PMC10306394_01
Diagnostic testing performed on admission. Twelve-lead electrocardiography (A), chest x-ray (B), pulse-wave carotid ultrasonography with Doppler in the left common carotid artery (C) and internal carotid artery (ICA) (D), and the diffusion-weighted magnetic resonance imaging (MRI) (E), apparent diffusion coefficient map (F), and fluid-attenuated inversion recovery MRI (G) displaying acute bilateral ICA territory infarction. R stands for right; L stands for left.
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F1
ECG revealed AF with ST-segment elevation at II, III, aVF and V4-6 (Figures 1A,B). Echocardiography showed hypokinesis of the anterior and inferior walls. Carotid ultrasonography exhibited a reduction in the end-diastolic velocity (right, 4.9 cm/s; left, 6.3 cm/s) and increased pulsatility index (2.2;2.3) at the bilateral common carotid arteries and did not detect pulse-wave Doppler in the bilateral internal carotid artery (ICA), suggesting that the bilateral ICA was occluded (Figures 1C,D). On brain non-contrast magnetic resonance imaging (MRI), diffusion-weighted MRI (Figure 1E) and apparent diffusion coefficient map (Figure 1F) showed almost the same signal intensity in the infarcted lesions of the bilateral ICA territories, whereas fluid-attenuated inversion recovery revealed no such lesions with a high signal intensity (Figure 1G), demonstrating acute cerebral infarction in the bilateral ICA territories with a nearly simultaneous onset.
Clinical course of the patient after stroke onset. GCS, Glasgow Coma Scale.
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F2
Eventually, the patient died on day 4 of hospitalization before the diagnosis was completed (Figure 2).
Gross appearance of the patient's brain and heart during autopsy. Representative pictures depicting bilateral internal carotid artery (ICA) filled with thromboemboli (A), mural thrombi in the left atrial appendage (LAA) (B, arrows), and acute myocardial hemorrhagic infarcts in the lateral-posterior wall of the left ventricle (C). R, right; L, left; A, anterior; P, posterior; RV, right ventricle; LV, left ventricle.
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F3
Macroscopic autopsy examination revealed bilateral ICA occlusion with red thrombi (Figure 3A), mural thrombi in the left atrial appendage (LAA) (Figure 3B), and acute myocardial hemorrhagic infarcts in the lateral-posterior wall (Figure 3C), which suggested the occurrence of coronary artery embolism and recanalization.
Representative microscopic images of the thromboemboli at the patient's left atrial appendage (LAA), middle cerebral artery (MCA), and left circumflex artery (LCX). The thromboemboli in the LAA, MCA, and LCX were stained with hematoxylin and eosin (H and E), for CD31, CD68, and CD168. Colored rectangles with lowest magnification in the MCA and LCX are magnified to the pictures surrounded with each colored rectangle. Inset in CD168 of the MCA represents the enlargement of the area outlined by the black rectangle.
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F4
Microscopic examination revealed thrombi with abundant cell-lytic changes on the wall of the LAA, in the middle cerebral artery (MCA), and in the left circumflex artery (LCX) (Figure 4). In these three sites, the thrombi included CD31-positive cells, and those in the MCA and LCX included CD68- and CD163-positive cells similarly (Figure 4).