A 74-year-old man had been taking warfarin for atrial fibrillation, but warfarin was discontinued due to upper gastrointestinal bleeding. One week later, left hemiplegia occurred, and cranial magnetic resonance imaging revealed multiple cerebral infarctions. Systemic examination revealed thrombi in both atria as well as duodenal cancer. Because all of the thrombi in both atria were larger than 30 mm in diameter, the risk of embolism or sudden death was assumed to be high. Although the use of cardiopulmonary bypass for cancer patients is controversial, bilateral atrial thrombectomy was performed 4 weeks after cerebral infarction onset because reasonable survival duration was expected with surgery for duodenal cancer after thrombectomy and further treatment. The timing of and indications for surgery in this case are discussed.

BACKGROUND AND PURPOSE: Not only clinical factors, including the CHADS2 score, but also echocardiographic findings have been reported to be useful for predicting the risk of ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it remains to be determined which of these factors might be more relevant for evaluation of the risk of stroke in each patient. METHODS: In 490 patients with NVAF who underwent transesophageal echocardiography (TEE), we examined the long-term incidence of ischemic stroke events (mean follow-up time, 5.7+/-3.3 years). For each patient, the predictive values of gender, the CHADS2 risk factors (congestive heart failure, hypertension, age > or =75 years, diabetes mellitus, history of cerebral ischemia), the CHADS2 score, and the findings on echocardiography, including TEE risk markers, were assessed. RESULTS: The ischemic stroke rate was significantly correlated with the CHADS2 score (p<0.05). According to the results of univariate analyses, age > or =75 years, history of cerebral ischemia, CHADS2 score > or =2, and presence of TEE risk were significantly correlated with the incidence of ischemic stroke. Cox proportional hazards regression analyses identified age > or =75 years and presence of TEE risk as significant predictors of subsequent ischemic stroke events in patients with NVAF. As compared with that in persons below 75 years of age without TEE risk, the ischemic stroke rate was significantly higher in persons who were > or =75 years of age with TEE risk (4.3 vs. 0.56%/year, adjusted hazard ratio=8.94, p<0.001). CONCLUSIONS: TEE findings might be more relevant predictors of ischemic stroke than the CHADS2 score in patients with NVAF. The stroke risk was more than 8-fold higher in patients aged > or =75 years with TEE risk.
Aged ; Atrial Fibrillation ; Brain Ischemia ; Diabetes Mellitus ; Echocardiography ; Echocardiography, Transesophageal ; Follow-Up Studies ; Heart Failure ; Humans ; Hypertension ; Incidence ; Risk Factors ; Stroke

Background: and Purpose Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. Methods: We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). Results: There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths. Conclusions During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT.