DOCSLIB.ORG

The Cholesterol Emboli Syndrome in Atherosclerosis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Cholesterol Emboli Syndrome in Atherosclerosis Curr Atheroscler Rep (2013) 15:315 DOI 10.1007/s11883-013-0315-y CORONARY HEART DISEASE (JA FARMER, SECTION EDITOR) The Cholesterol Emboli Syndrome in Atherosclerosis Adriana Quinones & Muhamed Saric # Springer Science+Business Media New York 2013 Abstract Cholesterol emboli syndrome is a relatively rare, artery (typically the aorta) embolize to small or medium caliber but potentially devastating, manifestation of atherosclerotic arteries, which then results in end-organ damage secondary to disease. Cholesterol emboli syndrome is characterized by either mechanical obstruction and/or inflammatory response waves of arterio-arterial embolization of cholesterol crystals [1•]. This syndrome has also been referred as atheroembolism, and atheroma debris from atherosclerotic plaques in the atheromatous embolization syndrome, cholesterol crystal em- aorta or its large branches to small or medium caliber bolization and cholesterol embolization syndrome [2]. arteries (100–200 μm in diameter) that frequently occur It is important to emphasize that CES is a separate entity after invasive arterial procedures. End-organ damage is from a more common phenomenon of another arterio- due to mechanical occlusion and inflammatory response in arterial embolization syndrome, namely arterio-arterial the destination arteries. Clinical manifestations may include thromboembolism, in which a thrombus overlying an ather- renal failure, blue toe syndrome, global neurologic deficits omatous plaque breaks loose and travels distally to occlude and a variety of gastrointestinal, ocular and constitutional large-caliber downstream arteries [3]. In arterio-arterial signs and symptoms. There is no specific therapy for cho- thromboembolism, there is typically a sudden release of lesterol emboli syndrome. Supportive measures include thrombi, resulting in acute ischemia of a target organ. In modifications of risk factors, use of statins and antiplatelet contrast, CES is characterized by multiple, small cholesterol agents, avoidance of anticoagulation and thrombolytic crystal emboli that are released over a period of time [4•]. agents, and utilization of surgical and endovascular techni- CES is but a manifestation of generalized atherosclerosis [5••]. ques to exclude sources of cholesterol emboli. Awide variety of clinical presentations of CES have been reported. Clinical manifestations are primarily dependent on the location of Keywords Atherosclerosis . Atheroma . Cholesterol the atheromatous plaque that serves as the source of cholesterol emboli . Plaque emboli, as well as the location of the affected distal arterial bed. Cholesterol crystal emboli that arise from the descending thoracic aorta may lead to renal failure, mesenteric ischemia and emboli to Introduction the skeletal muscles and skin. Emboli arising from the ascending aorta may also result in neurological compromise, frequently due The cholesterol emboli syndrome (CES) is a rare arterio- to multiple infarcts. In addition to specific signs of end-organ arterial embolization syndrome which occurs when cholesterol damage, CES is often characterized by systemic signs and symp- crystals located in an atherosclerotic plaque in a large caliber toms due to nonspecific acute inflammatory response. Systemic manifestations may include fever, malaise, hypereosinophilia and elevationininflammatoryserummarkerssuchaselevatederyth- This article is part of the Topical Collection on Coronary Heart rocyte sedimentation rate and C-reactive protein [6]. Disease A. Quinones : M. Saric (*) Leon H. Charney Division of Cardiology, New York University History Langone Medical Center, 560 First Avenue, New York, NY 10016, USA e-mail: [email protected] Probably the first case of apparent CES was reported in A. Quinones 1844 by a group of Danish physicians after performing the e-mail: [email protected] autopsy of Bertel Thorvaldsen, a famous Danish/Icelandic 315, Page 2 of 7 Curr Atheroscler Rep (2013) 15:315 sculptor [7]. In 1862, this report was translated into German individuals, the plaque histology becomes more complex and by Peter Ludvig Panum, another Danish physician, and undergoes progressive changes from atheromas to fibroather- disseminated into the broader medical literature [8]. omas to complex plaques with hemorrhage, surface ulcerations The first autopsy series