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Título

Blue toe syndrome and stroke: a case report on simultaneous cardioembolism.

RESUMO

Case report:A 76 years old male, with chronic atrial fibrillation (AF), CHA 2 DS 2 -VASc: 8, was
admitted with sudden homonymous left hemianopsia andmild lefthemiparesis (NIHSS 2)
associated with fixed cyanosis of the first left pododactile. A diagnosis of acute right posterior
cerebral artery occlusion was made concomitance with acute occlusion of the dorsal digital
artery.The patient had previously suspended warfarin treatment30 days before the event. Brain
magnetic resonanceshowed a definite ischemic area in the right occipital, left medial occipital,
and left cerebellar region. A transesophageal echocardiogram (TEE) showed a mobile thrombus
in the left atrial appendage (LAAT)measuring approximately 1.1 cm x 0.8 cm. The vascular
surgery team recognized systemic embolization to the distal arterial bed, and only medical
therapy with anticoagulants was recommended. Abdominal ultrasound revealed discrete
atheroma plaques inthe abdominal aorta without any other signs of embolic eventsat different
sites. The warfarin anticoagulation was resumed, but the patient presented a labile INR,
soanticoagulation was switched to dabigatran with good evolution. Discussion:AF is a
significantcause of systemic and especially brain embolization.Dislodgment of thrombus from
the left atrium into the circulation is one possible mechanism that explainsembolic episodes in
atrial fibrillation patients. Althoughblue toe syndrome was initially described in patients with
microemboli from proximal atherosclerotic lesions, an annual rate of 0,4%/yr was documented
in atrial fibrillation patients in antiagregation therapy. Prevention of stroke and systemic
embolic events had been successfully demonstrated with DOACs use in AF patients, but in
some series, the prevalence of LAAT in patientsanticoagulated for at least three weeks with
DOACs can be as high as 5,8% depending on the TEE screening strategy used a similar rate in
anticoagulation with warfarin.Final comments:We describe a simultaneous blue toe syndrome
and ischemic stroke secondary to multi-source embolic sourcestreatedwith anticoagulation with
dabigatran. DOACs use can be an option in cases like these, particularly in patients com labile
INR or contraindications to warfarin use.

Palavras Chave

Blue toe;cerebral artery occlusion;anticoagulation;dabigatran;embolization;