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Patients with mechanical heart valve replacement require lifelong anticoagulation therapy, and additional surgeries can pose a risk of bleeding and thromboembolic events due to the need for perioperative anticoagulation management. Here, we present a case report of a patient who underwent laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) after mechanical heart valve replacement and experienced postoperative cerebral embolism. The management of perioperative anticoagulation in these patients is discussed, including strategies for minimizing the risks of bleeding and thromboembolic events during and after surgery.
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OBJECTIVES: This study aimed to analyse the impact of preoperative septic cerebral embolism on early and late postoperative outcomes in patients with infective endocarditis undergoing valve surgery. METHODS: Retrospective multicentric study based on the Clinical Multicentric Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry comprising patients with infective endocarditis who underwent valve surgery between 1994 and 2018 at 6 German centres. Patients were divided into 2 groups for statistical comparison according to the presence or absence of preoperative septic cerebral embolism. Propensity score matching was performed for adjusted comparisons of postoperative outcomes. Primary outcomes were 30-day mortality and estimated 5-year survival. RESULTS: A total of 4917 patients were included in the analysis, 3909 (79.5%) patients without and 1008 (20.5%) patients with preoperative septic cerebral embolism. Patients with preoperative septic cerebral embolism had more baseline comorbidities. Mitral valve endocarditis (44.1% vs 33.0% P < 0.001), large vegetations >10 mm (43.1% vs 30.0%, P < 0.001), and Staphylococcus species infection (42.3% vs 21.3%, P < 0.001) were more frequent in the cerebral embolism group. Among patients with preoperative cerebral embolism, 286 (28.4%) patients had no stroke signs (silent stroke). After matching (1008 matched pairs), there was no statistically significant difference in 30-day mortality (20.1% vs 22.8%; P = 0.14) and 5-year survival (47.8% vs 49.1%; stratified log-rank P = 0.77) in patients with and without preoperative cerebral embolism, respectively. CONCLUSIONS: Preoperative septic cerebral embolism in patients with infective endocarditis requiring valve surgery does not negatively affect early or late mortality; therefore, it should not play a major role in deciding if surgery is to be performed.
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Embolia Intracraneal , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Embolia Intracraneal/mortalidad , Embolia Intracraneal/epidemiología , Anciano , Endocarditis/cirugía , Endocarditis/mortalidad , Endocarditis/complicaciones , Alemania/epidemiología , Complicaciones Posoperatorias/epidemiología , Resultado del Tratamiento , Sistema de Registros , Endocarditis Bacteriana/cirugía , Endocarditis Bacteriana/mortalidad , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/epidemiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Válvulas Cardíacas/cirugía , Factores de RiesgoRESUMEN
Introduction Predicting the shape of the occluded middle cerebral artery (MCA) from the contralateral MCA might help catheterization in endovascular mechanical thrombectomy (EMT). Materials and Methods We analyzed magnetic resonance (MR) angiography in 100 consecutive patients who had MR imaging for diseases other than acute ischemic stroke. To assess the symmetricity of MCA, the shape of M1, length of M1, number of M2, number of early branches (EBs), and distance from the top of the internal carotid artery to EB were investigated. Results The shape of M1 was upward in 42%, horizontal in 47%, and downward in 11%. The M1 shape was the same on both sides in 64%, which exceeded the probability assumed to be left-right independent. The number of M2 trunks and EBs matched left and right in 86 and 55% of patients, respectively; however, these agreement rates were not higher than those with independent left and right sides. No left-right correlation was found between the M1 length and the distance from the internal carotid artery to EB. Conclusion Based on our data, the symmetry of MCA was observed only in the shape of the M1 segment. This finding could be beneficial for EMT targeting MCA embolisms.
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Background: Cerebral air embolism (CAE) is an uncommon medical emergency with a potentially fatal course. We have retrospectively analyzed a set of patients treated with CAE at our comprehensive stroke center and a hyperbaric medicine center. An overview of the pathophysiology, causes, diagnosis, and treatment of CAE is provided. Results: We retrospectively identified 11 patients with cerebral venous and arterial air emboli that highlight the diversity in etiologies, manifestations, and disease courses encountered clinically. Acute-onset stroke syndrome and a progressive impairment of consciousness were the two most common presentations in four patients each (36%). Two patients (18%) suffered from an acute-onset coma, and one (9%) was asymptomatic. Four patients (36%) were treated with hyperbaric oxygen therapy (HBTO), high-flow oxygen therapy without HBOT was started in two patients (18%), two patients (18%) were in critical care at the time of diagnosis and three (27%) received no additional treatment. CAE was fatal in five cases (46%), caused severe disability in two (18%), mild disability in three (27%), and a single patient had no lasting deficit (9%). Conclusion: Cerebral air embolism is a dangerous condition that necessitates high clinical vigilance. Due to its diverse presentation, the diagnosis can be missed or delayed in critically ill patients and result in long-lasting or fatal neurological complications. Preventative measures and a proper diagnostic and treatment approach reduce CAE's incidence and impact.