of CES was published in 1945 and formation of overlying thrombi [14]. These advanced from New York Hospital, and contains classic descriptions atherosclerotic plaques are the usual source of cholesterol of the systemic and multiorgan nature of this syndrome [9]. crystal emboli in CES. During the progression of atheroscle- To this day, the definitive diagnosis of CES still relies on rosis calcifications may occur within plaques. biopsy of affected organs; biopsy techniques for visualizing Atheromas are composed of a necrotic core; when over- of cholesterol crystals lodged in destination arteries using laid by a fibrous cap they are referred to as fibroatheromas. polarized light were first reported in the 1950s [10]. Necrotic core consists of foam cells, cell debris and lipids. In 1961, Robert Hollenhorst, an ophthalmologist from the Low-density lipoprotein is the ultimate source of cholesterol Mayo Clinic, described pathognomonic retinal plaques con- emboli. Cholesterol exists in crystalline and soluble forms. sisting of refractive yellow cholesterol emboli at branching Crystalline cholesterol represents>40 % of cholesterol with- points of retinal arteries. This discovery allowed for the first in a plaque [15]. The cap is composed of endothelial and time to diagnose CES noninvasively [11]. In 1976, the term smooth muscle cells, as well as connective tissue. blue-toe syndrome was first coined; the term that is now partly Cap disruption precedes embolization of plaque contents. synonymous with CES [12]. In 1990, for the first time, an Rupture of this fibrous cap may be a result of forces from association between clinical syndromes of atheroembolism within the plaque (such as inflammation and hemorrhage), or and aortic plaques seen on transesophageal echocardiography from the luminal side (such as shearing forces or mechanical was reported from New York University [13]. disruption). The risk of embolism is directly correlated with the overall degree of atherosclerosis. Typically, the amount of plaque increases from the proximal to distal segments of the Pathophysiology aorta. Thus, the abdominal aorta and iliofemoral vessels are most frequent sources of emboli in CES [16]. The pathophysiology of CES involves six key elements: the Ante mortem visualization, characterization and quanti- presence of an atherosclerotic plaque in the proximal large- fication of plaque in the aorta can be achieved by trans- caliber artery, plaque rupture, embolization of plaque con- esophageal echocardiography (TEE), computerized tent, lodging of cholesterol crystal emboli in distal small- tomography (CT) or magnetic resonance imaging (MRI) caliber arteries, foreign body inflammatory response to cho- [17••, 18]. Simple plaques measure<4 mm in thickness. lesterol emboli and end-organ damage. Complex plaques measure≥4 mm and often have irregular, ulcerated borders, and may have mobile components that represent thrombi (Fig. 1). Atherosclerotic Plaque in a Proximal Artery Plaque thickness≥4mmintheascendingaortaoraortic arch as visualized by TEE has been strongly correlated with Development of atherosclerotic plaques is a life-long process cerebral embolization events [13, 19, 20]. Complex atheroma (Table 1). Plaques reside within the arterial intima. In early visualized by TEE have been documented in patients with stages, which typically developed in childhood and early biopsy-proven cholesterol emboli to the kidneys and skin adulthood, plaque lesions consist of intracellular and extracel- [21, 22]. CT and MRI have become increasingly popular lular lipid deposits and are clinically silent. In more advanced noninvasive imaging techniques to characterize atherosclerotic stages, which typically develop in middle-aged and elderly plaque [23, 24]. Limitations of TEE (such as inability to Table 1 Classification of atherosclerotic plaques Onset Stage Lesion Name Description Clinical Manifestations Early Lesions I Initial Lesion Small amounts of intracellular lipid deposits Typically silent (Childhood and Early II Fatty Streak Larger amounts of intracellular lipid deposits Adulthood) III Intermediate Lesion Small extracellular lipid deposits Late Lesions IV Atheroma Extracellular lipid core Silent or clinically (Middle Age and V Fibroatheroma Lipid core with fibrotic changes overt Elderly VI Complex Plaque Surface defects such as ulcerations, hemorrhage and thrombus. Curr Atheroscler Rep (2013) 15:315 Page 3 of 7, 315 isolated from>50 % of guiding catheters in