An Unusual Cause of Cardioembolic Stroke: Paradoxical Embolism Due to Thrombus Formation on the Eustachian Valve

Introduction: It is well known that the tendency toward thrombosis is increased in cancer patients. The increase in cancer procoagulant and tissue factor levels, endothelial damage, and stasis due to compression are among the most accused causes of thrombosis in cancer patients. Hypereosinophilia is a rare condition that causes endothelial damage leading to thrombosis. Case Presentation: We present a 64-year-old male patient with cardiac involvement of hypereosinophilia which developed in the T-cell lymphoma ground resulting in a fatal cardioembolic stroke. Despite normal left ventricular (LV) contractions, almost half of the ventricular volume was full of thrombus in this case. Conclusion: Hypereosinophilia is a rare cause of thrombus formation in the left ventricle in patients with preserved ejection fraction. However, hypereosinophilic cardiac involvement can lead to rapid, progressive, life-threatening complications.

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Eustachian valve, interatrial shunt, and paradoxical embolism

Echocardiography ◽

10.1111/echo.14682 ◽

2020 ◽

Vol 37 (6) ◽

pp. 939-944

Author(s):

Qiangjun Cai ◽

Masood Ahmad

Keyword(s):

Paradoxical Embolism ◽

Eustachian Valve ◽

Interatrial Shunt

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Prominence of the Eustachian valve in paradoxical embolism

European Journal of Echocardiography ◽

10.1093/ejechocard/jeq100 ◽

2010 ◽

Vol 12 (1) ◽

pp. 33-36 ◽

Cited By ~ 17

Author(s):

T. A. Vale ◽

J. D. Newton ◽

E. Orchard ◽

R. Bhindi ◽

N. Wilson ◽

...

Keyword(s):

Paradoxical Embolism ◽

Eustachian Valve

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Stroke Prevention with Percutaneous Left Atrial Appendage Closure

Clinical Medicine Insights Therapeutics ◽

10.4137/cmt.s18886 ◽

2016 ◽

Vol 8 ◽

pp. CMT.S18886

Author(s):

Peter Fahmy ◽

Jacqueline Saw

Keyword(s):

Stroke Prevention ◽

Left Atrial ◽

Left Atrial Appendage ◽

Thrombus Formation ◽

Vitamin K Antagonists ◽

Atrial Appendage ◽

Cardioembolic Stroke ◽

Bleeding Complications ◽

Operator Experience ◽

Considerable Morbidity

Atrial fibrillation (AF) is the most common cardiac arrhythmia with increasing prevalence. AF is associated with considerable morbidity and mortality. Cardioembolic stroke results as a consequence of thrombus formation within the left atrial appendage (LAA) in patients with AF and has a significant impact on our health system. Oral anticoagulation with either vitamin K antagonists or the novel anticoagulants is an effective medical therapy for prophylaxis against strokes in patients suffering from AF. Unfortunately, bleeding complications and compliance issues limit their use. A need for newer approaches have thereby been developed and studied such as percutaneous occlusion of the LAA. Several LAA occlusion devices have been developed, and with improved operator experience, they have been successful in stroke prevention in patients with nonvalvular AF and fewer periprocedural complications. This article reviews the use of percutaneous LAA occlusion devices in the prevention of cardioembolic stroke.

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Promising Biomarker Candidates for Cardioembolic Stroke Etiology. A Brief Narrative Review and Current Opinion

Frontiers in Neurology ◽

10.3389/fneur.2021.624930 ◽

2021 ◽

Vol 12 ◽

Author(s):

Arnold Markus ◽

Schütz Valerie ◽

Katan Mira

Keyword(s):

Randomized Clinical Trials ◽

Thrombus Formation ◽

Preventive Treatment ◽

Cardioembolic Stroke ◽

Prevention Strategies ◽

Vessel Occlusion ◽

Cerebral Vessel ◽

Stroke Etiology ◽

Underlying Mechanisms ◽

Made In

Determining the cause of stroke is considered one of the main objectives in evaluating a stroke patient in clinical practice. However, ischemic stroke is a heterogeneous disorder and numerous underlying disorders are implicated in its pathogenesis. Although progress has been made in identifying individual stroke etiology, in many cases underlying mechanisms still remain elusive. Since secondary prevention strategies are tailored toward individual stroke mechanisms, patients whose stroke etiology is unknown may not receive optimal preventive treatment. Cardioembolic stroke is commonly defined as cerebral vessel occlusion by distant embolization arising from thrombus formation in the heart. It accounts for the main proportion of ischemic strokes, and its share to stroke etiology is likely to rise even further in future decades. However, it can be challenging to distinguish cardioembolism from other possible etiologies. As personalized medicine advances, stroke researchers' focus is increasingly drawn to etiology-associated biomarkers. They can provide deeper insight regarding specific stroke mechanisms and can help to unravel previously undetected pathologies. Furthermore, etiology-associated biomarkers could play an important role in guiding future stroke prevention strategies. To achieve this, broad validation of promising candidate biomarkers as well as their implementation in well-designed randomized clinical trials is necessary. This review focuses on the most-promising candidates for diagnosis of cardioembolic stroke. It discusses existing evidence for possible clinical applications of these biomarkers, addresses current challenges, and outlines future perspectives.