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Atrial fibrillation (AF) is a significant precursor to cerebral embolism. Our study sought to unearth new diagnostic biomarkers for atrial fibrillation-related cerebral embolism (AF-CE) by meticulously examining multiple GEO datasets and meta-analysis. The gene expression omnibus (GEO) database provided RNA sequencing data associated with AF and stroke. We began by pinpointing genes with varied expressions in AF-CE patient blood samples. A meta-analysis was subsequently undertaken using several RNA sequencing datasets to verify these genes. LASSO regression discerned key genes for AF-CE, with their diagnostic prowess verified through ROC curve examination. Active signaling pathways within stroke patients were discerned via GO and KEGG enrichment, with PPI interactions detailing gene interplay. Differential gene analysis revealed an upregulation of sixteen genes and a downregulation of four in stroke patient blood samples. Eight genes showcased varied expression in the meta-analysis. LASSO regression zeroed in on five of these, culminating in HIST1H2BH's identification as a characteristic gene. HIST1H2BH's prowess in predicting AF-CE was confirmed through ROC. Integrin signaling, platelet activation, ECM interactions, and the PI3K-Akt pathway were found active in stroke victims. HIST1H2BH's interaction with the notably upregulated ITGA2B was spotlighted by PPI. Additionally, HIST1H2BH exhibited links with NK cells and eosinophils. HIST1H2BH emerges as an insightful diagnostic beacon for AF-CE. Its presence, post AF, potentially modulates pathways, accentuating platelet activation and consequent thrombus generation, leading to cerebral embolism.
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Objectives: Cardiogenic cerebral embolism (CCE) poses a significant health risk; however, there is a dearth of published prognostic prediction models addressing this issue. Our objective is to establish prognostic prediction models (PM) for predicting poor functional outcomes at 3 months in patients with acute CCE associated with non-valvular atrial fibrillation (NVAF) and perform both internal and external validations. Methods: We included a total of 730 CCE patients in the development cohort. The external regional validation cohort comprised 118 patients, while the external time-sequential validation cohort included 63 patients. Multiple imputation by chained equations (MICE) was utilized to address missing values and the least absolute shrink and selection operator (LASSO) regression was implemented through the glmnet package, to screen variables. Results: The 3-month prediction model for poor functional outcomes, denoted as N-ABCD2, was established using the following variables: NIHSS score at admission (N), Age (A), Brain natriuretic peptide (BNP), C-reactive protein (CRP), D-dimer polymers (D), and discharge with antithrombotic medication (D). The model's Akaike information criterion (AIC) was 637.98, and the area under Curve (AUC) for the development cohort, external regional, and time-sequential cohorts were 0.878 (95% CI, 0.854-0.902), 0.918 (95% CI, 0.857-0.979), and 0.839 (95% CI, 0.744-0.934), respectively. Conclusion: The N-ABCD2 model can accurately predict poor outcomes at 3 months for CCE patients with NVAF, demonstrating strong prediction abilities. Moreover, the model relies on objective variables that are readily obtainable in clinical practice, enhancing its convenience and applicability in clinical settings.