one series, CES is a relatively rare complication of cardiac catheteriza- tion [29]. The incidence of clinically apparent atheroembo- lism has been reported to occur in less than 2 % of all cardiac catheterizations [30, 31]. There is no significant difference between the risk of this complication when fem- oral access is compared to radial access, which suggests that the ascending aorta is the main source of embolus [32]. TheriskofCESfollowingcardiacsurgeryisstronglycor- related with the degree of atherosclerosis in the ascending aorta. The brain is the most commonly reported site of emboli, although multiple peripheral organs may also be involved. CES has been more frequently reported in patients undergoing coronary revascularization
Load more

Recommended publications
  • Review Cutaneous Patterns Are Often the Only Clue to a a R T I C L E Complex Underlying Vascular Pathology
    pp11 - 46 ABstract Review Cutaneous patterns are often the only clue to a A R T I C L E complex underlying vascular pathology. Reticulate pattern is probably one of the most important DERMATOLOGICAL dermatological signs of venous or arterial pathology involving the cutaneous microvasculature and its MANIFESTATIONS OF VENOUS presence may be the only sign of an important underlying pathology. Vascular malformations such DISEASE. PART II: Reticulate as cutis marmorata congenita telangiectasia, benign forms of livedo reticularis, and sinister conditions eruptions such as Sneddon’s syndrome can all present with a reticulate eruption. The literature dealing with this KUROSH PARSI MBBS, MSc (Med), FACP, FACD subject is confusing and full of inaccuracies. Terms Departments of Dermatology, St. Vincent’s Hospital & such as livedo reticularis, livedo racemosa, cutis Sydney Children’s Hospital, Sydney, Australia marmorata and retiform purpura have all been used to describe the same or entirely different conditions. To our knowledge, there are no published systematic reviews of reticulate eruptions in the medical Introduction literature. he reticulate pattern is probably one of the most This article is the second in a series of papers important dermatological signs that signifies the describing the dermatological manifestations of involvement of the underlying vascular networks venous disease. Given the wide scope of phlebology T and its overlap with many other specialties, this review and the cutaneous vasculature. It is seen in benign forms was divided into multiple instalments. We dedicated of livedo reticularis and in more sinister conditions such this instalment to demystifying the reticulate as Sneddon’s syndrome. There is considerable confusion pattern.
    [Show full text]
  • Presented: February 2, 2017 Thru February 4, 2017
    2017 ACP Colorado Chapter Meeting February 2, 2017 thru February 4,2017 Broadmoor Hotel, Colorado Springs, Colorado Resident Abstracts Presented: February 2, 2017 thru February 4, 2017 2017 ACP Colorado Chapter Meeting – February 2, 2017 thru February 4, 2017 – Broadmoor Hotel – Colorado Springs, Colorado Name: Angela Burgin, MD Presentation Type: Oral Presentation Residency Program: University of Colorado School of Medicine Additional Authors: Winthrop Lockwood MS3, Katarzyna Mastalerz, MD Abstract Title: Use Clean Needles, Boil you Cotton: Advice for the Modern Drug User Abstract Information: Introduction: Fever in an intravenous drug abuser results in a wide differential diagnosis for the physician to consider, ranging from simple soft tissue infections to endocarditis or epidural abscess. This large breadth of possibilities often leads to dilemmas on which studies to order first, usually resulting in an expensive evaluation. We present one more option to add to the differential diagnosis in an IV drug user who presents with fever, with the hopes of increasing awareness of this condition to the medical community. Case Description: A 31 year old female with a history significant for IV drug abuse presented with dyspnea, chest pain, severe abdominal pain, right arm swelling, and generalized weakness for several days. She worked for a home health company and admitted to recently injecting hydromorphone and other opiates into her veins. Physical exam on admission was notable for a high fever, tachycardia, and right forearm edema, erythema, and induration, with a benign chest and abdominal exam. Ancillary studies revealed a urine toxicology positive for opiates, methadone, and cocaine, as well as a white blood cell count of 13.
