Embolismo cerebral durante vuelo comercial: reporte de caso / Cerebral embolism during commercial flight: case report

RESUMEN Presentamos el caso de un varón de 25 años con antecedentes de consumo de marihuana y tabaco, que durante viaje en vuelo comercial a Cusco presentó disnea, pérdida de conciencia y estado epiléptico. Arribó a esta ciudad presentando hipotensión arterial, murmullo pulmonar abolido, sin recuperación de conciencia. La tomografía de tórax reveló bullas pulmonares y la tomografía mostró neumoencéfalo, diagnosticándose embolia gaseosa cerebral. La hipoxemia asociada a convulsiones y pérdida de conciencia en una persona joven durante el vuelo no es un evento común. La pérdida de la presión en la cabina durante el ascenso parece ser el evento desencadenante en pacientes con enfermedad pulmonar.

ABSTRACT We present the case of a 25-year old man with a history of marijuana and tobacco consumption who, during a commercial flight to Cusco, presented dyspnea, loss of consciousness, and epileptic condition. He arrived in this city presenting arterial hypotension, abolished pulmonary murmur, with no recovery of consciousness. The thorax tomography revealed lung bullae and the tomography showed pneumocephalus. He was diagnosed with cerebral gas embolism. Hypoxemia associated with seizures and loss of consciousness in a young person during a flight is not a common event. Loss of cabin pressure during climb appears to be the triggering event in patients with lung disease.

Embolia cerebral como presentación atípica de síndrome de May Thurner

El síndrome de May-Thurner es una anormalidad anatómica que consiste en la comprensión cronica de la vena iliaca común izquierda, entre la arteria ilíaca común derecha y la columna vertebral, que puede predisponer a la trombosis venosa profunda. Es una entidad rara, y es infrecuente que provoque una embolia paradojal cerebral. Se presenta el caso de una isquemia cerebral de origen embólico, en un varón de 30 años, luego de actividad sexual. Los estudios realizados revelaron síndrome de May-Thurner asociado con un foramen oval permeable y una trombofilia por factor V de Leiden. Fue tratado con anticoagulantes orales y no ha presentado recurrencias.

May-Thurner syndrome is an anatomic abnormality that predisposes patients to increase risk of paradoxical embolism and stroke. It consists of chronic compression of the left common iliac vein by the overlying right common iliac artery and lumbar spine. This may lead to deep venous thrombosis and paradoxical embolism that could provoke cerebral ischemia in patients with a cardiac shunt from right-to-left. Embolic cerebral ischemic event is reported in a 30-year-old man after sexual intercourse. Further studies revea led suggestive findings of May-Thurner syndrome coupled with a patent foramen ovale and a factor V Leiden thrombophilia. He was placed on anticoagulation therapy and has not had any recurrent events.

Accidente cerebrovascular secundario a mixoma auricular izquierdo: una causa infrecuente de embolismo cerebral / Stroke due to a auricular myxoma: a infrequent cause of cerebral embolism

BACKGROUND: Atrial myxomas are very infrequent primary bening cardiac neoplasms, being considered a rare but highly fatal cause of cerebral embolism. Objectives: We describe the case of an ischemic stroke (CVA) with hemorrhagic conversion secondary to atrila myxoma as an embolic source, and its subsequent early surgical resolution. CLINICAL CASE: A 63-year-old male has a clinical episode compatible with ischemic stroke, receiving thrombolytics treatment with subsequent hemorrhagic conversion. Embolic source study show a mass compatible with cardiac myxoma in the left atrium, performing surgical resection via transeptal approach at 12 days of evolution, with repair of the interatrial defect with autologous pericardium patch. DISCUSSION: Atrial myxoma is a silent pathology and little diagnosed at its early stage, associated with events of systemic repercussion of high mortality and uncertain prognosis. Hemorrhagic cerebrovascular events constitute contraindication for anticoagulation prior to 21 days of evolution. In this case, due to the high embolic risk of myxoma, the inactivy of the bleeding was demonstrated by performing the surgery successfully on the twelfth day of evolution.

