VERY LATE-ONSET WATCHMAN DEVICE ASSOCIATED THROMBUS FORMATION AND EMBOLIZATION PRESENTING AS ACUTE STROKE

Abstract Background Percutaneous patent foramen ovale (PFO) closure has been well established in the secondary prevention of cryptogenic stroke with overall low rates of procedural complications. One such complication is PFO closure device thrombus formation which is now rarely reported with newer generation devices. Case Summary We present the unusual case of a 59 year old woman with myelofibrosis who developed late onset recurrent embolic strokes related to Amplatzer PFO closure device thrombus whilst therapeutically anticoagulated on Warfarin. Surgical management was deemed too high risk and our patient was conservatively managed with enoxaparin. Serial trans-thoracic echocardiography demonstrated reduction in thrombus size and the patient had no further neurological events. Discussion Overall the risk of serious complications following percutaneous PFO closure, such as device-associated thrombus, remains low. The risk of thrombus formation in patients with hypercoagulable states is not well characterised. Despite good evidence for the efficacy in preventing recurrent cryptogenic stroke, the role of PFO closure in addition to anticoagulation is unclear. Given this uncertain benefit of PFO closure in anticoagulated patients and the unclear risk profile, patient selection and thorough preprocedural evaluation is vital when assessing the appropriateness of percutaneous PFO closure.

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Late left atrial appendage closure device displacement and massive thrombus formation: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa014 ◽

2020 ◽

Vol 4 (2) ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Benjamin Sasko ◽

Oliver Ritter ◽

Peter Bramlage ◽

Fabian Riediger

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Thrombus Formation ◽

Anticoagulation Therapy ◽

Bleeding Risk ◽

Atrial Appendage ◽

Closure Device ◽

Watchman Device ◽

High Bleeding Risk ◽

Laa Closure

Abstract Background Left atrial appendage (LAA) closure with the WATCHMAN device is an alternative to anticoagulation therapy for the prevention of stroke in selected patients with atrial fibrillation (AF). Infrequently, left atrial (LA) device-related thrombus formation occurs and it is poorly understood. Thrombus formation due to incomplete covering of the LAA is even rarer and may occur within the first few months after device implantation. Case summary Here, we present a case of a 68-year-old male patient with permanent AF, drug- and hepatitis induced liver cirrhosis (CILD Score B), and prior aortic valve replacement. The patient had a history of percutaneous LAA closure using a WATCHMAN device. He developed massive peri-device leak and thrombus arising from the space between the device and appendage cleft 2 years after implantation. Because of the high bleeding risk with a HAS-BLED score of 5 points, surgery was chosen as the therapy of choice instead of long-term anticoagulation. The patient was discharged in good clinical condition and has been scheduled for a yearly follow-up. Discussion This case emphasizes the importance of choosing appropriately sized LAA occluder devices and planning for regular post-interventional follow-ups to minimize the risk of per-device leaks and thrombi.

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Late onset neuromyelitis optica mimicking an acute stroke in an elderly patient

Journal of Neuroimmunology ◽

10.1016/j.jneuroim.2017.04.006 ◽

2017 ◽

Vol 309 ◽

pp. 1-3 ◽

Cited By ~ 5

Author(s):

Kushak Suchdev ◽

Sara Razmjou ◽

Praveen Venkatachalam ◽

Omar A. Khan ◽

Wazim Mohamed ◽

...

Keyword(s):

Elderly Patient ◽

Acute Stroke ◽

Neuromyelitis Optica ◽

Late Onset

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Pathophysiologic and Therapeutic Perspectives Based on Thrombus Histology in Stroke

Journal of Stroke ◽

10.5853/jos.2019.03440 ◽

2020 ◽

Vol 22 (1) ◽

pp. 64-75 ◽

Cited By ~ 5

Author(s):

Ji Hoe Heo ◽

Hyo Suk Nam ◽

Young Dae Kim ◽

Jin Kyo Choi ◽

Byung Moon Kim ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Prevention ◽

Thrombus Formation ◽

Neutrophil Extracellular Traps ◽

Reperfusion Therapy ◽

Prevention Research ◽

Endovascular Thrombectomy ◽

Stroke Etiology ◽

Extracellular Traps ◽

Histopathologic Analysis

Recent advances in endovascular thrombectomy have enabled the histopathologic analysis of fresh thrombi in patients with acute stroke. Histologic analysis has shown that the thrombus composition is very heterogeneous between patients. However, the distribution pattern of each thrombus component often differs between patients with cardiac thrombi and those with arterial thrombi, and the efficacy of endovascular thrombectomy is different according to the thrombus composition. Furthermore, the thrombus age is related to the efficacy of reperfusion therapy. Recent studies have shown that neutrophils and neutrophil extracellular traps contribute to thrombus formation and resistance to reperfusion therapy. Histologic features of thrombi in patients with stroke may provide some clues to stroke etiology, which is helpful for determining the strategy of stroke prevention. Research on thrombus may also be helpful for improving reperfusion therapy, including the development of new thrombolytic agents.

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An Interesting Case of Acute Stroke: When Many Things Went Wrong, but the Patient Laughed at Last!

