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Serial contrast saline transcranial Doppler examination in a patient with paradoxical brain embolism associated with pulmonary embolism
788
Case reports / Journal of Clinical Neuroscience 14 (2007) 788–791
Serial contrast saline transcranial Doppler examination in a patient with paradoxical brain embolism associated with pulmonary embolism Kensaku Shibazaki *, Yasuyuki Iguchi, Takeshi Inoue, Yuji Ueno, Kazumi Kimura Department of Stroke Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki City, Okayama 701 0192, Japan Received 26 November 2005; accepted 23 May 2006
Abstract We report a patient with paradoxical brain embolism due to patent foramen ovale (PFO) associated with pulmonary embolism (PE). The number of microembolic signals, as detected by contrast saline transcranial Doppler (c-TCD) exam, drastically decreased with improvement of increased right atrial pressure due to PE. In a patient with paradoxical brain embolism associated with PE, c-TCD may be useful for both diagnosis of the presence of right-to-left shunting and evaluation of cardio-pulmonary circulation. 2006 Elsevier Ltd. All rights reserved. Keywords: Patent foramen ovale; Contrast saline TCD; Pulmonary embolism; Right atrial pressure
1. Introduction Contrast saline transcranial Doppler (c-TCD) is effective in diagnosing patent foramen ovale (PFO) and pulmonary arteriovenous fistula.1–3 Large PFO and elevation of right atrial pressure is likely to increase the amount of microembolic signals (MES) during c-TCD examination, but it is still uncertain whether the number of MES correlates with the status of cardiopulmonary circulation in a patient with paradoxical brain embolism and massive pulmonary embolism. We report that the number of MES, as detected by cTCD, drastically decreased with improvement in increased right atrial (RA) pressure induced by pulmonary embolism.
2. Case report A 79-year-old right-handed woman was admitted to hospital due to sudden onset of consciousness disturbance. Her past medical history was hypertension and hyperlipidemia with medication. At the time of admission, her blood pressure was 124/72 mmHg with a regular heart beat of 104/min and a respiratory rate of 24/min. Systolic heart murmur to the apex was heard, and pathological breath sounds were absent. Pitting edema was present in her lower extremities. No bruits were heard on her neck or orbit. Neurological examination demonstrated consciousness disturbance with a score of 6 on the Glasgow Coma Scale. Her eyes were deviated to the right, and left central facial palsy and left hemiplegia were evident. The left planter response was extensor. Sensation, in particular pain, was *
Corresponding author. Tel.: +81 86 462 1111; fax: +81 86 464 1027. E-mail address: [email protected] (K. Shibazaki).
deficient on her left face, arm and leg. Laboratory examinations on admission revealed a D-dimer level of 12.0 lg/ mL (normal, 61.0) and a thrombin-antithrombin III complex level of 46.2 ng/mL (normal, 63.0). An arterial blood gas analysis showed hypoxemia with a PaO2 of 58.0 mmHg on 7L oxygen by mask. On hospital day 1, the patient was examined using a commercially available echo-planer instrument operating on a 1.5-T MRI unit (Signa EchoSpeed Horizon; GE Medical Systems, Milwaukee, WI). Diffusion-weighted images showed a hyperintense lesion in the right middle cerebral artery (MCA) territory, which was identified as the lesion responsible for her neurological deterioration (Fig. 1). Magnetic resonance angiography and ultrasonography revealed no atherosclerotic changes on cerebral vessels. A right-to-left shunt (RLS) was detected by TCD examination performed from the orbital window in order to monitor the right internal carotid artery (Fig. 2A). Contrast saline TCD was performed as previously described.4 Although electrocardiography indicated a normal sinus rhythm, an inverted T-wave was displayed in II, III, aVF and V1-3. Enlargement of the right atrium was detected by transthoracic