Carlos A. Roldan et al. JIMG 2013;6:

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Presentation transcript:

Carlos A. Roldan et al. JIMG 2013;6:973-983 55-Year-Old Woman With SLE and Acute Transient Ischemic Attack (A) This transesophageal echocardiography view demonstrates a moderately sized, elongated, sessile, and heterogeneously echoreflectant Libman-Sacks vegetation (arrow) on the atrial side of the posterior mitral leaflet (pml) (Online Video 1). Moderate thickening and sclerosis with decreased mobility of the mid and distal portions of the anterior mitral leaflet (aml) and pml are noted. (B) Transcranial Doppler ultrasound demonstrates a microembolic signal on the spectral Doppler (upper arrow) and vessels lumen (lower arrow) traveling through the left middle cerebral artery (red power M-mode) and anterior communicating artery (blue power M-mode). (C and D) Brain magnetic resonance imaging demonstrates multiple, bilateral, and variably sized periventricular and deep white matter infarcts (arrows). This patient had 75 brain lesions and a lesion load of 6.04 cm3. Her global neurocognitive z-score was −4.28, indicative of severe neurocognitive dysfunction. (E) Histopathology with hematoxylin and eosin (H&E 40×) stains demonstrates thickening and fibrosis of the posterior leaflet with a well-adhered, verrucoid, fibrinous vegetation (arrow). (F) (H&E 20×) Subacute cerebral infarct at the junction of the white and gray matter with necrotic debris and moderate cellular infiltration (arrow). (G and H) (H&E 40× and 100×, respectively) Old deeper (white matter) infarct with liquefactive necrosis, residual macrophages, and gliosis (arrows). (I) (H&E 100×) Large cerebral vessel with fibrin thrombi (arrow). (J) (H&E 100×) Small cerebral vessel with fibrin thrombi and neoangiogenesis (arrows). Multiple subacute and old microinfarcts and fibrin thrombosed microvasculature with neoangiogenesis characteristic of chronic cardiothromboembolic disease were demonstrated in both cerebral hemispheres. Please also see Online Videos 1A, 2A, 2B, 2E, 2F, 3A, 3D, 3F, 4A, 5A, 5D, 5E, and 5F. LA = left atrium; LV = left ventricle; SLE = systemic lupus erythematosus. Carlos A. Roldan et al. JIMG 2013;6:973-983 American College of Cardiology Foundation