Journal of Stroke Medicine ◽

10.1177/25166085211046148 ◽

2021 ◽

pp. 251660852110461

Author(s):

Debabrata Chakraborty ◽

Nirmalya Ray ◽

Sadanand Dey ◽

Sanjay Bhaumik

Keyword(s):

Acute Stroke ◽

Atrial Flutter ◽

Thrombus Formation ◽

Intravenous Thrombolysis ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Interesting Case ◽

Lower Limbs ◽

Systemic Embolization ◽

Short Period ◽

Life Threatening

A 52-year-old lady with hypertrophic obstructive cardiomyopathy, atrial flutter, and old right hemispheric stroke in the background underwent implantable cardioverter-defibrillator implantation for complete heart block. She was yet to start her regular anticoagulant and presented to hospital emergency with acute right middle cerebral artery (MCA) territory stroke (NIH Stroke Scale/Score of 14). After ruling out absolute contraindications, she was given intravenous thrombolysis (did not have a blood vessel target for endovascular therapy). Post thrombolysis, she had clot mobilization from the internal carotid artery to the MCA and systemic embolization to kidneys and lower limbs. The patient underwent an urgent embolectomy and lower limbs were saved from amputation. Our case highlights the importance of checking peripheral pulses in acute stroke patients post thrombolysis. Though the patient had initial deterioration after thrombolysis, she gradually improved and later achieved satisfactory modified Rankin scale underscoring the ultimate potential benefits of thrombolysis in acute stroke. There is a high chance of thrombus formation in patients with atrial flutter who undergo recent cardiac procedure especially if they are off anticoagulation for even a short period. Hence, unnecessary apprehension of anticoagulant use in proper situations may create life-threatening complications.

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Serum fatty acids and ischemic stroke subtypes in middle- and late-onset acute stroke patients

Clinical Nutrition Experimental ◽

10.1016/j.yclnex.2018.09.001 ◽

2018 ◽

Vol 22 ◽

pp. 19-29 ◽

Cited By ~ 3

Author(s):

Takahisa Mori ◽

Yuhei Tanno ◽

Shigen Kasakura ◽

Kazuhiro Yoshioka ◽

Noriyoshi Nakai

Keyword(s):

Fatty Acids ◽

Ischemic Stroke ◽

Acute Stroke ◽

Late Onset ◽

Stroke Patients ◽

Stroke Subtypes ◽

Serum Fatty Acids

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Abstract WMP67: Thrombogenic Effect of FFAs in Cardioembolic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wmp67 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Woo-Keun Seo ◽

Jin-Man Seo ◽

Kyungmi Oh

Keyword(s):

Acute Stroke ◽

Left Atrial ◽

Thromboembolic Event ◽

Thrombus Formation ◽

Left Ventricular ◽

Cardioembolic Stroke ◽

Stroke Patients ◽

Thromboembolic Risk ◽

Embolic Risk

Objective: Four decades ago, free fatty acids (FFA) were proved to enhance thrombus-formation. Recently, the role of FFA in thromboembolism has reemerged in the context of cardioembolic stroke. Therefore, we attempted to determine the role of FFA on the embolic risk in various potential sources of cardioembolism (PSCE) with the hypothesis that, if elevated FFA levels in stroke patients are associated with thrombogenesis, patients with a well-known high risk of embolic sources would have high FFA levels. Methods: Data collected from two hospital-based stroke registries were analyzed to investigate the association between FFA and PSCE. Results: A total of 2770 acute stroke patients, including 539 with cardioembolic stroke, were selected for analysis. FFA was an independent predictor for cardioembolism (OR 2.755, 95% CI 2.221-3.417, P <0.001) and significantly associated with fibrinogen and prothrombin time. Among the PSCE, atrial fibrillation, valvular heart disease, congestive heart failure with low ejection fraction, left atrial thrombus, left ventricular thrombus, left atrial smoke, and ventricular wall motion abnormality were independently associated with FFA. FFA level increased with the number of PSCE per patient. Significant correlation between the FFA ratio of PSCE to non-PSCE and the annualized thromboembolic event rate of each PSCE from the literature was noted ( r 2 =0.5829, P <0.001). Conclusions: Among acute stroke patients, FFA levels increase in proportion to the increase in thromboembolic risk for each PSCE. These results imply that enhanced thrombogenicity could be the main mechanism to explain the elevated FFA levels in patients with cardioembolic stroke.

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Thrombus formation on artificial surfaces: Correlative microscopy

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s042482010016176x ◽

1990 ◽

Vol 48 (3) ◽

pp. 840-841

Author(s):

Quintin J. Lai ◽

Stuart L. Cooper ◽

Ralph M. Albrecht

Keyword(s):

Electron Microscopy ◽

High Resolution ◽

Low Voltage ◽

Thrombus Formation ◽

Blood Platelets ◽

Polymer Surfaces ◽

Flow Conditions ◽

Transmission Electron ◽

Adhesion Of Platelets ◽

Microscopic Techniques

Thrombus formation and embolization are significant problems for blood-contacting biomedical devices. Two major components of thrombi are blood platelets and the plasma protein, fibrinogen. Previous studies have examined interactions of platelets with polymer surfaces, fibrinogen with platelets, and platelets in suspension with spreading platelets attached to surfaces. Correlative microscopic techniques permit light microscopic observations of labeled living platelets, under static or flow conditions, followed by the observation of identical platelets by electron microscopy. Videoenhanced, differential interference contrast (DIC) light microscopy permits high-resolution, real-time imaging of live platelets and their interactions with surfaces. Interference reflection microscopy (IRM) provides information on the focal adhesion of platelets on surfaces. High voltage, transmission electron microscopy (HVEM) allows observation of platelet cytoskeletal structure of whole mount preparations. Low-voltage, high resolution, scanning electron microscopy allows observation of fine surface detail of platelets. Colloidal gold-labeled fibrinogen, used to identify the Gp Ilb/IIIa membrane receptor for fibrinogen, can be detected in all the above microscopies.

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