    [Show full text]
  • Unprotected Carotid Artery Stenting in Symptomatic Patients with High-Grade Stenosis: Results and Long-Term Follow-Up in a Single- ORIGINAL RESEARCH Center Experience
    Published March 15, 2012 as 10.3174/ajnr.A2951 Unprotected Carotid Artery Stenting in Symptomatic Patients with High-Grade Stenosis: Results and Long-Term Follow-Up in a Single- ORIGINAL RESEARCH Center Experience R. Oteros BACKGROUND AND PURPOSE: The use of cerebral protection during CAS is an extended practice. E. Jimenez-Gomez Paradoxically it is open to question because it can lead to potential embolic complications. The aim of this study was to evaluate the safety and efficacy of CASWPD in patients with severe symptomatic F. Bravo-Rodriguez carotid artery stenosis. J.J. Ochoa R. Guerrero MATERIALS AND METHODS: A prospective study was performed including 210 consecutive patients (201 symptomatic and 9 asymptomatic) with carotid artery stenosis Ͼ70%. All patients were treated F. Delgado by CASWPD. Angiographic results and neurologic complications were recorded during the procedure and within 30 days after it. All patients underwent clinical evaluation and Doppler sonography follow-up at 3, 6, and 12 months after the procedure. RESULTS: Two hundred twenty carotid arteries were treated. The average degree of stenosis was 88.9%. The procedure was successfully completed in 212 (96.4%) arteries. After stent placement, 98.6% of arteries showed no residual stenosis or Ͻ30%. Balloon angioplasty dilation before stent placement was performed in 16% of cases. During the 30-day periprocedural period, there were 3 major complications (1.4%), including 1 disabling ischemic stroke, 1 acute stent thrombosis, and 1 MI. The last 2 patients died from these complications. At 1-year follow-up 24 (12.8%) restenoses, 2 new ipsilateral strokes, 1 contralateral stroke, and 5 deaths (2.7%) had occurred.
    [Show full text]
  • Atraumatic Ischaemic Myelopathy
    Paraplegia 19 (1981) 352-362 0031-1 758/8 1/006003 5 2 $02.00 © 1981 International Medical Society of Paraplegia ATRAUMATIC ISCHAEMIC MYELOPATHY By L. S. KEWALRAMANI, M.D., M.S. Orth. and R. S. R. KATTA, M.D. Louisiana Rehabilitation Institute, LSU School of Medicine New Orleans, Louisiana and Baylor College of Medicine, Houston, Texas Abstract. Significant and permanent neurological deficit due to ischaemic myelopathy continues to occur in 5-10 per cent of patients following surgery on the thoracic aorta for aneurysms, coarctation and lacerations, and following corrective surgery for scoliosis. Clinical features, patterns of neurological deficit, management and outcome in 29 patients with atraumatic ischaemic myelopathy following surgery on the aorta, aortocoronary bypass and cardiogenic shock, will be presented. Pertinent literature on the subject will also be reviewed. Key words: Secondary (non-traumatic neurological) ischaemic myelopathy; Aortic injury; Aortic aneurysms; Aortocoronary bypass surgery. Introduction INFARCTION of the spinal cord has been considered to be rare when compared with cerebral infarction (Garland et at., 1966) which may be due to the fact that the frequency of arteriosclerotic changes in major spinal arteries occur in 2·2-10 per cent of cases compared with cerebrovascular arteriosclerotic changes in 39 per cent of the population (Jellinger, 1967). Although Bastian in 1910 was firstto suggest that spinal cord softening might be a consequence of vascular occlusion but for several years the number of well documented cases of ischaemic myelopathy remained small and often anecdotal with syphilitic vasculitis. There continued to be limited interest in the spinovascular syndromes until neurological deficitfollowing surgery on the thoracic aorta brought into sharp focus the role of vascular occlusions and ischaemic injury to the spinal cord.