Endocarditis infecciosa por Staphylococcus aureus meticilino sensible en pediatría. Presentación de un caso y revisión de la literatura / Methicillin-sensitive Staphylococcus aureus infective endocarditis in pediatrics. A case report and literature review

Resumen: La endocarditis infecciosa es una enfermedad poco frecuente en pediatría pero con importante morbimortalidad. Si bien existen grupos de riesgo bien definidos puede presentarse en niños sin cardiopatía subyacente e inmunocompetentes, en quienes la etiología estafilocócica es la más frecuente y el diagnóstico continúa siendo un desafío. Presentamos el caso de un niño de 2 años, previamente sano, con una endocarditis a Staphylococcus aureus meticilino sensible de presentación no usual.

Summary: Infective endocarditis is rather an unusual condition in pediatrics, although it is associated with significant morbility and mortality. In spite of there being well defined risk groups the disease may present in children with no underlying heart disease who are immunocompetent, Staphylococcus aureus being the most frequent etiology. In those cases, diagnosis still constitutes a challenge. The study presents the case of a 2 year-old patient, with a healthy history, who presented methicillin-sensitive Staphylococcus aureus infective endocarditis, with rather an unusual presentation.

Is the patent foramen ovale closure the best option? / O fechamento do foramen oval patente é a melhor opção?

Patent foramen ovale (PFO) closure is indicated in some cases to protect patients against embolic events. The aim of this study was to certify that the method of PFO closure to prevent microemboli (MES) is reliable, using contrast enhanced transcranial Doppler (cTCD) as a diagnostic and follow-up tool. METHODS: cTCD was performed before and after PFO closure in 20 patients. Results obtained a minimum of 12 months after the procedure were analyzed in this study. RESULTS: After the procedure, 14 patients (82%) showed no microemboli in cTCD at rest, but after provocative Valsalva maneuver (VM) microembolic phenomenon were still detected in 14 (70%): 7 (35%) <10 MES, 3 (15%) 10-20 MES and 4 (20%) had more than 20 MES ("curtain"). Only six of the total patients presented no MES in both resting and VM. CONCLUSION: These results showed a large percentage of patients with MES detection in a bubble study with transcranial Doppler more than one year after the procedure of PFO closure, showing right-to-left residual shunting. Despite the small number of patients, this study provides important data about this therapeutic decision.

O fechamento do forame oval patente (FOP) é indicado em alguns casos para prevenir eventos embólicos. O objetivo deste estudo foi certificar que o fechamento do FOP previne contra microembolia usando o Doppler transcraniano contrastado (cTCD) como método diagnóstico e de controle. MÉTODOS: O cTCD foi realizado antes e depois do fechamento do FOP em 20 pacientes. Foram analisados somente os resultados obtidos após 12 meses do procedimento. RESULTADOS: Após o procedimento, 14 pacientes (82%) não apresentaram microembolia (MES) ao exame de repouso. Entretanto, após sensibilização com manobra de Valsalva (MV), detectou-se ainda passagem de MES em 14 (70%) dos pacientes: 7 (35%) <10 MES; 3 (15%) 10-20 MES e 4 (20%) com mais de 20 MES (padrão "cortina"). Somente seis pacientes não apresentaram sinais de MES em ambas as etapas do teste (repouso e MV). CONCLUSÃO: Grande porcentagem de pacientes apresentou MES após o procedimento para fechamento do FOP, o que é consistente com presença de shunt direito-esquerdo residual. Apesar do pequeno número de pacientes, este estudo apresenta dados que contribuem com esta importante decisão terapêutica.