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OBJECTIVE: To assess the utility of combined neutrophil-to-lymphocyte ratio (NLR) and D-dimer detection in determining the severity and short-term prognosis of acute cardiogenic cerebral embolism (ACCE) in older adults. METHODS: We selected 202 elderly non-valvular atrial fibrillation patients hospitalized at the Third Affiliated Hospital of Anhui Medical University from April 1, 2020, to April 1, 2023. They were divided into an observation group (69 cases combined with ACCE) and a control group (133 cases with non-valvular atrial fibrillation alone) based on whether acute cardioembolic cerebral embolism occurred. According to the National Institutes of Health Stroke Scale (NIHSS), the observation group was divided into a mild cerebral infarction group (MICI group), a moderate cerebral infarction group (MOCI group), and a severe cerebral infarction group (SCI group), with 26 cases, 29 cases, and 14 cases, respectively. According to the modified Rankin scale (mRS), after 3 months, 30 cases were divided into the good prognosis group and 39 cases were divided into the poor prognosis group. We detected and compared the differences in D-dimer and NLR levels among different groups of patients, as well as differences in some important laboratory indicators. Logistic regression analysis was used to identify factors influencing the short-term prognosis of patients with acute cardioembolic cerebral infarction, and ROC curves were plotted to evaluate the value of D-dimer and NLR in predicting the short-term prognosis of patients with acute cardioembolic cerebral infarction. RESULTS: The levels of D-dimer and NLR in peripheral blood in SCI group [1.82 (0.58-6.71) mg/l, 4.55 (3.14,7.21)] were higher than those in MOCI group [1.16 (0.65-1.90) mg/l, 3.84 (2.31,6.68)] and MICI group [0.53 (0.32-0.90) mg/l, 2.46 (2.09-3.79)]. The difference between groups was statistically significant (P < 0.05). Logistic regression analysis showed that D-dimer and NLR were independent risk factors for poor prognosis in patients with acute cardiogenic cerebral embolism (OR values were 1.772 and 1.603, and 95 %CI were 1.060-2.963 and 1.100-2.338, respectively, both P < 0.05). The AUC for the prediction of poor prognosis in acute cardioembolic stroke by combining D-dimer and NLR was 0.812 [95 % CI: 0.710-0.914], higher than the individual detections of D-dimer at 0.756 [95% CI: 0.642-0.869] and NLR at 0.733 [95 % CI: 0.613-0.854]. CONCLUSION: Peripheral blood D-dimer combined with NLR detection is helpful for the risk stratification and short-term prognosis assessment of patients with acute cardiogenic cerebral embolism. Clinical detection is of great significance for the prevention and monitoring of disease development.
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Fibrilación Atrial , Biomarcadores , Productos de Degradación de Fibrina-Fibrinógeno , Linfocitos , Neutrófilos , Valor Predictivo de las Pruebas , Índice de Severidad de la Enfermedad , Humanos , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Masculino , Anciano , Femenino , Pronóstico , Biomarcadores/sangre , Anciano de 80 o más Años , Recuento de Linfocitos , Factores de Tiempo , Factores de Riesgo , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/sangre , Fibrilación Atrial/complicaciones , Estudios Retrospectivos , Medición de Riesgo , Embolia Intracraneal/sangre , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/etiología , Factores de Edad , Evaluación de la DiscapacidadRESUMEN
Surgical treatment is indicated for Chiari malformation type 1 (CMI) with tonsillar descent (TD) of >5 mm and other clinical manifestations. However, some patients remain unresponsive to surgery; this is an active topic of discussion. A patient presented to the emergency department with dizziness and an impaired gait. He had a history of hypertension. Magnetic resonance investigations revealed a 9-mm TD and cervical syringomyelia. There was no evidence of interatrial septum pathology on transthoracic echocardiography performed preoperatively. Although his complaints were attributed to CMI and surgery was performed, his symptoms remained persistent. Two years later, when the patient's dizziness increased, a posterior fossa transient ischemic attack (TIA) was suspected. A large patent foramen ovale (PFO) and Chiari network (CN) were also detected on transesophageal echocardiography. His complaints were resolved following PFO closure. Our case suggests that neurosurgeons should be informed about the results of the companionship of a PFO and CN. Before deciding on CMI surgery for patients with only dizziness complaints, a detailed investigation of accompanying cardiac pathologies is paramount to ensure accurate diagnosis and treatment.
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A 31-year-old man with neurofibromatosis type 1 (NF-1) had undergone resection of a malignant peripheral nerve sheath tumor (MPNST) on the buttock 3 months previously. He subsequently underwent mechanical thrombectomy for a hyperacute left middle cerebral artery embolism. Histopathologically, the emboli comprised neurofilament-positive pleomorphic tumor cells with geographic necrosis and conspicuous mitosis and were identified as MPNST. The patient died of respiratory failure due to lung MPNST metastasis on day 15 of hospitalization. To our knowledge, this is the first report of a spontaneous cerebral embolism due to MPNST in a NF-1 patient.
