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["Top-of-the-basilar" syndrome and Chagas' disease]
F J Carod-Artal1, A P Vargas, M Melo
1Servicio de Neurología. Hospital Sarah, Brasilia DF, Brasil. FJCarod@aol.com
Insights
Chagas disease can cause stroke in the brainstem. Patients with Chagas disease experiencing top of basilar syndrome may have cardioembolic stroke, warranting anticoagulation therapy to prevent recurrence.
Area of Science:
- Neurology
- Cardiology
- Infectious Diseases
Background:
- Chagas disease (CD) can lead to chronic myocardiopathy, causing heart failure, arrhythmias, and thromboembolism.
- Vascular disease in the basilar artery can result in ischemia and necrosis in brain regions like the midbrain and thalamus.
Observation:
- Four patients (3 male, 1 female, average age 54) with positive Chagas serology and top of the basilar syndrome were studied.
- Coagulopathy tests were negative; however, ECG and echocardiograms showed cardiac abnormalities.
- Neuroimaging confirmed various brain infarctions, including thalamic, cerebellar, and occipital lobe involvement.
Findings:
- Electrocardiograms revealed right bundle branch block, atrial fibrillation, and repolarization disorders.
- Echocardiograms indicated left ventricular dysfunction, apical aneurysm, and mural thrombus.
- Neuroimaging identified multiple ischemic stroke locations in the brainstem and posterior circulation.
Implications:
- Positive Chagas serology in patients with basilar artery occlusion suggests a cardioembolic source.
- Secondary anticoagulation is recommended due to the high risk of recurrent cardioembolic events in Chagas disease patients.
Introduction:
As a chronic chagasic myocardiopathy, Chagas disease (CD) may give rise to cardiac insufficiency, arrhythmias, thromboembolism and stroke. Occlusive vascular disease of the rostral portion of the basilar artery or of its emergent branches may cause ischemia and necrosis in different areas of the midbrain, thalamic nuclei, cerebellum and occipital lobe.
Case Reports:
We describe four patients (three males and a female, the average age being 54 years) with positive chagasic serology (indirect immunofluorescence and hemagglutination) and suffering from CD and top of the basilar syndrome. All of them underwent tests to determine proteins C and S, antithrombin III, factor V Leiden, and lupic anticoagulant, as well as being submitted to explorations using electrocardiogram (ECG), echocardiogram, carotid and transcranial echo Doppler, computerised tomography (CAT) and magnetic resonance imaging (MRI).
Results:
The coagulopathy studies were normal or negative in the four patients. We also describe the findings from the electrocardiograms (blockage in right branch, two cases; auricular fibrillation, one case; repolarization disorder, one case) and the echocardiograms (left ventricular dysfunction, two patients; apical aneurysm, one patient; mural thrombus, one patient). Neuroimaging revealed one case of each of the following infarctions: bilateral thalamic, bilateral cerebellar and occipital, cerebellar, thalamic mesencephalic and occipital, and thalamic mesencephalic and occipitotemporal.
Conclusions:
In a patient with positive chagasic serology, with or without findings in the ECG and in the electrocardiogram that can be put down to a cardioembolic source, a vascular syndrome produced by occlusion of the distal basilar artery suggest a cardioembolism. We recommend secondary anticoagulation because of the high risk of recurrence.