Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 217 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
Table of Contents   
LETTER TO THE EDITOR  
Year : 2018  |  Volume : 29  |  Issue : 5  |  Page : 1245-1246
A case of recurrent embolic stroke of undetermined source in a chronic kidney disease patient undergoing hemodialysis


First Department of Integrated Medicine, Division of Nephrology, Saitama Medical Center, Jichi Medical University, Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture 330-8503, Japan

Click here for correspondence address and email

Date of Submission09-Jan-2018
Date of Acceptance14-Jan-2018
Date of Web Publication26-Oct-2018
 

How to cite this article:
Shindo M, Kaneko S, Minato S, Mutsuyoshi Y, Yanai K, Ishii H, Kitano T, Miyazawa H, Ito K, Ueda Y, Hirai K, Hoshino T, Ookawara S, Morishita Y. A case of recurrent embolic stroke of undetermined source in a chronic kidney disease patient undergoing hemodialysis. Saudi J Kidney Dis Transpl 2018;29:1245-6

How to cite this URL:
Shindo M, Kaneko S, Minato S, Mutsuyoshi Y, Yanai K, Ishii H, Kitano T, Miyazawa H, Ito K, Ueda Y, Hirai K, Hoshino T, Ookawara S, Morishita Y. A case of recurrent embolic stroke of undetermined source in a chronic kidney disease patient undergoing hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2018 Nov 15];29:1245-6. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1245/243941
To the Editor,

Embolic stroke of undetermined source (ESUS) is a newly characterized type of stroke.[1] ESUS is defined by following criteria: (1) no lacunar infarct on imaging, (2) rate of aortic stenosis in the cerebral infarct region <50%, and (3) no cardioembolic source of embolism.[1] However, there are no reports of ESUS in patients with chronic kidney disease undergoing hemodialysis (HD). Herein, we report a case of recurrent ESUS in a patient undergoing HD. A 72-year-old woman on maintenance HD for two years because of diabetic nephropathy had consciousness disturbance and myoclonus on the day before admission to our department. Brain magnetic resonance imaging (MRI) showed a high-intensity area in the pons on diffusion-weighted images [Figure 1]a. Magnetic resonance angiography showed no stenosis in the brain or carotid artery [Figure 1]b. Cerebral embolism was suspected based on the onset of symptom and MRI images although the embolism source, including the heart and aorta, could not be detected with close examination such as 24-h monitored electrocardiogram, transesophageal echocardiogram, or enhanced computed tomography of the chest, abdominal pelvis, and arteries. Enhanced computed tomography showed calcification of the aortic arch and common iliac artery.
Figure 1: Images from brain magnetic resonance imaging and magnetic resonance angiography. A highintensity area in the pons on diffusion-weighted imaging (a), no stenosis in the brain and carotid artery (b), and a high-density area in the left thalamus (c) and the left cerebellar hemisphere (d).

Click here to view


As her appetite had decreased, she received infusion therapy of extracellular fluids, after which her symptoms improved. However, six days after admission, she exhibited gait disturbance, and MRI showed high-density areas in the left cerebellar hemisphere and left thalamus [Figure 1]c and [Figure 1]d. She was diagnosed with recurrent ESUS, and administration of aspirin was initiated, after which her symptoms improved without recurrent stroke.

This represents a case of recurrent ESUS in a patient undergoing HD. Although the source of the embolisms was not determined, aortic arch calcification was observed. A previous study reported an association of aortic arch calcification with brain embolisms[2] although the specific mechanisms by which aortic arch calcification causes brain embolism including ESUS are unknown. Overall, these data suggest that patients undergoing HD with aortic arch calcification may have increased risk of ESUS. Further studies are required to investigate the prevalence, risk, and mechanism of ESUS and its association with aortic arch calcification, in patients undergoing HD.

In conclusion, we report a case of ESUS in a patient undergoing HD. Clinicians should note this complication when they manage patients undergoing HD.

Conflicts of interest: None declared.

 
   References Top

1.
Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: The case for a new clinical construct. Lancet Neurol 2014;13: 429-38.  Back to cited text no. 1
    
2.
Shimada Y, Ueno Y, Tanaka Y, et al. Aging, aortic arch calcification, and multiple brain infarcts are associated with aortogenic brain embolism. Cerebrovasc Dis 2013;35:282-90.  Back to cited text no. 2
    

Top
Correspondence Address:
Prof. Yoshiyuki Morishita
First Department of Integrated Medicine, Division of Nephrology, Saitama Medical Center, Jichi Medical University, Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture 330-8503
Japan
Login to access the Email id


DOI: 10.4103/1319-2442.243941

PMID: 30381530

Rights and Permissions


    Figures

  [Figure 1]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    References
    Article Figures
 

 Article Access Statistics
    Viewed72    
    Printed1    
    Emailed0    
    PDF Downloaded22    
    Comments [Add]    

Recommend this journal