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Background: The persistent primitive trigeminal artery (PPTA) is a persistent embryological carotid-basilar connection. Endovascular thrombectomy (EVT) for hypoplastic PPTA occlusion is a challenge. This case report aims to describe the successful recanalization of simultaneous occlusions in both the PPTA and basilar artery (BA) using the Solitaire FR (RECO SR)/Stent and Intermediate Catheter Assisting (SWIM) technique in a patient with acute cardiogenic cerebral embolism. To the best of our knowledge, this is the first report of such a case. Case Description: We present a case of a 70-year-old female patient who presented with acute right-sided hemiparesis and altered consciousness. Digital subtraction angiography confirmed the occlusion of both the distal portion of the PPTA and the BA. The patient underwent EVT using the SWIM technique, resulting in successful recanalization and significant improvement in the patient's condition. Conclusion: This case report demonstrates the successful application of the SWIM technique in achieving recanalization and improving outcomes in a patient with simultaneous occlusion of the acute PPTA and BA. These findings support the potential use of EVT in similar cases.
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The superior thyroid cornu (STC) is a normal anatomic structure that forms part of the thyroid cartilage. Here, we report a patient with unusually elongated and ossified STC that might result in recurrent cerebral embolisms. During a second endovascular therapy for recurrent middle cerebral artery embolism, a segment with an irregular filling defect was noted in the internal carotid artery (ICA), at the C1 level. This defect was unnoticed during the initial endovascular procedure. Three-dimensional computed tomography angiography performed after the second endovascular procedure revealed an ICA segment located between the STC and C1 with a tortuous course and irregular wall of the ICA. Therefore, we assumed that STC compression of the ICA could have resulted in thrombus formation at the site and consequent cerebral embolism. The STC should be considered a structure responsible for cerebral embolism. Careful evaluation of the entire ICA course is imperative prior to performing an endovascular thrombectomy for acute embolic occlusion of the middle cerebral artery.
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Angiografía por Tomografía Computarizada , Embolia Intracraneal , Humanos , Variación Anatómica , Arteria Carótida Interna/anomalías , Arteria Carótida Interna/diagnóstico por imagen , Procedimientos Endovasculares/métodos , Imagenología Tridimensional , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Recurrencia , Trombectomía/métodos , Glándula Tiroides/diagnóstico por imagenRESUMEN
Neuropsychiatric symptoms, depression, and progressive mental confusion should not be overlooked as onset symptoms of multiple cerebral ischemic lesions due to cardiac embolization. Comprehensive clinical evaluation due to progressive anemia led to the diagnosis of poorly differentiated adenocarcinoma of the esophagogastric junction as cause of embolizing nonbacterial mitral endocarditis.
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When starting a mechanical thrombectomy, manual aspiration with balloon guide catheters inserted into the internal carotid artery (ICA) is an efficient method for thrombus aspiration. However, no complications associated with this procedure have been reported. This study describes the case of a 76-year-old man who presented to our hospital with total aphasia and complete right-sided paralysis due to chronic atrial fibrillation and left occlusion of the ICA. When the balloon guide catheter was inserted and inflated at the origin of the left ICA, the patient's systolic blood pressure suddenly decreased from 114 mm Hg to 44 mm Hg. This sudden hypotension may have been caused by the carotid sinus reflex. Hypotension improved following balloon deflation. The procedure was continued, resulting in complete recanalization of the left ICA. The patient died from acute exacerbation of interstitial pneumonia. Although this complication is rare, similar phenomena have been recognized in carotid artery stenting and the use of flow-diverting devices. To the best of our knowledge, this is the first report of a case wherein the carotid sinus reflex was induced by manual aspiration using a balloon guide catheter placed in the ICA. Clinicians should recognize the importance of ensuring that the proximal end of the balloon crosses the carotid sinus when dilating and occluding the ICA with a balloon to avoid the carotid sinus reflex.
