In Sung Choo

Histologic features of acute thrombi retrieved from stroke patients during mechanical reperfusion therapy

Background The histologic features of thrombus may differ according to the stroke subtypes. However, in acute reperfusion therapy, fibrin-specific thrombolytics are used based on the assumption that all thrombi are alike. Aims The histologic characteristics of thrombi were compared between patients with different stroke etiologies. Methods Between April 2010 and March 2012, we analyzed thrombi retrieved from acute stroke patients during mechanical thrombectomy. All thrombi were analyzed using component-specific stains such as Martius scarlet blue for fibrins and immunostaining with CD42b antibody for platelets. The stroke subtypes were determined based on the Trial of ORG 10172 in Acute Stroke Treatment classification. Results Among 36 patients, 22 were diagnosed with cardioembolism, 8 with atherothrombosis, and 6 with undetermined etiology. In arteriogenic thrombi, red blood cells were most abundant (56.9 ± 12.2%), and the platelets covered the fibrin layers or were localized at the edge or periphery of the thrombus. In cardiogenic thrombi, fibrin was most abundant (39.5 ± 13.5%), and platelets were clustered within the rich fibrin. Red blood cells proportion was greater in arteriogenic thrombi than in cardiogenic thrombi (p < 0.001), whereas fibrin proportion was greater in cardiogenic thrombi than in arteriogenic thrombi (p = 0.003). Of six patients with undetermined etiology, the thrombi in five showed histologic features and composition similar to that of cardiogenic thrombi. Conclusions Acute thrombi showed different histologic features according to the stroke etiology. The distribution of platelets and proportion of red blood cells and fibrin were major distinguishing factors between stroke subtypes.

Acute cerebral infarction after pyrethroid ingestion

hypobetalipoproteinemia: early neurological, hematological, and ocular manifestations in two affected twins responding to vitamin supplementation. Curr Opin Pediatr 2009; 21: 824–827. 4 KaydenHJ, TraberMG. Absorption, lipoprotein transport, and regulation of plasma concentrations of vitamin E in humans. J Lipid Res 1993; 34: 343–358. 5 Muller DPR. Vitamin E and neurological function. Mol Nutr Food Res 2010; 54: 710–718.

Increased microbleeds after infective endocarditis in a patient with valvular replacement

A 35-year-old women with mechanical mitral valve replacement presented with fever followed by loss of consciousness. Brain magnetic resonance imaging showed left middle cerebral artery infarction with multiple microbleeds (Fig. 1a). Transesophageal echocardiography showed vegetation and blood culture was positive for Staphylococcus capitis. A parenteral antibiotic therapy was immediately started, and appropriate anticoagulation with warfarin was carried out (time in therapeutic range 68.9%). One year later, she experienced left hemiparesis, and the follow-up magnetic resonance imaging showed another right middle cerebral artery infarction with increased microbleeds during a relatively short period (Fig. 1b, arrows). In the case of a cerebral infarction as a result of septic emboli, there is a chance of septic erosion of the arterial wall caused by the embolus to increase microbleeds. As long-term anticoagulation increases the risk of intracerebral hemorrhage in patients with multiple microbleeds, it might be necessary to follow up magnetic resonance imaging including gradient echo imaging within short periods, especially in