In Vitro Observation of Air Bubbles during Delivery of Various Detachable Aneurysm Embolization Coils

OBJECTIVE: Device- or technique-related air embolism is a drawback of various neuro-endovascular procedures. Detachable aneurysm embolization coils can be sources of such air bubbles. We therefore assessed the formation of air bubbles during in vitro delivery of various detachable coils. MATERIALS AND METHODS: A closed circuit simulating a typical endovascular coiling procedure was primed with saline solution degassed by a sonification device. Thirty commercially available detachable coils (7 Axium, 4 GDCs, 5 MicroPlex, 7 Target, and 7 Trufill coils) were tested by using the standard coil flushing and delivery techniques suggested by each manufacturer. The emergence of any air bubbles was monitored with a digital microscope and the images were captured to measure total volumes of air bubbles during coil insertion and detachment and after coil pusher removal. RESULTS: Air bubbles were seen during insertion or removal of 23 of 30 coils (76.7%), with volumes ranging from 0 to 23.42 mm3 (median: 0.16 mm3). Air bubbles were observed most frequently after removal of the coil pusher. Significantly larger amounts of air bubbles were observed in Target coils. CONCLUSION: Variable volumes of air bubbles are observed while delivering detachable embolization coils, particularly after removal of the coil pusher and especially with Target coils.

Derrame isquêmico como a primeira manifestação de hipertrabeculação/não-compactação ventricular grave / Ischemic stroke as the first manifestation of severe ventricular hypertrabeculation/non-compaction

Um raro defeito congênito do miocárdio, conhecido como hipertrabeculação/não-compactação do ventrículo esquerdo (HTVE/NCVE) tem sido ocasionalmente descrito em associação com a formação de trombos com um potencial risco embólico sistêmico, mas sua associação com derrames isquêmicos permanece controversa. Reportamos o caso de um derrame isquêmico em paciente com grave (HTVE/NCVE) e disfunção ventricular como uma possível associação sinérgica etiológica. Na ausência de outras fontes embólicas, uma grave HTVE/NCVE associada com disfunção ventricular poderia constituir uma fonte potencial de embolismo cerebral, especialmente em pacientes com alta suspeita de um mecanismo embólico de derrame sistêmico.

A rare congenital myocardial defect, known as left ventricular hypertrabeculation/non-compaction (LVHT), has been occasionally described associated with thrombus formation with a potential systemic embolic risk, but its association with ischemic strokes remains controversial. We report a case of ischemic stroke in a patient with severe LVHT and ventricular dysfunction as a possible etiologic synergistic association. In absence of other embolic sources, a severe LVTH associated with ventricular dysfunction could constitute a potential source of brain embolism, especially in patients with high suspicion of an embolic mechanism of ischemic stroke.

Massive Paradoxical Air Embolism in Brain Occurring after Central Venous Catheterization: A Case Report

Cerebral air embolism is a rare but fatal complication of central venous catheterization. Here, we report a case of paradoxical cerebral air embolism associated with central venous catheterization. An 85-yr-old man underwent right internal jugular vein catheterization, and became obtunded. Brain MR imaging and CT revealed acute infarction with multiple air bubbles on the side of catheter insertion. The possibility of cerebral air embolism should be considered in patients developing neurological impairment after central venous catheterization, and efforts should be made to limit cerebral damage.

Four Cases of a Cerebral Air Embolism Complicating a Percutaneous Transthoracic Needle Biopsy

A percutaneous transthoracic needle biopsy is a common procedure in the practice of pulmonology. An air embolism is a rare but potentially fatal complication of a percutaneous transthoracic needle biopsy. We report four cases of a cerebral air embolism that developed after a percutaneous transthoracic needle biopsy. Early diagnosis and the rapid application of hyperbaric oxygen therapy is the mainstay of therapy for an embolism. Prevention is the best course and it is essential that possible risk factors be avoided.

Ressecção de mixoma ventricular esquerdo após acidente vascular cerebral embólico / Resection of left ventricular myxoma after embolic stroke

Mixoma cardíaco é o tumor primário mais comum do coração. Sua principal localização é no átrio esquerdo, mas pode surgir em qualquer câmara cardíaca. Os sintomas clínicos são variáveis, mas dispnéia e embolia são os mais freqüentes. Relatamos o caso de um jovem com acidente vascular cerebral isquêmico embólico causado por um grande mixoma no ventrículo esquerdo. O paciente foi submetido a cirurgia três semanas após o acidente vascular cerebral. O tumor foi ressecado com cuidado, sem fragmentar. O tratamento cirúrgico foi eficaz. Enfatizamos a raridade da presente localização, juntamente com uma revisão da literatura atual.

