Jump to comment:

• "thromboembolism until proved otherwise" should be the mantra
  oscar,m jolobe
  Published on: 8 April 2010

• Published on: 8 April 2010

  "thromboembolism until proved otherwise" should be the mantra

  • oscar,m jolobe, retired geriatrician

  In the presence of risk factors for thromboembolism, a focal neurological episode which has a sudden onset should be assumed to be embolic until proved otherwise. Whether or not that episode is purely ischaemic, or whether or not it undergoes subsequent hamorrhagic transformation is a separate issue which should not detract from the urgency to identify the embolic source by means of echocardiography. That is why I am so...

  Show More

  In the presence of risk factors for thromboembolism, a focal neurological episode which has a sudden onset should be assumed to be embolic until proved otherwise. Whether or not that episode is purely ischaemic, or whether or not it undergoes subsequent hamorrhagic transformation is a separate issue which should not detract from the urgency to identify the embolic source by means of echocardiography. That is why I am so surprised that echocardiography was not performed as a matter of urgency in this patient(1). The "mantra" of "thromboembolism until proved otherwise" is one which has stood the test of time in other contexts, notably in the context of acute abdominal pain(attributable to mesenteric embolism) in the presence of risk factors for thromboembolism such as atrial fibrillation, myocardial infarction, and infective endocarditis(2). "Frequently, [however], acute occlusive mesenteric ischemia remains unrecognised, initially, so that specific treatment is delayed for > 24 hours"(3). This is, arguably, attributable, at least in part, to underrecognition of the diagnostic utility of the "mantra", and the same might be true of the delayed recognition of the embolic nature and the embolic source in the case reported by the authors(1). Where the index of suspicion is sufficiently high, it should also be recognised that normal intensity anticoagulation is no bar to thromboembolism, as shown by the graph depicting occurence of embolic stroke despite chronic anticoagulat therapy in patients with non valvular atrial fibrillation, some of whom had international normalized ratios in the range 2-3.4(4) References (1) Nieuwkamp DJ., Kirkels JH., Rinkel GJE Multiple intracerebral haematomas during normal intensity anticoagulation Practical Neurology 2010;10:45-47 (2)Jolobe,O Intestinal ischaemia(letter) British journal of Hospital Medicine 2002;63:695 (3)Menke J., Luthje L., Kastrup A., Larsen J Thromboembolism in atrial fibrillation Am J Cardiol 2010;105:502-10 (4)Hylek EM., Skates SJ., Sheehan MA., Singer DE An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with non rheumatic atrial fibrillation N Engl J Med 1996;335:540-6

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top