CAPLAN CH10: Brain Embolism Flashcards
The most important risk factor for stroke after cardiopulmonary bypass surgery is ___.
aortic atheromatosis
What is the triad of fat embolism syndrome?
Respiratory distress
Decreased alertness
Petechial rash eveloping 24-49 hours after an injury
These strands probably form because of a degenerative process that causes fibrinous deposits on valve surfaces.
Lambl excrescences
Name diseases with similar lesions of the cardiac valves and endocardium.
SLE
APLA
NBTE
all likely have a similar pathogenesis
TRUE OR FALSE. Bioprosthetic valves have low thrombogenic tendencies, so long-term anticoagulation is ordinarily not prescribed?
TRUE
Six groups of cardiac disorders leading to stroke:
- Arrhythmias
- Valvular heart diseases
- Ventricular myocardial abnormalities
- Lesions in the cavity of the ventricles (tumors)
- Shunts
- Atrial lesion
What is the most common cause of brain ischemia?
Brain embolus
T/F. Brain emboli only loosely adhere to blood vessel walls.
TRUE
When does hemorrhagic transformation often occurs?
Day 2-7 after stroke
What do you call this description of a clinical pattern of embolic strokes: sudden, complete, or nearly complete clearing of sudden-onset severe neurological signs.
Spectacular shrinking deficits
Our of five emboli, how many goes to anterior circulation? posterior circulation?
4/5 anterior (equally on L and R)
1/5 posterior
Most frequent posterior circulation brain areas infarcted:
- PICA branch of ICVA- posterior inferior portion of the cerebellum
- SCA territory- superior surface of the cerebellum
- PCA- thalamic and hemispherical territories of the PCA
What is the essential cause of hemorrhagic infarction?
- Reperfusion of previously ischemic tissue
- Another cause is systemic hypoperfusion
Virchow’s Triad
- Circulatory stasis
- Endothelial injury
- Incrased blood coagulability
What is the ejection velocity of the left atrial appendage in patients with atrial fibrillation?
< 20 cm/s
Accordingf to the Framingham study:
What is the risk of stroke in:
a. AFIB + RHD?
b. AFIB alone?
A. 17.6x
B. 5.6x
Threshold of thrombi that cannot easily be detected?
< 2mm
Refers to the swirling hazes of echogenicity within the cardiac chambers.
Spontaneous echo contrast
Spontaneous echo contrast may be seen in _ % of patients with AFIB, and _% of patients with afib _ left atrial thrombi?
60%
85%
Two studies checking the utility of various durations of rhythm monitoring in detecting reater than 30-second instances of atrial fibrillation?
- EMBRACE
- CRYSTAL AF
Parameters that are studied to be related with increased chances of having atrial fibrillation:
- QT interval
- BNP
- NT-proBNP
ARISTOTLE drug?
Apixaban
Chaotic atrial activity, changing p-wave contour, and bradycardia, admixed with multiple and recurrent ectopic beats and runs of atrial and nodal tachycardia.
Sick sinus syndrome
Which arrhythmias are more likely to embolize in the brain? tacchyarrythmias or bradyarrythmias?
tachyarrhythmias
Why do we not like a valvular outlet obstruction?
Valcular outlet obstruction –> Increased turbulence of blood flow –> platelets are activated (hence, amount of thrombus formed is directly related to valve orifice turbulence)
Affected valves in RHD?
Top 1: Mitral valve
Top 2: Mitral + Aortic valves
isolated aortic valves is unusual
Most common causes of AORTIC LEAFLET DISEASE causing aortic insufficiency.
- Rheumatic valvulitis
- Infective endocarditis
Usual cases of AORTIC ROOT DISEASE.
Marfan’s syndrome
Aortic dissection
Annulo-aortic ectasia
Most frequently diagnosed cardiac valvular abnormality
Mitral Valve Prolapse
The most common TTE finding among elderly patients referred for a cardiac source of embolism?
Mitral annular calcification
Frequency of major embolism in patients with mechanical valves:
_ if no antithromboci therapy is used
_ if with medication that decrease platelet aggregation
_ if with warfarin anticoagulation?
