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Chapter 94: Cerebrovascular Disease and Neurologic Manifestations of Heart Disease

A 50-year-old woman with mitral valve prolapse (MVP) presents to the hospital with three days of fever. Blood cultures are positive for a Candida species, and transesophageal echo confirms the presence of a possible vegetation on the posterior mitral valve leaflet. Which of the following statements is correct?

A. Warfarin should be given to prevent embolization

B. Embolic complications are unusual in patients with infective endocarditis

C. Myotic aneurysms can cause fatal subarachnoid bleeding

D. Libman–Sacks endocarditis refers to valve lesions occurring in patients with rheumatoid arthritis

E. MVP is a relatively common source of embolic stroke

The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 94) Embolic complications are common in patients who have infective endocarditis (option B).1,2 Mycotic aneurysms can cause fatal subarachnoid bleeding (option C). Bleeding can also result from vascular necrosis as a result of an infected embolus.2 Embolization usually stops when the infection is controlled.3 Warfarin does not prevent embolization and is contraindicated in patients with endocarditis and known cerebral embolism (option A) unless there are other important lesions such as prosthetic valves or pulmonary embolism. In children and young adults with congenital heart defects, especially those with right-to-left shunts and polycythemia, brain abscess is an important complication. Valve lesions occur in patients with systemic lupus erythematosus (Libman–Sacks endocarditis)4 (not rheumatoid arthritis), antiphospholipid antibody syndrome,5 cancer, and other debilitating diseases (nonbacterial thrombotic endocarditis). Mitral valve prolapse (MVP) as a source of embolic stroke continues to be controversial.1,6 Several small clinical series have reported cerebral embolism in MVP patients who lacked other possible embolic sources.6-9 In the absence of atrial fibrillation, MVP/mitral regurgitation is probably not associated with a significant increase in the risk of first or recurrent stroke.8-10

A 75-year-old woman awakes from sleep with new left-sided weakness. Which of the following statements regarding cerebral infarction is incorrect?

A. MRI is more sensitive for the detection of acute brain infarcts than CT

B. MRI can image hemosiderin

C. The presence of superficial wedge-shaped infarcts in multiple different vascular territories is highly suggestive of a cardioembolic origin

D. The mechanism of hemorrhagic infarction is reperfusion of ischemic zones after iatrogenic opening of an occluded artery or after restoration of the circulation after a period of systemic hypoperfusion

E. Hemorrhagic cerebral infarction is considered characteristic of a ...

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