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Ischemic stroke is defined as a reduction in blood flow to brain tissue that results in the deterioration and death of neurons in a matter of minutes. While often seen in older patients with a history of atherosclerosis of the major arteries, a subset of ischemic strokes occur in younger individuals with minimal to no prior risk factors. Further evaluation of these unknown, or cryptogenic, strokes has yielded positive findings of a patent foramen ovale (PFO) in a concerning number of cases. Cryptogenic strokes attributable to PFO present an important clinical occurrence because they do not fit the typical template regarding those most at risk for such acutely devastating outcomes, making their identification uniquely important for both immediate and long-term patient care. A 20-year-old Hispanic female presented to the emergency department for evaluation of neurological symptoms indicating obstruction of a major cerebral vessel. After being placed on stroke alert and found to have an embolus occluding the left middle cerebral artery (MCA) via non-contrast computed tomography (CT), tissue plasminogen activator (tPA) was administered, and mechanical thrombectomy was performed to restore blood flow. Following stabilization, further testing done on the patient revealed a substantial PFO that likely allowed for the crossing of an embolus from venous blood returning to the heart directly into the arterial circulation. The patient opted for cardiac monitor placement and has remained asymptomatic to this point while awaiting surgical repair. This case demonstrates an unusual presentation of ischemic stroke in a young individual with no reported risk factors and highlights the importance of screening for large PFO in patients prior to a serious cerebrovascular accident. It is our hope that highlighting this case may heighten awareness of this condition and allow for timely recognition from medical personnel who may encounter this same medical emergency in the future.
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A 55-year-old man developed ischemic stroke in the bilateral cerebellar hemispheres and bilateral occipital lobes. He was admitted to our hospital 17 months later with recurrent ischemic stroke in the posterior circulation. The left vertebral artery (VA) was occluded on brain magnetic resonance angiography but was visualized with a delay on continuous three-phase CT angiography (CTA). Conventional angiography confirmed a to-and-fro blood flow pattern at the distal end of the left VA, therefore the patient was diagnosed with VA stump syndrome (VASS). VASS is a recurrent posterior circulation ischemic stroke caused by thrombi in an occluded unilateral VA. VASS should be suspected in patients with unilateral VA occlusion and repeated posterior-circulation ischemic stroke. The diagnostic criteria for VASS include confirmation of VA occlusion and the presence of an antegrade flow component at the distal end. In this case, the presence of collateral circulation in the VA was suspected based on CTA findings, leading to the diagnosis of VASS. It was thus suggested that devising the imaging method of CTA may help diagnose VASS.
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Angiografía por Tomografía Computarizada , Arteria Vertebral , Humanos , Masculino , Persona de Mediana Edad , Arteria Vertebral/diagnóstico por imagen , Síndrome , Circulación Colateral , Recurrencia , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/etiología , Angiografía por Resonancia Magnética , Angiografía CerebralRESUMEN
Cerebral arterial air embolism (CAE), a rare subtype of air embolism, carries a 21% mortality rate. We present a unique case involving a 69-year-old female with a history of usual interstitial pneumonia (UIP) who suffered a transient ischemic attack (TIA) due to CAE. Unlike typical cases, CAE in this instance resulted from spontaneous pneumothorax, not the more common iatrogenic causes. Adding complexity, an unexpected discovery emerged during evaluation: a patent foramen ovale, contributing to paradoxical embolism. This underscores the vital need to consider CAE as a differential diagnosis in UIP patients with neurological symptoms, highlighting its rarity and diagnostic challenges.
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BACKGROUND: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO), an effective short-term circulatory support method for refractory cardiogenic shock, is widely applied. However, retrospective analyses have shown that VA-ECMO-assisted cases were associated with a relatively high mortality rate of approximately 60%. Embolization in important organs caused by complications of left ventricular thrombosis (LVT) during VA-ECMO is also an important reason. Although the incidence of LVT during VA-ECMO is not high, the consequences of embolization are disastrous. CASE SUMMARY: A 37-year-old female patient was admitted to hospital because of fever for 4 d and palpitations for 3 d. After excluding the diagnosis of coronary heart disease, we established a diagnosis of "clinically explosive myocarditis". The patient still had unstable hemodynamics after drug treatment supported by VA-ECMO, with heparin for anticoagulation. On day 4 of ECMO support, a left ventricular thrombus attached to the papillary muscle root of the mitral valve was found by transthoracic echocardiography. Left ventricular decompression was performed and ECMO was successfully removed, but the patient eventually died of multiple cerebral embolism. CONCLUSION: LVT with high mobility during VA-ECMO may cause embolism in important organs. Therefore, a "wait and see" strategy should be avoided.
