Acute Mesenteric Ischemia after Recurrent Embolic Stroke

Abstract

We report the case of a 76-year-old woman with acute mesenteric artery ischemia and atrial fibrillation after recurrent embolic strokes. She had sudden severe abdominal pain and vomiting, and was admitted to the hospital in coma and shock state. Accompanied with metabolic acidosis and multiple organic failures, she died at 13 hours after the onset. Pathological examination revealed that acute thrombotic occlusion of superior mesenteric artery, splenic artery and right celiac artery. The occluded arteries pathologically showed progressive arteriosclerotic change and secondary multiple thrombi. This case demonstrated that atrial fibrillation with recurrent embolic stroke could cause mesenteric artery ischemia, progressive thrombi of abdominal viscera and sudden death. Acute Mesenteric Ischemia after Recurrent Embolic Stroke Keywords:Acute mesenteric ischemia, Recurrent embolic stroke, Case ReportOpen Access IntroductionAcute mesenteric artery ischemia is relatively rare acute abdominal vascular event caused by aging, atrial fibrillation, aortic atheroma and infectious endocarditis [1, 2]. The incidence is 5.3 per 100,000 inhabitants yearly, and its mortality is 60% to 80% [3]. It counts 0.4 % in patients with acute abdominal pain. Acute mesenteric ischemia is a life-threatening emergency that requires early diagnosis, intervention to restore mesenteric blood flow and resection of the necrotic bowel tissues by surgical treatments [4]. This report describes a patient with atrial fibrillation and recurrent stroke which rarely cause acute mesenteric ischemia and sudden death with multiple organic failures and lower limb ischemia. After stroke onset sudden abdominal pain and followed by shock state is suggestive of diagnosis of acute mesenteric ischemia. Case ReportA 77-year-old Japanese woman with atrial fibrillation and hypercardiomyopathy was treated by a cardiologist. Two months earlier she had embolic strokes of the right middle cerebral artery, then oral anticoagulation by warfarin had been administered to prevent recurrent stroke. In spite of controlling anticoagulant therapy by warfarin within two months, the prothrombin time-international normalized ratio(PT-INR) with 10 times analysis, three of ten times apparently showed inadequate values below the therapeutic range (0.93, 1.00 and 1.33). The CT scan of the head showed hemorrhagic infarction caused by recanalization after occlusion of the right middle cerebral artery (Figure 1). The echocardiography showed left atrial spontaneous echo contrast on previous stroke onset. On the 66 th day after the stroke onset, she experienced severe nausea, vomiting and abdominal pain in the morning, and delivered to our hospital. On arrival at our emergency department, she was coma. Her blood pressure could not be measured, and heart rater pulse was 124 bpm with irregular rhythm. Respiratory rate was 42/min and her temperature was 34.2 degrees. Right lower limb showed pale color and hemorrhagic purpura with pulseless iliac artery. Her abdomen showed rebound tenderne...