echocardiography, with severe right ventricular loading and tricuspid regurgitation pressure gradient of 80 mmHg. PFO was demonstrated using transesophageal echocardiography (TEE) with saline contrast. Lung perfusion scintigraphy implied multiple defects of the right upper lobe and left lower lobe (Fig. 3A). Pulmonary arterial angiography demonstrated occlusion of the right upper and left lower arteries (Fig. 4A), and pulmonary arterial pressure was elevated to a very high 61 mmHg. Venous thrombosis was present in the deep veins of the left leg as demonstrated by venous ultrasonography. Since paradoxical brain embolism due to PFO with PE and deep
Case reports / Journal of Clinical Neuroscience 14 (2007) 788–791
789
venous thrombosis was diagnosed, heparin sodium was administered intravenously. Serial c-TCD without the Valsalva maneuver was performed on days 2, 3, 5 and 7 after admission (Figs. 2B– D). MES on the RLS decreased dramatically with each passing day. The MES on days 1 and 2 resembled a shower, and 10 MES were counted just after injection of saline contrast on days 3 and 5. Finally, no MES were detected on day 7. Blood oxygen increased to normal and right ventricular loading in transthoracic echocardiography also immediately improved. The tricuspid regurgitation pressure gradient decreased to 46.5 mmHg on day 3 and 33.9 mmHg on day 7. Lung perfusion scintigraphy showed no defects in the right upper lobe or left lower lobe (Fig. 3B). Pulmonary arterial angiography demonstrated recanalization of the occluded arteries (Fig. 4B). Pulmonary artery pressure had decreased to 31 mmHg on day 45. She was then transferred to a rehabilitation facility. 3. Discussion Fig. 1. Diffusion-weighted MRI showing a hyperintense lesion in the right middle cerebral artery territory on admission.
We report a paradoxical brain embolism associated with PE. Contrast saline transcranial Doppler was useful not
Fig. 2. (A) Contrast saline transcranial Doppler (c-TCD) examinations demonstrating numerous microembolic signals (MES) on admission. Sequence of c-TCD examinations on (B) day 3, (C) day 5, and (D) day 7 (showing obvious decrease in number of MES).
790
Case reports / Journal of Clinical Neuroscience 14 (2007) 788–791
Fig. 3. (A) Lung perfusion scintigraphy showing multiple defects of the right upper lobe and left lower lobe. (B) Follow-up perfusion scintigraphy revealed no defect in the right upper lobe and left lower lobe.
only for diagnosis of the RLS, but also evaluation of cardiopulmonary circulation. When c-TCD demonstrates numerous MES without the Valsalva maneuver, then a large PFO, pulmonary ateriovenous fistula on a PFO with increased pressure in the right atrium due to pulmonary hypertension, should be considered.5 In the present case, massive PE was detected by lung perfusion scintigraphy. In fact, pulmonary arterial pressure increased to a very high 61 mmHg. Under such circumstances, an RLS via a PFO could easily develop due to the increased RA pressure, and numerous MES on cTCD during normal breathing would then be detected. Studies have shown that c-TCD detects TEE-proven RLS with a sensitivity of 90–100%, and specificity of 75– 100%.6,7 RLS detection by c-TCD has usually been conducted in previous studies by performing the Valsalva maneuver. However, c-TCD is not always performed on patients with acute ischemic stroke due to consciousness disturbance or aphasia. In contrast, our results suggest that c-TCD is sometimes a useful tool with which to detect RLS, despite severe stroke patients being unable to perform the Valsalva maneuver.
Fig. 4. (A) Pulmonary arterial angiography showing occlusion of the left lower pulmonary artery on admission. (B) Follow-up angiography revealing recanalization of the pulmonary artery (day 45).
In the present case, the number of MES detected by cTCD dramatically decreased with normalization of RA pressure. Therefore, serial c-TCD examinations in the acute phase of stroke should yield important information regarding cardio-pulmonary circulation.
