: =A s t r act = A cas e of cerebellar embolic inf arction in thy rotox ic atrial f ibrillation So Jean Choi, M.D., Chang Ryoul Lee, M.D.,

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1 : =A s t r act = A cas e of cerebellar embolic inf arction in thy rotox ic atrial f ibrillation So Jean Choi, M.D., Chang Ryoul Lee, M.D., Jun Ho Lee, M.D., Dong Suk Lee, M.D., Seo Ryong Han, M.D., Woo Seung Kim, M.D., and Seong Pyo Son, M.D. Department of Internal M edicine, St. Benedict H ospital, Pusan, K orea Atrial fibrillation occurs in 10 to 25% of patients with thyrotoxicosis. Several recent studies have found a high frequency of cerebral thromboembolism in such patients. Thus anticoagulation has been recommended for patients with thyrotoxic atrial fibrillation to prevent embolic complications especially when associated with predictors of an increased risk of arterial thromboembolism in nonrheumatic atrial fibrillation such as recent congestive heart failure, history of hypertension, previous thromboembolism, left atrial enlargement, and global left ventricular dysfunction. Most reported cases of embolic events involving central nervous system in thyrotoxic atrial fibrillation affected cerebrum, and cerebellar embolic infarction from the heart was rarely seen. We herein report our experience of a case of cerebellar embolism in thyrotoxic atrial fibrillation.(korean J Med 59: , 2000) Key Word : Atrial fibrillation; Thyrotoxicosis; Cerebellum; Infarction 10-25% 1-3). (acute hemodynamic instability). 1, 3,4), 5)., 35, : : :, 331-3, ( )

2 So Jean Choi, et al : A case of cerebellar embolic infarction in thyrotoxic atrial fibrillation 1. : 130/90 mmhg, :, 35, :, :,.. : 3300/uL, 13.4, g/dl, 120,000/uL,,,. : 10 7 TSH 0.02 uiu/ml, T ug/dl, T3 : Figure 1. The electrocardiography on admission demonstrates atrial fibrillation with controlled ventricular response. 96/, 36.8, 23/. motor power4/5 Babinsky sign.,,, 222 ng/dl, FT4 4.9 ng/dl. 96 (controlled ventricular response) (Figure 1). : X- (Figure 2), (Figure 3). : urokinase bolus ( low molecular weight) heparinnadroparine. semicomatous, (Figure 4) decompressive craniectomy with extraventricular drainage(evd). Figure 2. Simple chest X- ray on admission shows cardiomegaly with increased cardiothoracic ratio. Figure 3. Brain CT on admission shows no demonstrable abnormal finding

3 : Figure 4. Brain CT on third day of admission shows dilatation of both lateral ventricles and 3rd ventricle and nearly no visualization of 4th ventricle, the finding compatible with obstructing hydrocephalus. There is low density lesion in right cerebellar hemisphere with mass effect shifting midline to the left showing ischemic infarcion area. Figure 5. Previously shown hydrocephalus disappeared suggesting opening of cerebrospinal fliud pathway. Low density lesion in right cerebellar hemisphere still exists, but its size and mass effect much decreased. Posterior bony defect represents the site of decompression craniectomy. Fig ure 6. Brain CT at discharge shows atrophied right cerebellum surrounded by cerebrospinal fluid which fills the vacant space. propylthiouracil, propranolol nadroparine. (mass effect) 4. (visible thrombi) ejection fraction 41%, global hypokinetic w all motion, digoxin. 9 (Figure 5) EVD T ng/dl, T ug/dl, FT ng/dl, T SH 0.02 uiu/ml T SH.. 4 (Figure 6). (Figure 7), X- (Figure 8). methimazole, warfarin % 1-3), 0.4% 60 1%, 69 5%. (rapid ventricular response)

4 6: 1 Figure 7. The electrocardiography before discharge still shows atrial fibrillation. Fig ure 8. Simple chest X- ray before discharge demonstrates much decreased heart size compared to that on admission. 25% 6) 62% 4 6 6). 3,14). 8) 76% 8). 9) beta- adrenergic- like effect (direct thyroid hormone effect),,,. 10) (cardiomegaly),, 11). 1, 4) 4). transient ischemic attack ( 22.5), ( 1.7), ( 1.6), (10 1.4) 12) 4%. 3 13). 2.5 cm/m % 1,3, 4). 1, 3, 4) % 15% 7). (anterior circulation infaction)

