Detection of Source of Emboli - circulation · Detection of Source of Emboli Pusan National...

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Detection of Source of Emboli Pusan National University Yangsan Hospital Park Yong Hyun

Transcript of Detection of Source of Emboli - circulation · Detection of Source of Emboli Pusan National...

Page 1: Detection of Source of Emboli - circulation · Detection of Source of Emboli Pusan National University Yangsan Hospital Park Yong Hyun. Embolus ... Stroke is the 3rd leading cause

Detection of Source of Emboli

Pusan National University Yangsan Hospital

Park Yong Hyun

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Embolus• "any detached, itinerant intravascular mass

(solid, liquid, or gaseous) as carried by circulation and capable of clogging arterial capillary beds at a site distant from its point of origin"

• In medicine, an embolism (from the Greek ἐμβολισμός "insertion") is the event of lodging of an embolus into a narrow capillary vessel of an arterial bed which causes a blockage (vascular occlusion) in

di t t t f th b d

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WHY DO WE NEED TO DETECT

CARDIAC SOURCES OF EMBOLISM?

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StrokeStroke

A Matter of Importance

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WHY DO WE NEED TO DETECT CARDIAC SOURCES OF EMBOLISM?

• Stroke is the 3rd leading cause of death in several industrial countries.

• Ischemic stroke : 80%

• Cardiogenic embolism accounts for 15-30% of ischemic strokes.

Arch Neurol 1989;46:727-43

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iagnosis of Cardioembolic Strok

“The presence of a potential cardioembolic source in the absence ofcerebrovascular disease in a patient with a non-lacunar stroke”

Cerebral Embolism Task Force, 1989

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Diagnosis of cardioembolic source

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Why do we detect ?

✓Presence of potencause : 2~3 fold ↑ stroke risk

✓Poor outcome : 50mortality after 3 yrs

Deep Impact

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Classification of StrokeThe TOAST criteria

i. Large-artery atherosclerosis

ii. Cardiac embolism

iii.Cerebral small artery occlusion

iv.Stroke of another determined etiology

v. Stroke of undetermined etiologyCategory ii, v : particular interest for echocardiography

i. Large-artery atherosclerosis

ii. Cardiac embolism

iii.Cerebral small artery occlusion

iv.Stroke of another determined etiology

v. Stroke of undetermined etiology

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Findingsindicating cardioembolic stroke• Abrupt onset

• Striking stroke severity in the elderly

• Previous infarction in various arterial distribution

• Other systemic thromboembolism

• Territorial distribution involving cortex, ...

• Hyperdense MCA Sg.

• Rapid recanalization of occluded major branch artery

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Which Tool ?

• Cornerstone of evaluation

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Proven sources

• Thrombus : LA, LV or DVT (/c shunt)

• Atherosclerotic thrombus

• Vegetation

• Cardiac Tumor

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Proven Source

• LA thrombus

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Proven Sources

• Tumor• Vegetation• Atheromatous

thrombus

Myxoma : villous

Infective endocarditisMV, AV

Aortic atherosclerosisarch, prox. DTA

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Stroke in LA myxoma63/F, CVA

“Vill ”

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Stroke in IEM/57, CVA

Vegetation (MV)

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Atheromatous plaque

• In SPAF, 35% with

✓Complex aortic plaque (mobile, ulcerated, > 4mm)

➡4 fold increased rate of stroke

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Grading of aortic atherosclerosis

Montgomery DH et al. JACC 1996;27:95-101

• Grade I : intimal thickening < 4 mm

• Grade II : diffuse intimal thickening ≥ 4 m

• Grade III : atheroma < 5 mm

• Grade IV : atheromas > 5 mm

• Grade V : any mobile atheroma

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Potential sources

The usual suspects

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Potential sources

• AF : clinically most important cause of cardiogenic brain embolism

LA thrombus

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Stroke in HCM

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Stroke in RCM

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Stroke in RCMM/54, CVA

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Stroke in RCMM/54, CVA

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Potential Source

• LV thrombus

• CHF : DCM

• MI : aneurysm

• Myocarditis

• Stress-induced CM

• LVNC

• RCM : EMF, Loefflerendomyocarditis

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Left Ventricular Thrombus: Acute Myocardial Infarction

• 7~20% of acute MI

• Most frequent in anterior or apical MI

• Aneurysm – Mural thrombi in 50% of pts

– Embolisation tend to occur early after MI

– Systemic emboli extremely uncommon in pts with chronic LV aneurysm in pts not

i i l ti l t

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Stroke in MS & SCM

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Stroke in RCM

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Stroke in LVNC

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Embolism• Systemic Pulmonary

LA thrombus

LV thrombus

Atherosclerotic plaque

Tumor

Vegetation

...

LA thrombus

LV thrombus

Atherosclerotic plaque

Tumor

Vegetation

...

Venous thrombusVenous thrombus

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Gate

• DVT

+

• PFO

• PAVF

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Protocol in PNUYH

1. TTE : Routine views

2. TTE : agitated saline test for R-L shunt

3. TEE : LA/LAA thrombus or SEC

4. TEE : IAS ASA PFO (agitated saline)

5. TEE : Thoracic aorta( asc. desc. arch )

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Sources?

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Sources?27/F, Dizziness

Cbll Infarction

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Sources?

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Sources?

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Not always monocausal !

Page 38: Detection of Source of Emboli - circulation · Detection of Source of Emboli Pusan National University Yangsan Hospital Park Yong Hyun. Embolus ... Stroke is the 3rd leading cause

Not always monocausal !

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Not always usual!

Aortic thrombus

34/M, Stroke

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Not always usual!

Aortic thrombus

34/M, Stroke

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Conclusion

• All patients with stroke or TIA can have potential sources

• Remember “not monocausal” & “unusual”- comprehensive evaluation

• Echo is powerful tool

- for the evaluation- to establish recommendations

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Thank you for your attention!