Case reports / Journal of Clinical Neuroscience 14 (2007) 791–793
In conclusion, in a patient with paradoxical brain embolism associated with PE, c-TCD may be useful for not only the diagnosis of the presence of RLS, but also for evaluation of cardio-pulmonary circulation.
4.
References
5.
1. Chimowitz MI, Nemec JJ, Marwick TH, et al. Transcranial Doppler ultrasound identifies patients with right-to-left cardiac or pulmonary shunts. Neurology 1991;41:1902–4. 2. Karnik R, Stollberger C, Valentin A, et al. Detection of patent foramen ovale by transcranial contrast Doppler ultrasound. Am J Cardiol 1992;69:560–2. 3. Kimura K, Minematsu K, Wada K, et al. Transcranial Doppler of a paradoxical brain embolism associated with a
6.
7.
791
pulmonary arteriovenous fistula. AJNR Am J Neuroradiol 1999;20:1881–4. Kimura K, Minematsu K, Nakajima M. Isolated pulmonary arteriovenous fistula without Rendu-Osler-Weber disease as a cause of cryptogenic stroke. J Neurol Neurosurg Psychiatry 2004;75: 311–3. Kimura K, Hashimoto Y, Ishihara A, et al. A case of paradoxical cerebral embolism through a patent foramen ovale diagnosed by necropsy. Rinsho Shinkeigaku 1994;34:56–60. Droste DW, Kriete JU, Stypmann J, et al. Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: comparison of different procedures and different contrast agents. Stroke 1999;30:1827–32. Venketasubaramanian N, Sacco RL, Di Tullio M, et al. Vascular distribution of paradoxical emboli by transcranial Doppler. Neurology 1993;43:1533–5.
doi:10.1016/j.jocn.2006.05.011
Staged bilateral thalamic electrode implantation utilizing frameless stereotactic guidance Shearwood McClelland III a, Patrick B. Senatus b, Blair Ford c, Guy M. McKhann II b, Robert R. Goodman b,* a Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA Department of Neurological Surgery, Neurological Institute of New York, Columbia College of Physicians and Surgeons, 710 West 168th Street, Box 99, New York, New York, USA Department of Neurology, Neurological Institute of New York, Columbia College of Physicians and Surgeons, New York, New York, USA b
c
Received 24 February 2006; accepted 28 March 2006
Abstract Deep brain stimulation (DBS) for medically intractable Parkinson’s disease (PD) is well established, but carries the inconveniences of frame-based neurosurgery. Previous reports have demonstrated that ventricular shunt placement and some functional procedures can be accurately performed using frameless stereotaxy. We present a report indicating that staged deep brain electrode placement can be accurate and efficacious using a frameless skull-mounted guide. 2006 Elsevier Ltd. All rights reserved. Keywords: Deep brain stimulation; Frameless stereotactic guidance; Staged implantation; Parkinson disease
1. Case illustration Deep brain stimulation (DBS) for medically intractable Parkinson’s disease (PD) is well established, but carries the inconveniences of frame-based neurosurgery.1–3 Previous reports have demonstrated that ventricular shunt placement and some functional procedures can be accurately performed using frameless stereotaxy.4,5 We present a report indicating that staged deep brain electrode placement
*
Corresponding author. Tel.: +1 212 305 3774; fax: +1 212 305 3629. E-mail address: [email protected] (R.R. Goodman).
can be accurate and efficacious using a frameless skullmounted guide. A 69-year-old man with a progressive 13-year history of atypical Parkinson syndrome characterized by severe highamplitude full-body tremors during ‘off’ periods that were increasingly refractory to medication was recommended for bilateral thalamic stimulation therapy. Three days before electrode implantation skull fiducials were placed under local anesthesia in an ambulatory setting. Thin-slice T1-weighted spoiled gradient recalled acquisition in steady state (SPGR) volumetric axial images were obtained and transferred to a Stealth FrameLink 4 program (Medtronic Inc., Minneapolis, MN, USA) for surgical planning.
