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Haboub M, Abouradi S, Mechal H, Minko G, Moukhliss A, Arous S, Benouna MEG, Drighil A, Azzouzi L, Habbal R. Spontaneous calcific cerebral embolization revealing a calcified rheumatic mitral stenosis: a case report. J Med Case Rep 2023; 17:254. [PMID: 37330507 DOI: 10.1186/s13256-023-03982-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/10/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Cerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis. CASE PRESENTATION We report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2-3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke. CONCLUSION Spontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.
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Affiliation(s)
- M Haboub
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco.
| | - S Abouradi
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - H Mechal
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - G Minko
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - A Moukhliss
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - S Arous
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - M E G Benouna
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - A Drighil
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - L Azzouzi
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
| | - R Habbal
- Cardiology Department, Hospital University Ibn Rochd, Casablanca, Morocco
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Juvenile stroke caused by calcific bicuspid aortic valve: A case report. Clin Neurol Neurosurg 2020; 195:106079. [PMID: 32663736 DOI: 10.1016/j.clineuro.2020.106079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 11/20/2022]
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3
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Soylu M, Demir AD, Ozdemir O, Uzun Y, Korkmaz S. Relationship Between Plaque Morphology of Carotid Artery and Aortic Valve Calcification. Angiology 2016; 54:637-40. [PMID: 14666950 DOI: 10.1177/000331970305400601] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aortic and mitral valvular calcifications are found to be associated with atherosclerotic risk factors and are largely accepted as part of a generalized atherosclerotic process. As well as the severity of stenosis, embologenic properties of plaques are also responsible for ischemic poten tials of atherosclerotic plaques in carotid arteries. In this study, the authors aimed to define the characteristics of plaque morphology in patients with and without aortic valvular calcification (AVC) and to show the association between AVC and carotid plaque characteristics. Carotid plaque morphology in 182 consecutive patients with AVC was compared with plaque charac teristics in 170 patients without AVC. Risk factors for atherosclerosis, age, and gender were similar in patients with and without AVC. The presence of carotid atherosclerosis, complex atheromas, and carotid artery stenosis was significantly higher in patients with AVC when compared with those without AVC (p < 0.001, p < 0.001, and p < 0.05, respectively). Unstable plaques (Types I and II) were also found to be more common in the patients with AVC than in those without AVC (p < 0.001). This study demonstrated the strong correlation between AVC and carotid atheromas. The plaques in patients with AVC are more unstable in morphology than in those without AVC, and this may explain the higher stroke incidence in these patients.
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Affiliation(s)
- Mustafa Soylu
- Department of Cardiology, Yüksek Ihtisas Hospital, Ankara, Turkey.
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Hoey ETD, Mankad K, Al-Chalabi H, Rosa S. The emerging role of cardiovascular MRI for suspected cardioembolic stroke. Clin Radiol 2012; 68:107-16. [PMID: 22939694 DOI: 10.1016/j.crad.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 06/22/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
Stroke is a leading cause of morbidity and long-term disability worldwide and is often the result of embolic material from the heart or proximal aorta. These are referred to as cardioembolic sources of stroke. The investigation of patients with suspected cardioembolic stroke has traditionally been the mainstay of echocardiography. Cardiac magnetic resonance imaging (MRI) is a powerful imaging technique that has rapidly evolved over the last decade and is playing an ever increasing role in clinical cardiovascular imaging. This review of the literature aims to furnish the reader with an understanding of the role of cardiac MRI across the spectrum of causes of cardioembolic sources of stroke by providing the reader with an overview of the indications, technical considerations, a proposed imaging algorithm, and capabilities of this technology with selected illustrated examples of disease entities.
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Affiliation(s)
- E T D Hoey
- Department of Radiology, Heart of England NHS Foundation Trust, Birmingham, UK
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Rodriguez CJ, Bartz TM, Longstreth WT, Kizer JR, Barasch E, Lloyd-Jones DM, Gottdiener JS. Association of annular calcification and aortic valve sclerosis with brain findings on magnetic resonance imaging in community dwelling older adults: the cardiovascular health study. J Am Coll Cardiol 2011; 57:2172-80. [PMID: 21596233 DOI: 10.1016/j.jacc.2011.01.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 12/10/2010] [Accepted: 01/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the associations of mitral annular calcification, aortic annular calcification, and aortic valve sclerosis with covert magnetic resonance imaging (MRI)-defined brain infarcts. BACKGROUND Clinically silent brain infarcts defined by MRI are associated with increased risk for cognitive decline, dementia, and future overt stroke. Left-sided cardiac valvular and annular calcifications are suspected as risk factors for clinical ischemic stroke. METHODS A total of 2,680 CHS (Cardiovascular Health Study) participants without clinical histories of stroke or transient ischemic attack underwent brain MRI in 1992 and 1993, 1 to 2 years before echocardiographic exams (1994 to 1995). RESULTS The mean age of the participants was 74.5 ± 4.8 years, and 39.3% were men. The presence of any annular or valvular calcification (mitral annular calcification, aortic annular calcification, or aortic valve sclerosis), mitral annular calcification alone, or aortic annular calcification alone was significantly associated with a higher prevalence of covert brain infarcts in unadjusted analyses (p < 0.01 for all). In models adjusted for age, sex, race, body mass index, physical activity, creatinine, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking, diabetes, coronary heart disease, and congestive heart failure, the presence of any annular or valve calcification remained associated with covert brain infarcts (risk ratio: 1.24; 95% confidence interval: 1.05 to 1.47). The degree of annular or valvular calcification severity showed a direct relation with the presence of covert MRI findings. CONCLUSIONS Left-sided cardiac annular and valvular calcifications are associated with covert MRI-defined brain infarcts. Further study is warranted to identify mechanisms and determine whether intervening in the progression of annular and valvular calcification could reduce the incidence of covert brain infarcts as well as the associated risk for cognitive impairment and future stroke.