    [Show full text]
  • University of Illinois, December 2003
    Case #1 Case Presented by Virginia C. Fiedler, MD, Michelle Bain, MD and Alexander L. Berlin, MD History of Present Illness: This 9-year-old African American girl presented with hair shedding and patchy hair loss since infancy. Additionally, her hair has been brittle. Her scalp is comfortable, without pruritus. The patient’s mother has also noticed deviations of multiple finger joints since the age of 3 along with more recent similar changes in toe joints. These changes are not associated with pain or joint swelling. The patient denies decreased body sweating, but she does note increased sweating in the areas of scalp hair loss. Past Medical History: Febrile seizures as a child Multiple finger and toe joint deviations starting at 3 years of age History of ankle deformities treated with braces for 2 years Medications: None Allergies: No known drug allergies Family History: No history of autoimmune or other skin disorders; no joint abnormalities Social History: Patient is a 4th grade student and is doing well in school Review of Systems: Denies visual problems or arthralgias Diet is adequate for protein Physical Examination: The patient had patchy alopecia that was most pronounced in the ophiasis distribution and also involved the vertex. The affected areas had miniaturized hair follicles. Hair pull test was positive for 5-6 hairs in catagen and telogen phases. Ears were not low-set. There was an increased distance between the nose and the upper lip, and the philtrum was difficult to appreciate. The patient had retained deciduous teeth, as well as hypodontia and partial anodontia.
    [Show full text]
  • Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism
    ASE GUIDELINES AND STANDARDS Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism Muhamed Saric, MD, PhD, FASE, Chair, Alicia C. Armour, MA, BS, RDCS, FASE, M. Samir Arnaout, MD, Farooq A. Chaudhry, MD, FASE, Richard A. Grimm, DO, FASE, Itzhak Kronzon, MD, FASE, Bruce F. Landeck, II, MD, FASE, Kameswari Maganti, MD, FASE, Hector I. Michelena, MD, FASE, and Kirsten Tolstrup, MD, FASE, New York, New York; Durham, North Carolina; Beirut, Lebanon; Cleveland, Ohio; Aurora, Colorado; Chicago, Illinois; Rochester, Minnesota; and Albuquerque, New Mexico Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echo- cardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sour- ces in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommen- dation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures.
    [Show full text]
  • A Case of Cholesterol Embolism with ANCA Treated with Corticosteroid
    726 Matters arising, Letters associated diseases in southern Chinese among whom anti-MPO predominate. S S LEE JWMLAWTON KHKO Department of Pathology, The University of Hong Kong, Queen Mary Hospital Compound, Pokfulam Road, Hong Kong Special Administrative Region, China Correspondence to: Dr S S Lee, 5/F Yaumatei Jockey Club Clinic, 145 Battery Street, Yaumatei, Kowloon, Hong Kong SAR [email protected] 1 Esnault VL, Testa A, Audrain M, Roge C, Hamidou M, Barrier JH, et al. Alpha 1-antitrypsin genetic polymorphism in ANCA- positive systemic vasculitis. Kidney Int 1993;43:1329–32. 2GriYth ME, Lovegrove JU, Gaskin G, White- house DB, Pusey CD. C-antineutrophil cyto- plasmic antibody positivity in vasculitis pa- tients is associated with the Z allele of alpha-1- antitrypsin, and P-antineutrophil cytoplasmic antibody positivity with the S allele. Nephrol Dial Transplant 1996;11:438–43. Figure 1 Skin biopsy specimen showing cholesterol embolism in arterioles within subcutaneous 3 Savige JA, Chang L, Cook L, Burdon J, Daska- tissues (haematoxylin and eosin, × 400). lakis M, Doery J. Alpha 1-antitrypsin defi- ciency and anti-proteinase 3 antibodies in anti- neutrophil cytoplasmic antibody (ANCA)- h. Anaemia was noted with a red blood cell acute deterioration of renal function.5 Cyclo- associated systemic vasculitis. Clin Exp 9 Immunol 1995;100:194–7. count of 2500×10 /l, while the patient’s WBC phosphamide and PSL improved the symp- 4 Elsouki AN, Eriksson S, Lofberg , Nasberger L, count was high at 12×109/l. His platelet count toms, but cyclophosphamide was discontin- Wieslander J, Lindgren S.