Case reports / Journal of Clinical Neuroscience 14 (2007) 788–791
Serial contrast saline transcranial Doppler examination in a patient with paradoxical brain embolism associated with pulmonary embolism Kensaku Shibazaki *, Yasuyuki Iguchi, Takeshi Inoue, Yuji Ueno, Kazumi Kimura Department of Stroke Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki City, Okayama 701 0192, Japan Received 26 November 2005; accepted 23 May 2006
Abstract We report a patient with paradoxical brain embolism due to patent foramen ovale (PFO) associated with pulmonary embolism (PE). The number of microembolic signals, as detected by contrast saline transcranial Doppler (c-TCD) exam, drastically decreased with improvement of increased right atrial pressure due to PE. In a patient with paradoxical brain embolism associated with PE, c-TCD may be useful for both diagnosis of the presence of right-to-left shunting and evaluation of cardio-pulmonary circulation. 2006 Elsevier Ltd. All rights reserved. Keywords: Patent foramen ovale; Contrast saline TCD; Pulmonary embolism; Right atrial pressure
1. Introduction Contrast saline transcranial Doppler (c-TCD) is effective in diagnosing patent foramen ovale (PFO) and pulmonary arteriovenous fistula.1–3 Large PFO and elevation of right atrial pressure is likely to increase the amount of microembolic signals (MES) during c-TCD examination, but it is still uncertain whether the number of MES correlates with the status of cardiopulmonary circulation in a patient with paradoxical brain embolism and massive pulmonary embolism. We report that the number of MES, as detected by cTCD, drastically decreased with improvement in increased right atrial (RA) pressure induced by pulmonary embolism.
2. Case report A 79-year-old right-handed woman was admitted to hospital due to sudden onset of consciousness disturbance. Her past medical history was hypertension and hyperlipidemia with medication. At the time of admission, her blood pressure was 124/72 mmHg with a regular heart beat of 104/min and a respiratory rate of 24/min. Systolic heart murmur to the apex was heard, and pathological breath sounds were absent. Pitting edema was present in her lower extremities. No bruits were heard on her neck or orbit. Neurological examination demonstrated consciousness disturbance with a score of 6 on the Glasgow Coma Scale. Her eyes were deviated to the right, and left central facial palsy and left hemiplegia were evident. The left planter response was extensor. Sensation, in particular pain, was *
Corresponding author. Tel.: +81 86 462 1111; fax: +81 86 464 1027. E-mail address: [email protected] (K. Shibazaki).
deficient on her left face, arm and leg. Laboratory examinations on admission revealed a D-dimer level of 12.0 lg/ mL (normal, 61.0) and a thrombin-antithrombin III complex level of 46.2 ng/mL (normal, 63.0). An arterial blood gas analysis showed hypoxemia with a PaO2 of 58.0 mmHg on 7L oxygen by mask. On hospital day 1, the patient was examined using a commercially available echo-planer instrument operating on a 1.5-T MRI unit (Signa EchoSpeed Horizon; GE Medical Systems, Milwaukee, WI). Diffusion-weighted images showed a hyperintense lesion in the right middle cerebral artery (MCA) territory, which was identified as the lesion responsible for her neurological deterioration (Fig. 1). Magnetic resonance angiography and ultrasonography revealed no atherosclerotic changes on cerebral vessels. A right-to-left shunt (RLS) was detected by TCD examination performed from the orbital window in order to monitor the right internal carotid artery (Fig. 2A). Contrast saline TCD was performed as previously described.4 Although electrocardiography indicated a normal sinus rhythm, an inverted T-wave was displayed in II, III, aVF and V1-3. Enlargement of the right atrium was detected by transthoracic echocardiography, with severe right ventricular loading and tricuspid regurgitation pressure gradient of 80 mmHg. PFO was demonstrated using transesophageal echocardiography (TEE) with saline contrast. Lung perfusion scintigraphy implied multiple defects of the right upper lobe and left lower lobe (Fig. 3A). Pulmonary arterial angiography demonstrated occlusion of the right upper and left lower arteries (Fig. 4A), and pulmonary arterial pressure was elevated to a very high 61 mmHg. Venous thrombosis was present in the deep veins of the left leg as demonstrated by venous ultrasonography. Since paradoxical brain embolism due to PFO with PE and deep