Cardiac myxoma is the most common primary tumor of the heart. The tumor is located mainly in the left atrium but can arise from any heart chamber. Clinical symptoms are variable but dyspnea and embolism are the most frequent. We report a case of a young man that had embolic ischemic stroke caused by a large left ventricular myxoma. The patient underwent surgery three weeks after the stroke. The tumor was carefully resected without fragmentation. Surgical treatment was effective. We emphasize the rarity of this location together with a review of the current literature.

Estratégias de prevenção do acidente vascular encefálico cardioembólico na doença de Chagas / Prevention strategies of cardioembolic ischemic stroke in Chagas' disease

FUNDAMENTO: O acidente vascular encefálico isquêmico (AVEi) cardioembólico é uma manifestação clínica importante da cardiopatia chagásica crônica, no entanto, ainda não foram definidos sua incidência e os fatores de risco associados a este evento. OBJETIVO: Definir estratégias de prevenção de uma complicação freqüente e incapacitante da doença de Chagas, o AVEi cardioembólico. MÉTODOS: No período de março de 1990 a março de 2002, 1.043 pacientes com doença de Chagas foram recrutados e acompanhados até março de 2003 em um estudo prospectivo e observacional de coorte. Por meio da regressão de Cox foi desenvolvido um escore de risco de AVEi, que se correlacionou com a incidência anual desse evento: 4-5 pontos, > 4 por cento; 3 pontos, 2 por cento a 4 por cento; 2 pontos, 1 por cento a 2 por cento; e 0-1 ponto, < 1 por cento. Foram avaliadas a eficácia e a segurança de duas coortes de tratamento: grupo 1, 52 pacientes em uso de varfarina por 14 ± 14 meses, mantendo INR 2-3; e grupo 2, 104 pacientes em uso de ácido acetilsalicílico (AAS) 200 mg/dia, por 22 ± 21 meses. RESULTADOS: No grupo 1, a taxa anual de sangramento maior necessitando hemotransfusão foi de 1,9 por cento, sem ocorrência de AVEi. Por meio da regressão de Cox foram identificadas 4 variáveis independentes associadas ao evento (disfunção sistólica, aneurisma apical, alteração primária da repolarização ventricular e idade > 48 anos) sendo desenvolvido um escore de risco de AVEi, que se relacionou com a incidência anual desse evento. No grupo 2, não houve complicações hemorrágicas, e a incidência anual de AVEi foi de 3,2 por cento, todos em pacientes com 4-5 pontos. CONCLUSÃO: Por meio da análise de risco-benefício, varfarina estaria indicada aos pacientes com 4-5 pontos, cuja incidência de evento supera a taxa de sangramento maior. No subgrupo de 3 pontos, as taxas de evento e sangramento com anticoagulante se equivalem, sendo indicados AAS ou varfarina, conforme...

BACKGROUND: The cardioembolic (CE) ischemic stroke is an important clinical manifestation of chronic chagasic cardiopathy; however, its incidence and the risk factors associated to this event have yet to be defined. OBJECTIVE: To determine prevention strategies for a common and devastating complication of Chagas' disease, the cardioembolic (CE) ischemic stroke. METHODS: 1,043 patients with Chagas' disease were prospectively evaluated from 03/1990 to 03/2002 and followed up to 03/2003. Cox regression was performed to create the CE risk score that was related with the annual incidence of this event: 4-5 points - >4 percent; 3 points - 2-4 percent; 2 points - 1-2 percent; 0-1 points - <1 percent. We evaluated the efficacy and safety of two treatment cohorts: (1) 52 patients who used warfarin (INR 2-3) for 14±14 months; (2) 104 patients who used acetylsalicylic acid (ASA) (200 mg/d) for 22±21 months. RESULTS: In group (1), the risk of a major bleeding that needed blood transfusion was 1.9 percent a year, without CE. Cox regression was used to identify 4 independent variables associated to the event (systolic dysfunction, apical aneurysm, primary alteration of ventricular repolarization and age > 48 years) and an CE risk score was developed, which was associated with the annual incidence of this event. In group (2) there were no bleeding complications and the annual incidence of CE was 3.2 percent, all of them in patients with 4-5 points. CONCLUSION: Based on the risk-benefit analysis, warfarin prophylaxis for cardioembolic stroke in Chagas' disease is recommended for patients with a score of 4-5 points, in whom the risk of CE overweighs the risk of a major bleeding. With a 3-point score, the risks of bleeding and CE are the same, so the medical decision of using either warfarin or ASA has to be an individual one. In patients with a low risk of CE (2-point score) either ASA or no therapy can be chosen. The prophylaxis is not...