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Affiliation(s)
- Carlos J Rodriguez
- Department of Epidemiology and Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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6
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Calcific aortic valve and spontaneous embolic stroke: A review of literature. J Neurol Sci 2009; 287:32-5. [DOI: 10.1016/j.jns.2009.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 06/28/2009] [Accepted: 07/23/2009] [Indexed: 11/15/2022]
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7
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Stroke secondary to calcific bicuspid aortic valve: Case report and literature review. J Cardiol 2009; 54:158-61. [DOI: 10.1016/j.jjcc.2008.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 10/24/2008] [Accepted: 10/31/2008] [Indexed: 11/20/2022]
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8
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Okajima K, Abe Y, Suzuki K, Salameh MJ, Di Tullio MR, Jin Z, Sacco RL, Mohr JP, Homma S. Impact of Valvular Thickness on Stroke Recurrence in Medically Treated Patients with Stroke. Cerebrovasc Dis 2007; 24:375-80. [PMID: 17804905 DOI: 10.1159/000107918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/07/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It remains controversial whether left-sided valvular thickening (VaT) is a risk factor for ischemic stroke. Little is known about the relationship between VaT and the recurrent adverse event rate in medically treated patients with stroke. METHODS We examined the outcomes of 627 noncardioembolic stroke patients who were double-blindly assigned to either warfarin or aspirin therapy and assessed VaT using transesophageal echocardiography. Endpoints were recurrent ischemic stroke or death from any cause. The Cox proportional hazards model was used to adjust for covariates. RESULTS VaT was present in 57.3% of the patients (359/627), 34.6% (271/627) involving the aortic valve and 46.4% (291/627) involving the mitral valve. There was no difference in the time to primary endpoints between those with and without VaT of the aortic valve (p = 0.49; hazard ratio, HR: 1.17; 95% CI: 0.74-1.85; 2-year event rates: 18.9 vs. 13.2%) or mitral valve (p = 0.66; HR: 0.91; 95% CI: 0.60-1.38; 2-year event rates: 16.9 vs. 14.7%). Among the patients with VaT, there was no significant difference in the time to primary endpoints between those treated with warfarin and those with aspirin (p = 0.13, HR: 0.65, 95% CI: 0.37-1.14, 2-year event rates: 15.2 vs. 22.7% for the aortic valve; p = 0.22, HR: 0.70, 95% CI: 0.40-1.23, 2-year event rates: 14.2 vs. 19.6% for the mitral valve). CONCLUSIONS VaT does not appear to increase recurrent adverse event rates in medically treated patients with ischemic stroke, regardless of warfarin or aspirin therapy.
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Affiliation(s)
- K Okajima
- Department of Medicine, Columbia University, New York, NY 10032, USA.
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9
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Abstract
Spontaneous calcific cerebral embolus is a rare complication of calcific vascular disease such as calcified aortic plaques, and calcific aortic and mitral stenosis. Fewer than 10 case reports are described in the literature. Cerebral ischaemic symptoms may provide the indication for surgical replacement, even in the absence of valvular insufficiency or stenotic symptoms. We report a case of stroke in a young man with a known bicuspid calcific aortic valve.
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Affiliation(s)
- R B Gearry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.