    [Show full text]
  • Administration of Retinal S Antigen As an Oral Tolerizing Ofrapport, the Benefit Is Less Clear, Particularly in the Later Agent
    Postgraduate Medical Journal EDITOR B.I. HofTbrand, London ASSISTANT EDITOR P.J.A. Moult, London EDITORIAL BOARD J. Bamford, Leeds K.T. Khaw, Cambridge P.J. Barnes, London R.I. McCallum, Edinburgh A.H. Barnett, Birmingham P.H. Millard, London G.F. Batstone, Salisbury M.W.N. Nicholls, London C.J. Bulpitt, London N.T.J. O'Connor, Shrewsbury C. Coles, Southampton M. Sarner, London G.C. Cook, London M. Super, Manchester P.N. Durrington, Manchester I. Taylor, London J.C. Gingell, Bristol T. Treasure, London T.E.J. Healy, Manchester P. Turner, London C.R.K. Hind, Liverpool I.V.D. Weller, London D. Ingram, London P.D. Welsby, Edinburgh C.D. Johnson, Southampton W.F. Whimster, London P.G.E. Kennedy, Glasgow P.R. Wilkinson, Ashford, Middx National Association of Clinical Tutors Representatives I.J.T. Davies, Inverness R.D. Abernethy, Barnstaple International Editorial Representatives G.J. Schapel, Australia P. Tugwell, Canada J.W.F. Elte, The Netherlands E.S. Mayer, USA F.F. Fenech, Malta B.M. Hegde, India C.S. Cockram, Hong Kong Editorial Assistant Mrs J.M. Coops Volume 69, Number 818 December 1993 The Postgraduate Medical Journal is published Subscription price per volume oftwelve issues EEC monthly on behalf ofthe Fellowship of Postgraduate £E130.00; Rest ofthe World £140.00 or equivalent in Medicine by the Scientific & Medical Division, any other currency. Orders must be accompanied by Macmillan Press Ltd. remittance. Cheques should be made payable to Macmillan Press, and sent to: the Subscription Postgraduate Medical Journal publishes original Department, Macmillan Press Ltd, Brunel Road, papers on subjects ofcurrent clinical importance.
    [Show full text]
  • Cholesterol Emboli Syndrome: Significance of the Lesional Skin Biopsies
    Letters to the Editor 527 Cholesterol Emboli Syndrome: Significance of the Lesional Skin Biopsies Sonia Molinos1, Carlos Feal2, Argimiro Ga´ndara3, Josefa Morla1, Carlos De la Torre2 and Elena Roso´n2 Departments of 1Internal Medicine, 2Dermatology and 3Nephrology, Pontevedra Hospital, c/Mourente s/n ES-36000 Pontevedra, Spain. E-mail: [email protected] Accepted February 21, 2005. Sir, enoxaparin 40 mg/day for 10 days had been given 3 months Cholesterol emboli syndrome (CES) is an underdiag- prior to his admission. nosed multisystemic disease with important sequelae Examination revealed a temperature of 38.7˚C, a blood pressure of 150/90 mmHg and an aortic systolic murmur. He resulting in a poor prognosis with 80% mortality within had bilateral livedo reticularis on his lower limbs and lower 12 months after acquiring the disease. The syndrome trunk with necrosis of right fifth toe; peripheral pulses and usually affects elderly patients who have some known temperature were normal (Fig. 1). risk factors for vascular disease and is often precipitated Laboratory examination revealed a total white cell count of 9 by some trigger factor (1, 2). Diagnosis is based on 11.8610 /l with 83% neutrophils but no eosinophilia, plasma suspicious clinical findings and can be confirmed by urea 42.1 mmol/l, plasma creatinine 423 mmol/l, total protein 56 g/l (normal 60–80), albumin 26 g/l (normal 35–50), trigly- lesional tissue biopsy (1, 3). This article reports two cerides 2.4 g/l (normal 0.4–1.6) and ESR 113 mm/h. Urine cases of CES in relation to treatment with anti- analysis: urinary protein excretion 1.17 g/24 h (normal coagulants.