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Cardioembolic stroke: everything has changed

Stroke and Vascular Neurology ◽

10.1136/svn-2018-000143 ◽

2018 ◽

Vol 3 (2) ◽

pp. 76-83 ◽

Cited By ~ 10

Author(s):

J David Spence

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulants ◽

Antiplatelet Agents ◽

Paradoxical Embolism ◽

Percutaneous Closure ◽

Cardioembolic Stroke ◽

Severe Haemorrhage ◽

Selection Of Patients ◽

Selection Of ◽

Metabolic Deficiency

Historically, because of the difficulty of using warfarin safely and effectively, many patients with cardioembolic stroke who should have been anticoagulated were instead given ineffective antiplatelet therapy (or no antithrombotic therapy). With the arrival of new oral anticoagulants that are not significantly more likely than aspirin to cause severe haemorrhage, everything has changed. Because antiplatelet agents are much less effective in preventing cardioembolic stroke, it is now more prudent to anticoagulate patients in whom cardioembolic stroke is strongly suspected. Recent advances include the recognition that intermittent atrial fibrillation is better detected with more prolonged monitoring of the cardiac rhythm, and that percutaneous closure of patent foramen ovale (PFO) may reduce the risk of stroke. However, because in most patients with stroke and PFO the PFO is incidental, this should be reserved for patients in whom paradoxical embolism is likely. A high shunt grade on transcranial Doppler saline studies, and clinical clues to paradoxical embolism, can help in appropriate selection of patients for percutaneous closure. For patients with atrial fibrillation who cannot be anticoagulated, ablation of the left atrial appendage is an emerging option. It is also increasingly recognised that high levels of homocysteine, often due to undiagnosed metabolic deficiency of vitamin B12, markedly increase the risk of stroke in atrial fibrillation, and that B vitamins (folic acid and B12) do prevent stroke by lowering homocysteine. However, with regard to B12, methylcobalamin should probably be used instead of cyanocobalamin. Many important considerations for judicious application of therapies to prevent cardioembolic stroke are discussed.

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Abstract 2787: Elevated Circulating Levels Of Platelet-derived Microparticles Are Associated With The Thrombus Formation In The Left Atrial Appendage In Patients With Ischemic Stroke That Is Resistant To Anti-coagulant Therapies

Circulation ◽

10.1161/circ.116.suppl_16.ii_619-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Harutoshi Tamura ◽

Osamu Hirono ◽

Hidenobu Okuyama ◽

Satoshi Nishiyama ◽

Yasuchika Takeishi ◽

...

Keyword(s):

Platelet Activation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Thrombus Formation ◽

Serum Levels ◽

Atrial Appendage ◽

Cardioembolic Stroke ◽

Negative Group ◽

Warfarin Treatment ◽

Circulating Levels

Introduction: It is well known that elevation of fibrinolytic markers reflects thrombus formation in the left atrial appendage (LAA) that is identified as a fibrin-rich thrombus. On the other hand, it is sometimes difficult to remove LAA thrombus by the treatment of anti-coagulants alone. Hypothesis: Circulating platelet activation is also responsible for the thrombus formation in the LAA in patients with cardioembolic stroke. Methods: In 98 consecutive patients with cerebral infarction (mean age, 71±12 years old), we performed trans-esophageal echocardiography within 7 days after the onset, and at the same time, measured circulating platelet-derived microparticles (PDMP, as a marker of platelet activation, < 20 U/ml), and serum levels of D-dimer (DD, as a marker of fibrinolytic activity, normal level < 1.0 μg/ml). Patients with LAA peak emptying flow velocity < 20 cm/s were classified as having LAA dysfunction. Results: In patients without warfarin treatment, both PDMP and DD levels were significantly higher in LAA thrombus positive (n=12) than in negative group (n=70) (PDMP, 113.5±80.4 vs. 65.5±30.7 U/ml, P<0.001; DD, 7.3±10.4 vs. 2.9±3.7 μg/ml, p < 0.01). In patients with warfarin treatment (PT-INR 1.64±0.35), PDMP, but not DD levels, was markedly higher in LAA thrombus positive (n=6) than in negative group (n=10) (PDMP, 113.4±84.5 vs. 49.7±23.9 U/ml, P<0.05; DD, 2.1±1.8 vs. 1.6±1.3 μg/ml, NS), because DD were effectively suppressed by the anti-coagulant therapy. Furthermore, in LAA thrombus negative patients, there were no significant differences in PDMP between cases with and without LAA dysfunction (LAA dysfunction, n=13, 70.2±26.5 vs. No dysfunction, n=67, 63.3±31.1 U/ml). Conclusions : PDMP plays an important role in the LAA thrombus formation that is resistant to anti-coagulant treatment, and may be a useful predictor for the cardioembolic stroke occurrence.

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