Noninfective mitral valve vegetations identified by transesophageal echocardiography as a cause of stroke.

BACKGROUND: Transesophageal echocardiography (TEE) is a useful procedure to evaluate selected stroke patients for cardiac sources of embolism. To date, noninfective valvular vegetations have not been described in large studies using transesophageal echocardiography to detect cardiac sources of embolism. We sought to investigate the frequency of noninfective valvular vegetations in patients with unexplained stroke referred for TEE and to determine the relationship of these vegetations to unrecognized thrombophilic disorders. METHODS: We evaluated 641 consecutive patients referred for TEE as a result of unexplained stroke or transient ischemic attack for the presence of valvular vegetations. Of those with vegetations identified, serial blood cultures were obtained to evaluate for an infectious etiology. Patients also had serum testing for thrombophilic disorders and selected patients underwent cerebral angiography. RESULTS: Thirteen patients (2%) who underwent TEE evaluation for unexplained stroke or transient ischemic attack were found to have noninfective valvular vegetations, all involving the mitral valve; none were identified by transthoracic echocardiography. Antiphospholipid antibodies were identified in 8 of these 13 patients (62%) and a protein C deficiency in 1 patient (8%). CONCLUSIONS: Noninfective valvular vegetations are a potential cardiac source of embolism in patients with unexplained stroke that can be better identified using transesophageal echocardiography. A large percentage of these individuals have a previously unrecognized thrombophilic disorder.

Pattern and frequency of recurrent transient ischemic attacks.

Objectives. Natural history studies and stroke prevention trials in patients with transient ischemic attacks (TIAs) have focused primarily on stroke or death outcomes and not recurrent TIA, yet treatment decisions are often based on recurrences. This study was undertaken to evaluate the frequency and pattern of recurrent TIAs in patients presenting with their first TIA. Methods. We monitored TIA recurrence for an average of 16 months in 47 consecutive patients hospitalized in a tertiary care center within 3 weeks of their first TIA. Treatment in 22 patients was aspirin or ticlopidine alone, and 12 underwent endarterectomy. Remaining patients received warfarin, dipyridamole, or pentoxifylline alone or with aspirin, including two who underwent endarterectomy. Treatment was changed in only four patients during the follow-up period. Results. Thirty-four patients (72%) had more than one TIA; 23 of these (68%) had two to five recurrences and 11 (32%) had more than five TIAs. Nineteen of the 34 patients with multiple TIAs had recurrences within 1 month of the initial TIA. Only four patients (12%) had recurrent TIAs throughout the follow-up period. Stroke occurred in five patients (11%); one patient had a single prior TIA, and the rest had multiple TIAs. No risk factors or treatments predicted which patients had single or multiple TIAs. Conclusions. Most patients have few recurrent TIAs, and recurrences usually occur within the first month of the initial TIA. The patterns of TIA recurrence identified should aid in treating patient and in devising appropriate outcome measures in treatment trials in which TIA is an endpoint.

Cranial sinus thrombosis and preeclampsia.

Cranial sinus thrombosis (CST) is known to be associated with pregnancy and puerperium. A literature review of patients with CST showed a significant proportion of preeclamptic women. The relationship between nephrotic syndrome and hypercoagulability has been well established. We present a 23-year-old gravida III, para I woman with preeclampsia who developed CST. Proteinuria may have played an important pathogenetic role in this setting.

Mitral valve strands in patients with focal cerebral ischemia.

BACKGROUND AND PURPOSE: Filamentous strands attached to the mitral valve are a recently described finding in occasional patients undergoing transesophageal echocardiography (TEE), but the frequency and clinical significance of these strands remain poorly defined. The purpose of the present study was to review the prevalence of mitral valve strands in patients undergoing TEE examination and to explore the relation of these strands to cardioembolic cerebral ischemia. METHODS: All patients with native mitral valves referred for clinically indicated TEE over a 2-year period at our institution were evaluated for the presence of mitral valve strands (defined as highly mobile filamentous masses <1 mm thick attached to the atrial surface of mitral leaflets). RESULTS: Of 968 study patients, mitral valve strands were identified in 22 individuals (2.3%). Mitral valve strands were significantly more common in patients referred for TEE as a result of a recent ischemic cerebrovascular event compared with patients referred for other study indications (6.3% versus 0.3%, respectively; P<.00001). Among patients < or = 50 years of age with likely cardioembolic stroke or transient ischemic attack, 16% were found to have mitral valve strands on TEE examination. In 9% of these young patients, no other TEE finding associated with cardioembolic risk was present. CONCLUSIONS: Filamentous strands attached to the mitral valve appear to represent another risk factor for embolic cerebral ischemia, particularly in patients < or = 50 years of age.

Extracranial plasma cell granuloma presenting as a diffuse meningeal and intraparenchymal mass.

Plasma cell granuloma (PCG) is uncommon, characterized by polyclonal proliferation of mature plasma cells, usually within systemic organs. Only four previous cases have involved the central nervous system (CNS).