4%
2%
1%
TRUE OR FALSE. Anticoagulation is recommended for all aptients with prosthetic heart valves.
TRUE.
What is the most common life-threatening complication in patients with infective endocarditis?
1st: congestive heart failure
2nd: arterial embolism
Features of TEE of IE patients with high risk for clinical thromboembolism?
- > 10mm size
- high mobility of the lesions
TRUE or FALSE. Patients with S. aureaus acute endocarditis are more often encephalopathic than in endocarditis caused by other ogranisms.
TRUE
Valve most commonly affected in SLE?
Mitral valve
Characteristics of APLA:
fetal loss
myocardial infarcts
phlebothrombosis
pulmonary emboli
thrombocytopenia
Serological testing for patients with APLA
lupus anticoagulant
anticardiolipin antibodies
Non-infective valvle lesions are found in patients with carcinoid tumors or after use of some drugs like?
Ergotamine
Methysergide
Dexfenfluramine
Fenfluramine
Phentermine
Cabergoline
Pergolide
Finding of the GISSI-3 trial (location of carduac infarct location and infarct size)
The incidence of left ventricule thrombus among those with an anterior infarction increased to 18% for pt with <40% EF compared to 10% with higher EF.
Systemic embolization happens at what day after a myocardial infarction?
14 days after a myocardial infarction and is unusual after 4-6 weeks.
Limitation of TEE in searching for thrombi in left ventricles post-MI?
Inability of TEEto visualize the true left ventricle apex makes TEEa less appropriate imaging test for suspected left ventricle apical thrombi.
Three most important factors that determine thrombus formations.
- involvement of the endocardial surface
- ventricular contractility and blood flow and ejection patterns
- activation of platelets and coagulation system
Characteristic apical ballooning of the heart recognizable on echcardiography that resembles the Japanese octobus trap.
Takotsubo
In patients with cardiomyopathies, mural thrombi form mostly within ___.
trabeculae carnae near the cardiac apex
TRUE or FALSE. Embolism iis usual in patients with hypertrophic cardiomyopathies.
FALSE. It is unusual unless they develop atrial fibrillation.
Most common area of cardiac myxoma?
Left atrium
Aside from emboli, give another mechanism of stroke in patients with cardiac myxoma?
Embolism from myxoma tissue to the wall of brain arteries causes ANEURYSYMS that are identical to mycotic aneurysms found in patient with bacterial endocarditis.
Tumors consisting of multiple papillary fronds that radiate from an avascular fibrocollagenous core attached by a short pedicle to the endothelium.
Papillary fibroelastomas (cardiac tumor that can give rise to embolism)
The most common potential intracardiac shunt
Residual PFO
Number of bubbles and TTE/TEE.
<10 trivial
10-30 small shunt
>30 large shunt
These are usually defined by echocardiography as bulging/ spetal mobility in the region of the fossa ovalis due to redundant atrial septal tissue
ASA- Atrial septal aneurysms
Electrocardiographic finding in patients with PFO
M-shaped notch on the ascending branch or on the peak of the R-wave in II, III aVF.
Why was the ARCH trial stopped prematurely? (Aortic Arch Related Cerebral Hazard Trial)
Hemorrhages were common in both groups and there was no clear superiority of either antiplatelets or anticoagulant therapy,
Most common neurologic complication of CABG surgery?
Cognitive dysfunction without accompanying focal motor, sensory, or visual dysfunction
What is the most important cause of cognitive deficits after cardiac surgery using cardiopulmonary bypass?
Microembolism
What is the triad of fat embolism syndrome?
- respiratory distress
- decreased alertness
- petechial rash developing 24-48 hours after an injury
Where can one find the petechiae in a patient with fat embolism syndrome?
lower palpebral conjunctivae
skin of the neck, shoulder and axillary folds
One of the most effective and specific tests for fat embolism
bronchopulmonary lavage
The most common tumors to embolize to the brain?
Primary pulmonary neoplasms or tumors that have metastasized to the lungs