5 Korean Journal of Medicine : Vol. 59, No. 2, 2000 (external cardioversion). (cardioversion) (elective cardioversion) 3, 3-4 warfarin INR (emergency cardioversion)heparin., warfarininr , aspirin. 75 INR 3.0. INR ). warfarin 70%, aspirin 325 mg/d aspirin 44% aspirin 50% 12). vitamin K prothrombin time warfarin 16), aspirin (free form). class IA, IC, III (amiodarone, sotalol). proarrhythmia. digitalis, - blocker calcium 60-80/ 100/. Propranolol - adrenergic blocking agent (negative inotropic action ), digitalis. digitalis digitalis, sodium- transport unit 17) ).. 2 (early recurrent stroke) 18) (long- term rate)1 10% 19). 40%.,,, (left atrial enlargement), (global left ventricular dysfunction) 5)

6 So Jean Choi, et al : A case of cerebellar embolic infarction in thyrotoxic atrial fibrillation., 35,, 1. R E F E R E N C E S 1) Yuen R, Gutteridge D, Thompson P, Robinson J. Em bolism in thyrotoxic atrial fibrillation. M ed J A ust 1: , ) Woeber KA. thyrotoxicosis and the heart. N Engl J M ed 327:94-98, ) Staffurth J, Gibberd M, Ng T ang Fui S. Arterial embolism in thyrotoxicosis with atrial fibrillation. Br M ed J 2: , ) Hurley D, Hunter A, Hewett M, Stockigt J. Atrial fibrillation and arterial embolism in hyperthyroidism. Aust N Z J M ed 11: , ) The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of throm boembolism in atrial fibrillation. I. Clinical features of patients at risk. Ann Intern M ed 116:1-5, ) Godtfredsen J. Atrial fibrillation. Etiology, Course and Prognosis. A Follow- up Study of 1,212 Cases. Copenhagen, M unksgaard, ) Wolf PA, Abbott R, Kannel W. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22:983-8, ) Bogousslavsky J, Van Melle G, Regli F, Kappenberger L. Pathogenesis of anterior circulation stroke in patients with nonvalvular atrial fibrillation: T he Lausanne Stroke Registry. N eurology 40: , ) Arnsdorf, MF, Childers RW. Atrial electrophysiology in experimental hyperthyroidism in rabbits. Circ Res 26: , ) Sandler G, Wilson GM. T he nature and prognosis of heart disease in thyrotoxicosis: a review of 150 patients treated with 131I. QJ Med 28:347-69, ) Prystowsky EN, Benson DW Jr, Fuster V, Hart RG, Kay GN, Myerburg RJ, Naccarelli GV, Wyse DG. AH A M edical/ Scientific Statement.. Special report: M anagement of patients eith atrial fibrillation. A report for health professionals from the Subcommittee on Electrocardiography and Electrophysiology. American Heart Association. Circulation 93: , ) Atrial fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five random ized trials. Arch Intern M ed 154: , ) Albers GW. A trial fibrillation and stroke: three new studies, three remaining questions. Arch Intern M ed. 154: , ) Nakazawa HK, Sakurai K, Hamada N, Manotani N, Ito K. M anagement of atrial fibrillation in the postthyrotoxic state. Am J M ed 72: , ) The Boston Area Anticoagulation T rial for Atrial Fibrillation Investigators. T he effect of low- dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J M ed 323: , ) McIntosh T J, Brunk SF, Kolln I. Increased sensitivity to warfarin in thyrotoxicosis. J Clin Invest 49:63a, ) Chaudhury S, Ismail-Beigi F, Gick GG, Levenson R, Edelman IS. Effect of thyroid hormone on the abundance of N a,k - adenosine triphosphatase - subunit messenger ribonucleic acid. M ol Endocrinol 1:83-89, ) Vangerhoets F, Bogousslavsky J, Regli F, VanMelle G. A trial fibrillation after acute stroke. Stroke 24:26-30, ) EAFT Study Group. Europian Atrial Fibrillation T rial: Secondary prevention of vascular events in patients with nonrheumatic atrial fibrillation and recent transient ischemic attack or m inor stroke. Lancet 342: ,