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Table 34-7 Causes of cerebral embolism 1 Cardiac origin a Atrial brillation and other arrhythmias (with rheumatic, atherosclerotic, hypertensive, congenital, or syphilitic heart disease) b Myocardial infarction with mural thrombus c Acute and subacute bacterial endocarditis d Heart disease without arrhythmia or mural thrombus (mitral stenosis, myocarditis, etc) e Complications of cardiac surgery f Valve prostheses g Nonbacterial thrombotic (marantic) endocardial vegetations h Prolapsed mitral valve i Paradoxical embolism with congenital heart disease (eg, patent foramen ovale) j Myxoma 2 Noncardiac origin a Atherosclerosis of aorta and carotid arteries (mural thrombus, atheromatous material) b From sites of dissection and/or bromuscular dysplasia of carotid and vertebrobasilar arteries c Thrombus in pulmonary veins d Fat, tumor, or air e Complications of neck and thoracic surgery f Pelvic and lower extremity venous thrombosis in presence of right-to-left cardiac shunt 3 Undetermined origin
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ognized in the last decades to be a more frequent source of embolism than had been appreciated Amarenco and colleagues reported that as many as 38 percent of a group of patients with no discernible cause for embolic stroke had echogenic atherosclerotic plaques in the aortic arch that were greater than 4 mm in thickness, a size thought to be associated on a statistical basis with strokes Disseminated cholesterol emboli are known to occur in the cerebral circulation and may be dispersed in other organs as well; rarely, this is suf ciently severe to cause an encephalopathy and pleocytosis in the spinal uid Paradoxic embolism can occur when an abnormal communication exists between the right and left sides of the heart (particularly a patent foramen ovale, or PFO) or when both ventricles communicate with the aorta; thus embolic material arising in the veins of the lower extremities or pelvis or elsewhere in the systemic venous circulation can bypass the pulmonary circulation and reach the cerebral vessels Pulmonary hypertension (often from previous pulmonary embolism) favors the occurrence of paradoxic embolism, but this may occur with a PFO even in the absence of pulmonary hypertension Of 30 patients in whom a PFO could be demonstrated, 17 had evidence of a right-to-left shunt; brain infarction was associated with positive phlebography of the legs and abnormal pulmonary scintigraphy (Itoh et al) Several studies indicated that the presence of a small atrial septal aneurysm adjacent to the patient foramen increases the likelihood of stroke In the series of Mas and colleagues, patients ages 18 to 55 who had a stroke were followed for 4 years; the risk of second stroke was 2 percent in those with a PFO alone and 15 percent among those with both a PFO and an atrial septal aneurysm (curiously, the risk among those with neither congenital abnormality was 4 percent higher
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than for PFO) This mechanism comes into play mainly in considering the causes of stroke in the younger patient Subendocardial broelastosis, idiopathic myocardial hypertrophy, cardiac myxomas, and cardiac lesions of trichinosis are rare causes of embolism The vegetations of acute and subacute bacterial endocarditis give rise to several different lesions in the brain (page 606) Mycotic aneurysm is a rare complication of septic embolism and may be a source of intracerebral or subarachnoid hemorrhage Marantic or nonbacterial thrombotic endocarditis is a frequently overlooked cause of cerebral embolism; at times it produces a baf ing clinical picture, especially when associated, as it often is, with carcinomatosis, cachexia from any cause, or lupus erythematosus This subject is discussed on page 735 Mitral valve prolapse may be a source of emboli, especially in young patients, but its importance has probably been overestimated The initial impetus for considering this abnormality as a source of embolus came from the study of Barnett and colleagues of a group of 60 patients who had TIAs or partial strokes and were under 45 years of age; prolapse was detected (by echocardiography and a characteristic midsystolic click) in 24 patients but in only 5 of 60 age-matched controls However, in several subsequent large studies (Sandok and Giuliani and Jones et al), only a very small proportion of strokes in young patients could be attributed to prolapse; even then, the connection was only inferred by the exclusion of other causes of stroke Indeed, in a recent study using stringent criteria for the echocardiographic diagnosis of prolapse, Gilon and colleagues could not establish any relation to stroke Rice and colleagues have described a family with premature stroke in association with valve prolapse and a similar relationship has been reported in twins; the same may occur in Ehlers-Danlos disease The pulmonary veins are a potential if infrequent source of cerebral emboli, as indicated by the occurrence of cerebral abscesses in association with pulmonary suppurative disease and by the high incidence of cerebral deposits secondary to pulmonary carcinoma In Osler-Weber-Rendu disease, pulmonary shunts serve as a conduit for emboli As remarked above, surgery of the neck and thorax can be complicated by cerebral embolism A rare type is that which follows thyroidectomy, where thrombosis in the stump of the superior thyroid artery extends proximally until a section of the clot, protruding into the lumen of the carotid, is carried into the cerebral arteries During cerebral arteriography, emboli may arise from the tip of the catheter, or manipulation of the catheter may dislodge atheromatous material from the aorta or carotid or vertebral arteries and account for some of the accidents during this procedure Transcranial Doppler insonation has suggested that small emboli frequently arise during these procedures; a study by Bendszus and colleagues found that 23 of 100 consecutive patients had new cortical lesions shown on diffusion-weighted MRI just after cerebral arteriography However, none of these were symptomatic and with good technique, emboli from vascular catheters are infrequent Cerebral embolism must always have occurred when secondary tumor is deposited in the brain, and cerebral embolism regularly accompanies septicemia, but a mass of tumor cells or bacteria is seldom large enough to occlude a cerebral artery and produce the picture of stroke Nevertheless, tumor embolism with stroke has been reported from cardiac myxomas and occasionally with other tumors It must be distinguished from embolism due to marantic endocarditis that complicates malignant neoplasms (nonbacterial thrombotic endocarditis, discussed further on) Cerebral fat embolism is related to severe bone trauma As a rule, the emboli are
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