Case reports / Journal of Clinical Neuroscience 14 (2007) 788–791
789
venous thrombosis was diagnosed, heparin sodium was administered intravenously. Serial c-TCD without the Valsalva maneuver was performed on days 2, 3, 5 and 7 after admission (Figs. 2B– D). MES on the RLS decreased dramatically with each passing day. The MES on days 1 and 2 resembled a shower, and 10 MES were counted just after injection of saline contrast on days 3 and 5. Finally, no MES were detected on day 7. Blood oxygen increased to normal and right ventricular loading in transthoracic echocardiography also immediately improved. The tricuspid regurgitation pressure gradient decreased to 46.5 mmHg on day 3 and 33.9 mmHg on day 7. Lung perfusion scintigraphy showed no defects in the right upper lobe or left lower lobe (Fig. 3B). Pulmonary arterial angiography demonstrated recanalization of the occluded arteries (Fig. 4B). Pulmonary artery pressure had decreased to 31 mmHg on day 45. She was then transferred to a rehabilitation facility. 3. Discussion Fig. 1. Diffusion-weighted MRI showing a hyperintense lesion in the right middle cerebral artery territory on admission.
We report a paradoxical brain embolism associated with PE. Contrast saline transcranial Doppler was useful not
Fig. 2. (A) Contrast saline transcranial Doppler (c-TCD) examinations demonstrating numerous microembolic signals (MES) on admission. Sequence of c-TCD examinations on (B) day 3, (C) day 5, and (D) day 7 (showing obvious decrease in number of MES).
790
Case reports / Journal of Clinical Neuroscience 14 (2007) 788–791
Fig. 3. (A) Lung perfusion scintigraphy showing multiple defects of the right upper lobe and left lower lobe. (B) Follow-up perfusion scintigraphy revealed no defect in the right upper lobe and left lower lobe.
only for diagnosis of the RLS, but also evaluation of cardiopulmonary circulation. When c-TCD demonstrates numerous MES without the Valsalva maneuver, then a large PFO, pulmonary ateriovenous fistula on a PFO with increased pressure in the right atrium due to pulmonary hypertension, should be considered.5 In the present case, massive PE was detected by lung perfusion scintigraphy. In fact, pulmonary arterial pressure increased to a very high 61 mmHg. Under such circumstances, an RLS via a PFO could easily develop due to the increased RA pressure, and numerous MES on cTCD during normal breathing would then be detected. Studies have shown that c-TCD detects TEE-proven RLS with a sensitivity of 90–100%, and specificity of 75– 100%.6,7 RLS detection by c-TCD has usually been conducted in previous studies by performing the Valsalva maneuver. However, c-TCD is not always performed on patients with acute ischemic stroke due to consciousness disturbance or aphasia. In contrast, our results suggest that c-TCD is sometimes a useful tool with which to detect RLS, despite severe stroke patients being unable to perform the Valsalva maneuver.
Fig. 4. (A) Pulmonary arterial angiography showing occlusion of the left lower pulmonary artery on admission. (B) Follow-up angiography revealing recanalization of the pulmonary artery (day 45).
In the present case, the number of MES detected by cTCD dramatically decreased with normalization of RA pressure. Therefore, serial c-TCD examinations in the acute phase of stroke should yield important information regarding cardio-pulmonary circulation.
