Annals of Pediatric Cardiology
About us | Current Issue | Archives | Ahead of Print | Instructions | Submission | Subscribe | Advertise | Contact | Login 
     
     
 


 

 
     
    Advanced search
 

 
 
     
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed2340    
    Printed55    
    Emailed0    
    PDF Downloaded136    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

 


 
Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 98-99
Atrial septal aneurysm and stroke


Department of Pediatrics, S.M.G.S Hospital, Government Medical College Jammu, Jammu and Kashmir, India

Click here for correspondence address and email

Date of Web Publication12-Mar-2012
 

How to cite this article:
Mohd Razaq, Parihar RK, Saini G. Atrial septal aneurysm and stroke. Ann Pediatr Card 2012;5:98-9

How to cite this URL:
Mohd Razaq, Parihar RK, Saini G. Atrial septal aneurysm and stroke. Ann Pediatr Card [serial online] 2012 [cited 2019 Oct 19];5:98-9. Available from: http://www.annalspc.com/text.asp?2012/5/1/98/93726


Sir,

An atrial septal aneurysm (ASA) is a rare but well recognized and localized saccular deformity of the atrial septum that bulges into the right or left atrium with uncertain clinical significance. [1],[2] Diagnosis can be established using transthoracic (TTE) and transesophageal echocardiography. Although these abnormalities are considered clinically benign entities, they have been independently associated with ischemic stroke. [3],[4] We present a small atrial septal aneurysm in a child with left middle cerebral artery (MCA) stroke.

A 6-year-old male presented with vomiting for 2 days and inability to speak with right-sided hemiparesis for 1 day. He was conscious with no other symptoms. Physical examination revealed right facial palsy, a mid systolic murmur best heard at the apex, right upper and lower limb grade IV power with planters up-going, blood pressure was 90/60 mm hg. Electrocardiogram showed sinus rhythm. Chest X-ray was normal. Laboratory findings including complete blood count, liver functions test, erythrocyte sedimentation rate, and cerebrospinal fluid analysis as well as coagulation screening presented no abnormalities. Electroencephalography (EEG) and routine 48 h ambulatory (Holter) ECG were normal. Brain computed tomography (CT) scan showed ischemic infarct in the vicinity of left middle cerebral artery. Magnetic resonance imaging of brain confirmed the findings of the CT head, Doppler sonography of lower extremities excluded deep vein thrombosis, and transthoracic echocardiography revealed a small atrial septal aneurysm.

According to Hanley's diagnostic criteria, atrial septum is considered to be aneurysmal, when a dilated segment protrudes at least 15 mm beyond the level surface of the atrial septum. [1] An echo contrast was also performed in order to exclude patent foramen ovale. The images recorded were not diagnostic of right to left shunting. A transesophageal echocardiography confirmed the findings of transthoracic echocardiography [Figure 1]. The patient was started with warfarin in loading doses of 0.2 mg/kg body weight followed by maintenance doses of 0.1 mg/kg B.W. He improved and was discharged from the hospital a week after admission with no neurological deficit.
Figure 1: Transoesophageal echocardiogram showing atrial septal aneurysm

Click here to view


An aneurysm of the interatrial septum is an infrequent finding in adult patients. Atrial septal aneurysm is a congenital malformation of the septum primum layer of the interatrial septum but differences between interatrial pressure forces have also been reported as a cause of its development. [1] The widespread availability of transthoracic and transoesophageal echocardiography has identified atrial septum aneurysm with increasing frequency. [5] The frequency of the anomaly in the general adult population is low (2.2%). [1] It has been speculated that ASA is a direct source of thrombus formation. [6] This is supported by anecdotal findings demonstrating thrombotic material within the aneurysmal sac in the patients at autopsy [1] or cardiac surgery. [7] The mechanism of stroke in patients with ASA remains poorly understood. [8] Cerebral embolism might result from paradoxical embolism of venous thrombi across a right to left shunt, passage of a thrombus created on the left atrial side of the aneurysm with atrial fibrillation. [9] In our case, brain CT and MRI demonstrated ischemic infarcts that possibly reflected cryptogenic stroke in a patient with isolated small atrial septal aneurysm. Thrombus formation on the left atrial side of the aneurysm appears to be the most possible underlying mechanism. Bulging of the aneurysm that extends to the portion between the primum and secundum atrial septum and thus leading to a minor interatrial communication that allows paradoxical embolism, which seems to be a less possible explanation.

This case highlights that the presence of an isolated small ASA may be possible risk factor for ischemic stroke even in the pediatric age group; till date there is not much literature available in the pediatric age group. Further prospective studies need to be conducted in order to elucidate the mechanism between such cardiac abnormalities and ischemic cerebral disease.

 
   References Top

1.Silver MD, Dorsey JS. Aneurysms of the septum primum in adults. Arch Pathol Lab Med 1978;102:62-5.  Back to cited text no. 1
[PUBMED]    
2.Gondi B, Nanda NC. Two dimensional echocardiographic features of atrial septal aneurysms. Circulation 1981;63:452-7.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Gallet B, Malergue MC, Adams C, Saudemont JP, Collot AM, Druon MC, et al. Atrial septal aneurysm a potential cause of systemic embolism. Br Heart J 1985;53:292-7.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Belkin RN, Hurwitz BJ, Kisslo J. Atrial septal aneurysm: Association with cerebrovascular and peripheral embolic events. Stroke 1987;18:856-62.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Hanley PC, Tajik AJ, Hynes JK, Edwards WD, Reeder GS, Hagler DJ, et al. Diagnosis and classification of atrial septal aneurysm by two dimensional echocardiography: Report of 80 consecutive cases. J Am Coll Cardiol 1985;6:1370-82.  Back to cited text no. 5
[PUBMED]    
6.Schneider B, Haurath P, Vogel P, Meinertz T. Improved morphologic characterization of atrial septal aneurysm by transoesophageal echocardiography: Relation to cerebrovascular events. J Am Coll Cardiol 1990;66:761-4.  Back to cited text no. 6
    
7.Grosgogeat Y, Lhermitte F, Carpentier A, Facquet J, Alhomme P, Tran T. Aneurysm of the interauricular septum revealed by a cerebral embolism. Arch Mal Coeur Vaiss 1973;66:169-77.  Back to cited text no. 7
[PUBMED]    
8.Mugge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon L, et al. Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and tarnsoesophageal echocardiography. Circulation 1965;91:2785-92.  Back to cited text no. 8
    
9.El-Chami MF, Hanna IR, Helmy T, Block PC. Atrial septal abnormalities and cryptogenic stroke: A paradoxical science. Am Heart Hosp J 2005;3:99-104.  Back to cited text no. 9
    

Top
Correspondence Address:
Ravi Kumar Parihar
Department of Pediatrics, S.M.G.S Hospital, Government Medical College Jammu, Jammu and Kashmir
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2069.93726

Rights and Permissions


    Figures

  [Figure 1]

This article has been cited by
1 Risk Factor and Etiology Analysis of Ischemic Stroke in Young Adult Patients
Rosaria Renna,Fabio Pilato,Paolo Profice,Giacomo Della Marca,Aldobrando Broccolini,Roberta Morosetti,Giovanni Frisullo,Elena Rossi,Valerio De Stefano,Vincenzo Di Lazzaro
Journal of Stroke and Cerebrovascular Diseases. 2014;
[Pubmed] | [DOI]



 

Top