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INTRODUCTION: Endovascular left atrial appendage occlusion (LAAO) is associated with a high incidence of peri-procedure silent cerebral embolism (SCE), while the recommended activated clotting time (ACT) level by the expert consensus is lower than that in atrial fibrillation (AF) ablation. The aim of our study was to investigate whether raising the targeted ACT level during LAAO to the same level as AF ablation could decrease the incidence of SCE. METHODS: It was a prospective observational cohort study. Consecutive AF patients receiving LAAO between January 2021 and December 2022 were included and categorized into two groups based on the time of enrollment. Patients enrolled in 2021 (group 250) maintained a target ACT level of ≥250 s during LAAO procedure, while patients enrolled in 2022 (group 300) maintained the peri-procedure ACT ≥300 s. All patients underwent cerebral magnetic resonance imaging before and after the procedure. RESULTS: A total of 81 patients were included (38 in the group 250 and 43 in the group 300). After inverse probability of treatment weighting (IPTW), patients in the group 250 showed a significantly lower incidence of SCE than group 300 (IPTW p = 0.038). Only a stable high ACT pattern could decrease the risk of SCE. No significant differences were found between other ACT change patterns on the SCE incidence. CONCLUSION: Raising the peri-procedure ACT level to a stable 300 s could decrease the risk of the SCE without increasing the major bleeding events.
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Anticoagulantes , Apéndice Atrial , Fibrilación Atrial , Embolia Intracraneal , Humanos , Masculino , Femenino , Fibrilación Atrial/complicaciones , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Estudios Prospectivos , Apéndice Atrial/cirugía , Apéndice Atrial/diagnóstico por imagen , Anciano , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Persona de Mediana Edad , Incidencia , Tiempo de Coagulación de la Sangre Total , Imagen por Resonancia Magnética , Procedimientos EndovascularesRESUMEN
ABSTRACT Acute gastric variceal bleeding is a life-threatening condition that could be effectively treated with endoscopic cyanoacrylate injection diluted with lipiodol. The mixture acts as a tissue adhesive that polymerizes when in contact with blood in a gastric varix. This work reports a patient that presented to the emergency department with upper gastrointestinal bleeding due to acute variceal bleeding, who developed systemic embolization following cyanoacrylate injection therapy. This complication culminated in cerebral, splenic and renal infarctions with a fatal outcome. Systemic embolization is a very rare, but the most severe complication associated with endoscopic cyanoacrylate injection and should be considered in patients undergoing this treatment.
RESUMEN La hemorragia digestiva por várices gástricas es una afección potencialmente mortal que puede tratarse eficazmente con la inyección endoscópica de cianoacrilato diluida con lipiodol. La mezcla actúa como un adhesivo tisular que se polimeriza cuando entra en contacto con la sangre de la várice gástrica. Este trabajo nos reporta un paciente que acudió al servicio de urgencias con hemorragia digestiva alta debido a hemorragia aguda por várices, que desarrolló embolización sistémica después de la terapia con inyección de cianoacrilato. Esta complicación culminó en infartos cerebrales, esplénicos y renales con desenlace fatal. La embolización sistémica es una complicación muy rara, pero con alta mortalidad, asociada con la inyección endoscópica de cianoacrilato y debe considerarse en pacientes sometidos a este tratamiento.
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Introduction: A thrombus straddling the patent foramen ovale (PFO) is a very rare clinical entity. Optimal management remains unclear due to the availability of various therapeutic options; thus, an individualized approach is recommended. Case presentation: The authors describe a case presenting with recurrent cerebral embolism and a large and mobile thrombus straddled in the PFO. Historically, cardiac surgery, thrombolysis or anticoagulation were possible management options for this patient. However, there are no guidelines on what the optimal treatment is. Our patient was a poor surgical candidate because of advanced age and multiple comorbidities. Furthermore, she had a recent ischaemic stroke which was a relative contraindication to thrombolysis. After consulting the Heart Team, medical treatment alone with systemic anticoagulation was administered. Subsequent transthoracic echocardiography (TTE) after 1 week showed complete thrombus resolution. After 4 months, the PFO was successfully occluded with an Amplatzer device. The patient received rehabilitation therapy and had good functional recovery. Clinical discussion: Anticoagulant therapy alone was chosen because of high risk for surgery. Complete thrombus resolution was achieved after 1 week although the initial thrombus size was quite large. Nevertheless, this approach may not be applicable to every patient. In addition to TTE, multimodality imaging using transesophageal echocardiography and cardiac magnetic resonance is helpful to identify the mechanism of stroke, which in our case is a thrombus-straddled PFO, and to make early treatment decisions. Serial TTEs help assess the response to anticoagulation. An individualized approach should be made with a multidisciplinary Heart Team. Conclusion: Echocardiography plays an important role in the diagnosis and treatment evaluation for patients with a thrombus straddling a PFO. An individualized approach to manage the patient should be made with a multidisciplinary Heart Team.