: 59 2 2000 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 59:192-197, 2000) Key Word : Atrial fibrillation; Thyrotoxicosis; Cerebellum; Infarction 10-25% 1-3). (acute hemodynamic instability). 1, 3,4), 5)., 35, : 1999615 : 1999720 :, 331-3, (601-731) E-mail : sojean-kr@yahoo.co.kr - 192 -
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, T4 17.3 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. - 193 -
: 59 2 480 2000 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 12 18. 20 T 3 107 ng/dl, T 4 9.4 ug/dl, FT 4 1.0 ng/dl, T SH 0.02 uiu/ml T SH.. 4 (Figure 6). (Figure 7), X- (Figure 8). methimazole, warfarin. 10-25% 1-3), 0.4% 60 1%, 69 5%. (rapid ventricular response).. - 194 -
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/m2.. 10-40% 1,3, 4). 1, 3, 4). 20-25% 15% 7). (anterior circulation infaction). - 195 -
Korean Journal of Medicine : Vol. 59, No. 2, 2000 (external cardioversion). (cardioversion) (elective cardioversion) 3, 3-4 warfarin INR 2.0-3.0. (emergency cardioversion)heparin., warfarininr 2.0-3.0, aspirin. 75 INR 3.0. INR 2.0 15). 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).. 60 14).. 2 (early recurrent stroke) 18) (long- term rate)1 10% 19). 40%.,,, (left atrial enlargement), (global left ventricular dysfunction) 5). - 196 -
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