Fibroelastoma valvular aórtico como causa de accidente cerebrovascular embólico: reporte de un caso / Aortic valve fibroelastoma as a cause of an embolic cerebrovascular accident: a case report

Los tumores cardíacos son una causa rara de accidente cerebrovascular embólico. Comunicamos el caso de una paciente de 65 años quien debuta su historia con un accidente cerebrovascular. El estudio de fuente embólica con ecocardiografía transesofágica demostró un fibroelastoma de la válvula aórtica en el borde libre del velo no coronariano. El tumor fue extraído mediante circulación extracorpórea. El estudio anatomopatológico confirmó el diagnóstico y la paciente se encuentra en capacidad funcional I y sin síntomas neurológicos a 19 meses de seguimiento.

Background: Cardiac tumors are an infrequent cause of an embolic source and aortic fibroelastoma is even more rare as causative of a stroke. We report a 65 year old female with no particular clinical history admitted to the hospital with an embolic cerebrovascular accident whose embolic source study with a transesophageal echocardiogram revealed a fibroelastoma in the free edge of the non coronarian leaflet of the aortic valve. The patient was subjected to surgery by means of extracorporeal circulation and the tumor was excised. The pathological study confirmed the diagnosis. Post operative recovery was uneventful with no neurological damage and after 19 months of follow up she is in functional class I.

A case of left atrial myxoma: anaesthetic management.

Left Atrial Myxomas are notorious for their varied presentations. We describe one such case which initially presented with hemiparesis and seizures and was diagnosed as cerebral infarction and treated accordingly and decompression craniotomy with hinge flap was done for raised ICP and impending brain herniation. The main cause was a left atrial myxoma, which was diagnosed only in follow up. The myxoma has embolised to give rise to cerebral infarction. The LA myxoma was then successfully operated under general anaesthesia and Cardiopulmonary bypass (CPB).

Transesophageal echocardiography discloses unexpected cardiac sources of embolus in stroke patients aged more than 45 years

Embolia cerebral de fonte cardíaca é frequentemente relacionada a acidente vascular cerebral (AVC) em jovem.OBJETIVO: Descrever achados ecocardiográficos em jovens e não jovens com AVC isquêmico, sem suspeita de fonte cardíaca.MÉTODO: Estudo transversal; 523 pacientes (267 homens e 256 mulheres) com AVC isquêmico sem evidência de fonte cardíaca submeteram-se ao ecocardiograma transesofágico (ECOTE). RESULTADOS: 10% dos pacientes tinha 45 anos; ou menos. Hipertrofia do ventrículo esquerdo, aumento do átrio esquerdo, contraste espontâneo na aorta, aneurisma do septo interatrial, calcificação da válvula mitral e aórtica, insuficiência aórtica e placas de ateroma na aorta foram significantemente mais frequentes nos pacientes com mais que 45 anos; 2.8% dos não-jovens apresentaram trombo nas câmaras esquerdas.CONCLUSÃO: ECOTE é amplamente sugerido na investigação de embolia em pacientes jovens, porém parece ser tão importante também no grupo de pacientes mais velhos, nos quais o risco de embolia cerebral é subestimado; etiologia cardioembólica e aterosclerótica coexistem, e ambas devem ser identificadas e tratadas para melhor prognóstico.