Case reports / Journal of Clinical Neuroscience 14 (2007) 791–793
In conclusion, in a patient with paradoxical brain embolism associated with PE, c-TCD may be useful for not only the diagnosis of the presence of RLS, but also for evaluation of cardio-pulmonary circulation.
4.
References
5.
1. Chimowitz MI, Nemec JJ, Marwick TH, et al. Transcranial Doppler ultrasound identifies patients with right-to-left cardiac or pulmonary shunts. Neurology 1991;41:1902–4. 2. Karnik R, Stollberger C, Valentin A, et al. Detection of patent foramen ovale by transcranial contrast Doppler ultrasound. Am J Cardiol 1992;69:560–2. 3. Kimura K, Minematsu K, Wada K, et al. Transcranial Doppler of a paradoxical brain embolism associated with a
6.
7.
791
pulmonary arteriovenous fistula. AJNR Am J Neuroradiol 1999;20:1881–4. Kimura K, Minematsu K, Nakajima M. Isolated pulmonary arteriovenous fistula without Rendu-Osler-Weber disease as a cause of cryptogenic stroke. J Neurol Neurosurg Psychiatry 2004;75: 311–3. Kimura K, Hashimoto Y, Ishihara A, et al. A case of paradoxical cerebral embolism through a patent foramen ovale diagnosed by necropsy. Rinsho Shinkeigaku 1994;34:56–60. Droste DW, Kriete JU, Stypmann J, et al. Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: comparison of different procedures and different contrast agents. Stroke 1999;30:1827–32. Venketasubaramanian N, Sacco RL, Di Tullio M, et al. Vascular distribution of paradoxical emboli by transcranial Doppler. Neurology 1993;43:1533–5.
doi:10.1016/j.jocn.2006.05.011
Staged bilateral thalamic electrode implantation utilizing frameless stereotactic guidance Shearwood McClelland III a, Patrick B. Senatus b, Blair Ford c, Guy M. McKhann II b, Robert R. Goodman b,* a Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA Department of Neurological Surgery, Neurological Institute of New York, Columbia College of Physicians and Surgeons, 710 West 168th Street, Box 99, New York, New York, USA Department of Neurology, Neurological Institute of New York, Columbia College of Physicians and Surgeons, New York, New York, USA b
c
Received 24 February 2006; accepted 28 March 2006
Abstract Deep brain stimulation (DBS) for medically intractable Parkinson’s disease (PD) is well established, but carries the inconveniences of frame-based neurosurgery. Previous reports have demonstrated that ventricular shunt placement and some functional procedures can be accurately performed using frameless stereotaxy. We present a report indicating that staged deep brain electrode placement can be accurate and efficacious using a frameless skull-mounted guide. 2006 Elsevier Ltd. All rights reserved. Keywords: Deep brain stimulation; Frameless stereotactic guidance; Staged implantation; Parkinson disease
1. Case illustration Deep brain stimulation (DBS) for medically intractable Parkinson’s disease (PD) is well established, but carries the inconveniences of frame-based neurosurgery.1–3 Previous reports have demonstrated that ventricular shunt placement and some functional procedures can be accurately performed using frameless stereotaxy.4,5 We present a report indicating that staged deep brain electrode placement
*
Corresponding author. Tel.: +1 212 305 3774; fax: +1 212 305 3629. E-mail address: [email protected] (R.R. Goodman).
can be accurate and efficacious using a frameless skullmounted guide. A 69-year-old man with a progressive 13-year history of atypical Parkinson syndrome characterized by severe highamplitude full-body tremors during ‘off’ periods that were increasingly refractory to medication was recommended for bilateral thalamic stimulation therapy. Three days before electrode implantation skull fiducials were placed under local anesthesia in an ambulatory setting. Thin-slice T1-weighted spoiled gradient recalled acquisition in steady state (SPGR) volumetric axial images were obtained and transferred to a Stealth FrameLink 4 program (Medtronic Inc., Minneapolis, MN, USA) for surgical planning.