurological manifestations of SS include headache, seizures, and vascular dementia. Here, we report two cases with clinical and imaging features suggestive of SS. In both patients skin biopsy was performed and sections were stained with hematoxylin and eosin (H&E).

Paradoxical Emboli from Calf and Pelvic Veins in Cryptogenic Stroke

Journal of Neuroimaging, 2003

The increased prevalence of patent foramen ovale in patients with cryptogenic strokes suggests the occurrence of paradoxical embolism. The identification of deep venous thromboses (DVTs) in this population would strengthen this hypothesis. The purpose of this study was to image the subdiaphragmatic venous system in a cohort of patients with cryptogenic strokes. Materials and Methods. In 37 patients with cryptogenic brain ischemia and interatrial communication, duplex studies of calf, popliteal, and femoral veins, and magnetic resonance imaging venograms of the pelvis veins were performed. Results. In 10 patients, DVTs were diagnosed that were considered to be the cause of cryptogenic brain ischemia on probable (n = 6) or possible (n = 4) bases. In these patients, the median time from stroke to DVT was 3.25 days. In 5 of these 10 patients, DVTs did not involve popliteal and femoral veins, areas thought most important to pulmonary embolism, but instead were isolated to calf or pelvic veins. Although none of these 10 patients had abnormal blood hypercoagulation tests, 8 of the 10 did have clinical conditions suggesting predisposition to developing DVTs, such as concomitant neoplasms or pulmonary embolism. Conclusions. Increased evidence for paradoxical embolism may emerge when diagnostic strategies use multiple imaging methods and evaluate a broad extent of the subdiaphragmatic veins.

Nonaccidental Arterial Cerebral Air Embolism: A Ten-Year Stroke Center Experience

Cerebrovascular Diseases, 2013

A 77-year-old woman was diagnosed with platypneaorthodeoxia syndrome due to massive patent foramen ovale (PFO). During the control transthoracic echocardiography (showing moderate residual shunt) the day after PFO closure, immediately after the microbubble injection (bubbles produced by injecting 0.5-1.0 ml of ambient air in 10 ml of a mixture of a 0.9% saline/5% glucose solution which is shaken manually for 1 min; residual visible air on top of the solution was evacuated before injection), the patient developed mutism, somnolence and right hemiparesis. The patient improved rapidly with hyperbaric oxygen therapy (HOT) and became asymptomatic 2 days later. Patient 2: A 49-year-old man had a right middle cerebral artery TIA 14 years earlier, attributed to a massive PFO with atrial septal aneurysm. The patient now decided to close the PFO. Thirty seconds after the microbubble injection (for method, see patient 1) during a transthoracic echocardiography to confirm the PFO, the patient presented with bilateral transient visual loss and a left hemisyndrome. HOT was started immediately after hospital arrival and before neuroimaging. After HOT, only a left-sided hyperreflexia was present and the MRI taken 7 h after stroke onset was normal. The PFO was closed 3 weeks later. Patient 3: A 67-year-old woman with chronic superior vena cava syndrome was dialyzed for diabetic nephropathy through a central venous catheter (CVC). Fifteen minutes after the beginning of a dialysis session, she developed acute right eye deviation and left hemiparesis. Right frontal intracortical air bubbles were found on acute CT, and focal cerebral edema was found 5 days later (fig. 1 a, b). A moderate-sized PFO was detected. She initially had partial recovery but died 6 weeks later from sepsis. Patient 4: A 34-year-old man with Rendu-Osler-Weber disease had multiple pulmonary arteriovenous malformations (PAVMs) embolized 13 years earlier. Over a period of 5 days he now experienced multiple episodes of transitory left hemiparesis, followed by a stroke with a left hemisyndrome. After partial improvement over 2 days, he developed multiple episodes of chest pain and secondarily generalized seizures. Ischemic ECG changes and cardiac enzyme elevation occurred, but coronary angiography was normal. After partial embolization of the PAVMs, he developed another acute left hemisyndrome, followed by cardiorespiratory arrest, cardiac massage and intubation. Cerebral CT showed parenchymal air emboli (fig. 2 b), MRI revealed ischemic strokes (fig. 2 c), and transcranial Doppler detected multiple spontaneous embolic signals. More PAVMs were embolized (fig. 2 a), and the patient recovered progressively. Patient 5: A 74-year-old man with chronic liver cancer developed syncope 30 min after a needle biopsy of a lung nodule, followed by dysarthria and gait ataxia. The thoracic CT at the end of the biopsy retrospectively showed air bubbles in the left ventricle (fig. 3 a). MRI confirmed ischemic strokes. A minor-sized PFO was also detected (fig. 3 b). The patient recovered completely spontaneously within 48 h.

Evaluation of transthoracic and transesophageal echocardiographic findings in acute ischemic stroke

EVALUATION, 2001

Objective: A p p ro xim a te ly 20% of all Ischem ic strokes are the result of an em b o lu s originating from the heart. T ra n sth o ra cic e ch o ca rd io g ra p h y (TTE) has long been used to e valuate the cardiac source of em boli but recently tra n sesoph ageal e ch ocardio graphy (TEE), w hich has higher yield for detecting left atrium , aortic arch and left atrial appen dage lesions, Is reco m m e n d e d fo r the assessm ent of patients w ith clinical risk factors fo r ca rdioem bo lism or u n e xpla ined stroke. Methods: In this study, the d ia g n o stic yield of TTE and TEE fo r dete ctin g potential cardiac sources of the e m bolus w as co m p a re d in 46 consecutive patients (26 m en and 20 w om en, aged 23-84 years) w ith tra n sie n t ischem ic attack (TIA) or acute ischem ic stroke. Results: T T E re v e a le d a p o te n tia l c a rd ia c source of em bolism in 12 (26%) patients, all of w hom had clinical evid e n ce of heart disease, TE E d e te c te d p o te n tia l c a rd ia c s o u rc e s of em bolism in 32 (69%) patients; 7 (21%) of these had no clinical e vidence of heart disease. Conclusion: TE E is a su p e rio r tech n iq u e to TTE fo r identifying potential ca rd ia c source of the em bolus and should be re co m m ended fo r early m anagem e nt and p revention of fu rth e r stroke in p a tie n ts w ith u n d e rly in g h e a rt d is e a s e or unexpla ined c e re b ro v a s c u la r accident.