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10
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Adler Y, Levinger U, Koren A, Tanne D, Fink N, Vaturi M, Iakobishvili Z, Battler A, Zelikovski A, Sagie A. Relation of nonobstructive aortic valve calcium to carotid arterial atherosclerosis. Am J Cardiol 2000; 86:1102-5. [PMID: 11074207 DOI: 10.1016/s0002-9149(00)01167-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recently it was shown that subjects with aortic valve calcium (AVC) are at increased risk for future cardiovascular disease including stroke. We hypothesized that the increased risk of stroke may be due to an association with carotid artery atherosclerotic disease. Between 1995 and 1999 our laboratory made a diagnosis of AVC without significant stenosis in 3,949 patients. Of those, 279 patients without other cardiac structural exclusion criteria (148 men and 131 women; mean age 73 +/- 9 years, range 45 to 90) underwent carotid artery duplex ultrasound for various indications, and formed the study group. Age- and sex-matched patients without AVC (n = 277), who underwent carotid artery duplex ultrasound during the same period and for the same indications, served as the control group. Compared with the control group, the AVC group had a significantly higher prevalence of carotid stenosis (> 40% to 60%, 89% vs 78% [p < 0.001]; >60% to 80%, 43% vs 23% [p <0.001];and > 80% to 100%, 32%vs 14% [p < 0.001]). The AVC group had a similar, significantly higher prevalence of > or = 2-vessel disease and bilateral carotid stenosis (stenosis levels of > 20% to 40%, >40% to 60%, > 60% to 80%, and > 80% to 100%). In multivariate analysis, AVC, but not traditional risk factors, was the only independent predictor of severe carotid atherosclerotic disease (stenosis > 80% to 100%; p = 0.0001). Thus, there is a significant association between the presence of AVC and carotid atherosclerotic disease.
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Affiliation(s)
- Y Adler
- Department of Cardiology, Rabin Medical Center, Petah Tiqva, Israel
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Adler Y, Vaturi M, Wiser I, Shapira Y, Herz I, Weisenberg D, Sela N, Battler A, Sagie A. Nonobstructive aortic valve calcium as a window to atherosclerosis of the aorta. Am J Cardiol 2000; 86:68-71. [PMID: 10867095 DOI: 10.1016/s0002-9149(00)00830-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Aortic valve calcium without stenosis and mitral annulus calcium (MAC) are known to correlate with atherosclerotic risk factors. Recently, it has been reported that MAC is associated with atherosclerosis of the cardiovascular system, suggesting MAC as an atherosclerotic process by itself. Hence, the aim of the present study was to determine whether a similar association between aortic valve calcium and aortic atheroma exists. Ninety-six patients (54 men and 42 women, mean age 72 +/- 12 years) with aortic valve calcium who underwent transesophageal echocardiography (TEE) formed the study group. They were compared with 92 sex- and age-matched patients without aortic valve calcium who underwent TEE for the same indications during the same period. The presence and echocardiographic features of aortic atheromas were evaluated by TEE. No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the aortic valve calcium group for prevalence of aortic atheroma (86% vs 30%, p = 0.001). This significant trend was also consistent with the dimension and complexity of the atheromas. On multivariate analysis aortic valve calcium, and MAC were the only independent predictors of aortic atheroma (p = 0.0001, 0.006 respectively). We conclude that there is a significant association between the presence of aortic valve calcium and the presence and severity of aortic atheroma. Thus, aortic valve calcium may serve as a window to atherosclerosis of the aorta.
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Affiliation(s)
- Y Adler
- Cardiology Department, The Scheingarten Echocardiography Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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12
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Kaul H, Gutzwiller JP, Schneider K, Dirsch O, Häusermann M. Aortic valve stenosis as a cause of major systemic embolism--a case report. Angiology 1998; 49:231-4. [PMID: 9523547 DOI: 10.1177/000331979804900310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This is the first documented case of a patient suffering from embolic occlusion of the left brachial artery caused by a large embolus growing on a lesion of a stenosed calcified aortic valve. Supported by their own additional observations the authors suggest that severe calcified aortic valve stenosis should be considered as an indication for anticoagulation in the period before surgical valve replacement.
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Affiliation(s)
- H Kaul
- Regional Hospital of Wil, Switzerland
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13
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Boon A, Lodder J, Cheriex E, Kessels F. Risk of stroke in a cohort of 815 patients with calcification of the aortic valve with or without stenosis. Stroke 1996; 27:847-51. [PMID: 8623104 DOI: 10.1161/01.str.27.5.847] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE We sought to establish the possible role of calcification of the aortic valve with or without stenosis as a risk factor for stroke. METHODS Occurrences of stroke, stroke subtypes, and concomitant cardiovascular risk factors were prospectively analyzed in 300 patients with echocardiographic evidence of aortic valve calcification, 515 patients with calcified aortic valve stenosis, and 562 control subjects. RESULTS Twenty-four patients with aortic valve calcification, 24 patients with calcified aortic valve stenosis, and 27 control subjects had a stroke during follow-up. Using Cox proportional hazards models, we found that strokes were not significantly associated with aortic valve calcification with or without stenosis, but hypertension and any carotid stenosis were associated. On multiple logistic regression analysis, we did not find any association between one of the two valve lesions and indirect possible indications of cardiogenic embolism such as territorial as opposed to small deep brain infarcts or the presence of silent brain infarcts. CONCLUSIONS Aortic valve calcification with or without stenosis is not a risk factor for stroke.
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Affiliation(s)
- A Boon
- Department of Neurology, St-Anna Hospital, Geldrop, Netherlands
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