    [Show full text]
  • Recurrent Cholesterol Embolism As a Cause of Fluctuating Cerebral Symptoms
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.30.6.489 on 1 December 1967. Downloaded from J. Neurol. Neurosurg. Psychiat., 1967, 30, 489 Recurrent cholesterol embolism as a cause of fluctuating cerebral symptoms W. IAN McDONALD From the National Hospital, Queen Square, London Embolic occlusion of a large cerebral artery com- amplitude. The remainder of the cranial nerves were monly results in easily recognized cerebral infarction. normal. There was marked plastic rigidity of all four When arterioles are involved by small emboli limbs, more on the right and on this side there was ankle of neuro- clonus and an extensorplantar reflex. The leftplantar reflex there may be only transient disturbances was flexor. There was little spontaneous movement of the logical function, as, for example, when attacks of limbs,andtherewas moderate weakness in the legs. All the monocular blindness occur in association with recur- tendon reflexes, including the jaw jerk, were abnormally rent retinal artery embolism (Fisher, 1959; Russell, brisk and the abdominal reflexes were absent. Detailed 1961, 1963). A third, less common clinical ex- sensory testing was impossible but he responded to pin pression of cerebral embolism is that of a fluctuating prick in all areas. On general examination there were but increasing neurological deficit. The present moderately enlarged firm, discrete, rubbery lymph nodes guest. Protected by copyright. report concerns two cases of this last kind in which in the neck, axillae, groins, and epitrochlear regions. The multiple embolism of small arteries by cholesterol liver was palpable one inch below the costal margin, but thespleencould not be felt.
    [Show full text]
  • Prognosis of Patients with Retinal Embolism
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.9.1142 on 1 September 1987. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry 1987;50:1 142-1147 Prognosis of patients with retinal embolism R S HOWARD, R W ROSS RUSSELL From the Departments ofNeurology and Medical Ophthalmology, St Thomas' Hospital, London, UK SUMMARY Eighty-five patients with retinal emboli, visible ophthalmoscopically, were studied retro- spectively. All the patients had presented with transient or permanent visual loss. Follow up from the time of presentation was one year to 12 years with a mean of 4-5 years. Life expectancy in the 58 medically treated patients who presented with cholesterol emboli was significantly reduced (p = 0028). Stroke was the commonest cause of death and was significantly more frequent than in the general population (p < 0001); there was also an increased total incidence of cerebrovascular disease (fatal and non-fatal) compared with the Oxfordshire Stroke Project (p < 0001). The mortality from ischaemic heart disease was not significantly increased. We report a series of 85 patients with retinal emboli, 69 of whom had cholesterol emboli (70 fundi), 15 calcific emboli and one platelet-fibrin embolus. The natural history of medically treated patients with cholesterol emboli is compared both with an age and sex matched population and with patients with amaurosis fugax but no visible retinal emboli. guest. Protected by copyright. Emboli in retinal arteries may occur in the absence of plaques in retinal arterioles of patients with athero- any visual symptoms. Sometimes they may be seen sclerotic carotid disease, who may suffer transient during or after an attack of temporary visual loss; at visual loss.
    [Show full text]
  • Nephrology, Dialysisand Transplantation
    Postgrad Med J (1993) 69, 516-546 © The Fellowship of Postgraduate Medicine, 1993 Postgrad Med J: first published as 10.1136/pgmj.69.813.516 on 1 July 1993. Downloaded from Reviews in Medicine Nephrology, dialysis and transplantation K. Farrington1 and P. Sweny2 'Lister Hospital, Stevenage and 2Royal Free Hospital, London, UK Nephrology 1. Urine microscopy Pathogenesis of ARF Careful phase contrast microscopy of freshly Changes in renal haemodynamics are a feature of prepared urine sediment is one of the simplest, all types ofARF irrespective ofprecipitating insult. cheapest and most helpful investigations in neph- Recent studies have examined the role of rology and urology, but it is often omitted or endothelium-derived vasoactive factors in these delegated to the routine microbiology laboratories.1 changes. It should be the first investigation in all cases of haematuria or suspected glomerular disease. The Endothelin Endothelin is a 21-amino acid pep- rapid identification of red cell casts or dysmorphic tide. It is the most potent vasoconstrictor yet red cells can point the clinicians in the direction of discovered, being ten times more potent than renal biopsy and away from cystoscopy and angiotensin II. It has many other properties includ- arteriography.2 Doctors investigating renal pa- ing effects on ion transport, eicosanoid synthesis, tients should have access to a centrifuge and a good and renin and atrial natriuretic peptide (ANP) quality phase contrast microscope. With phase release. The renal vasculature appears particularly copyright. contrast, damaged or distorted red cells can easily susceptible to its vasoconstrictive effect. Renal be recognized (dysmorphic red cells).3 The ex- vascular resistance is increased by an effect on both tremes of osmolarity experienced with passage afferent and efferent arterioles.
    [Show full text]