Aortogenic cerebral embolism treated by ascending aorta replacement in an 80-year-old male

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  • 大動脈原性脳塞栓症を発症し，上行大動脈置換術を施行した80 歳男性例

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An 80-year-old man, a smoker, was admitted to our hospital complaining mild weakness of the right limb. Diffusion-weighted magnetic resonance imaging (MRI) disclosed multiple small high signal intensities at bilateral cerebral hemispheres. Thus he was diagnosed as having cerebral embolism, and anticoagulation therapy using heparin was started. Four days after admission, contrast enhanced computed tomography (CT) showed complex atheromatous plaque 15 mm in diameter at ascending aorta. We diagnosed him as having aortogenic cerebral embolism. Dual antiplatelet therapy using aspirin and clopidogrel, in combination with atorvastatin, was added 5 days after admission. At 20 days after admission, anticoagulation was switched from heparin to warfarin, when his international normalized ratio of prothrombin time (PT-INR) reached the target level between 1.6 and 2.6. Enhancement CT 20 days after admission, however, showed no improvement of aortic atheroma. In addition, a new embolic lesion was detected on brain MRI 22 days after admission. Therefore, ascending aorta replacement was carried out at 24 days after admission. We restarted clopidogrel, atorvastatin, and warfarin after the operation. The patient was discharged at 43 days after admission without any deficit. We considered that the decision of surgical indication for aortogenic cerebral embolism should be made after temporal evaluation of the aortic lesion under medical treatment. A new embolic lesion detected on each brain MRI 23 days and 6 months after operation detected one silent embolic lesion, but we did not change medical therapy. No more new lesion occurred on brain MRI 7 months and 11 months after operation. We considered that the decision of surgical indication for aortogenic embolism should be made after medical treatment and evaluation of the aortic lesion for 2 weeks.

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