Síndrome de regresión espectacular de isquemia encefálica: (spectacular shrinking deficit) / Spectacular shrinking deficit of brain ischemia

El síndrome de regresión espectacular de la isquemia encefálica (spectacular shrinking deficit) corresponde a la isquemia hemisférica encefálica que se resuelve en forma espontánea y deja un déficit neurológico residual mínimo o nulo. Reportamos el caso de una mujer de 86 años con un síndrome de isquemia hemisférica izquierda súbito y resolución clínica espontánea completa en pocas horas. El estudio con resonancia magnética de encéfalo y angiorresonancia mostró múltiples infartos pequeños en el territorio de la arteria cerebral media izquierda y oclusión completa de la arteria carótida interna izquierda.

Micro embolic signals in patients with cerebral ischaemic events.

The aim of this study was to evaluate the occurrence of micro embolic signals (MES) in patients with a cerebral ischaemia using transcranial doppler monitoring and to find out its diagnostic relevance. We prospectively performed bilateral multigated transcranial doppler monitoring from both middle cerebral arteries in 359 patients with an acute or recent (<4 weeks) cerebral ischaemic event, and in 182 control subjects without a cerebral ischaemic event. MES were analysed according to the standardised protocol. Patients with cerebral ischaemic events had a significantly higher (p<0.00001) rate of MES occurrence (31.8%) than control subjects (5.5%). MES were detected significantly higher in patients with partial or total anterior circulation infarcts (39.1%) than in those with lacunar infarcts (26.0%) or transient ischaemic attacks (27.3%). A correlation of MES and neuroimaging finding was also tried. TCD was found to have a predictive role in microemboli monitoring, predominantly in patients with large vessel territory infarction.

Is the number of microembolic signals related to neurologic outcome in coronary bypass surgery?

Coronary artery bypass surgery (CABG) without cardiopulmonary bypass (CPB) may potentially reduce the number of microembolic signals (MES) associated with aortic manipulation or generated by the pump circuit, resulting in a better neurologic outcome after surgery. Our aim was to compare the frequency of MES and neurologic complications in CABG with and without CPB. Twenty patients eligible to routine CABG without CPB were randomized to surgery with CPB and without CPB and continuously monitored by transcranial Doppler. Neurologic examination was performed in all patients before and after surgery. The two groups were similar with respect to demographics, risk factors, grade of aortic atheromatous disease and number of grafts. The frequency of MES in the nonCPB group was considerably lower than in CPB patients, however, we did not observe any change in the neurologic examination during the early postoperative period. Neurologic complications after CABG may be related to the size and composition of MES rather than to their absolute numbers. A large prospective multicentric randomized trial may help to elucidate this complex issue

Clinical features of cardioembolic strokes identified by transesophageal echocardiography.

Clinical and CT scan features predictive of a cardiac source of embolism (CSOE) are helpful in planning appropriate investigations in ischaemic strokes. The currently described predictors of CSOE were determined before the availability of trans esophageal echocardiography (TEE). After the advent of TEE, many new CSOE were discovered. The present study was planned to investigate if the previously described predictors of CSOE are also valid for patients with CSOE detectable only with TEE (TEE-detected CSOE). From 1992-1995, 485 consecutive patients of ischemic stroke were enrolled in the Maryland Stroke Data Bank (MSDB). Patients with CSOE identified only by TEE and not by clinical, electrocardiographic or transthoracic echocardiographic (TTE) examination were compared to patients with a CSOE with respect to the features of the history, neurologic examination and CT scan. Of 485 patients with cerebral infarction, 132 (27%) patients had CSOE. In 21/132 (16%), diagnosis of high risk CSOE could be established only by TEE. The most discriminating clinical findings in TEE-detected CSOE patients were visual field deficit (OR 2.9; 95% CI, 1.1-7.4) and neglect (OR 3.4; 95% CI,1.2-9.3). Less strong associations were also found with other clinical features described previously for CSOE. No significant differences were found for features of the initial CT scan. In summary, presence of visual field defect and hemineglect may suggest a higher likelihood of finding a CSOE by TEE, even if the clinical cardiac examination and TTE are normal.