Atrial Fibrillation and Systemic Embolization

An elderly was admitted due to abdominal pain and confusion.

BP 160/90, HR irregular, not in distress, afebrile, O2sat 96%. Abdomen distended but no tenderness, no focal weakness. CBC unremarkable except for WBC 13.5, lytes - N, BUN- 15, creatinine - 1.4, INR -1, UA unremarkable except for proteinuria.

What is the rhythm and its relationship to the CT and MRI images?

Image 1 - Composite image - Long lead II, CT of the abdomen and MRI of the brain

The rhythm is atrial fibrillation. 

Image on the left and middle is the CT of the abdomen 

RED ARROW - showing embolus occluding the proximal mesenteric artery 

BLUE CIRCLE - showing embolus occluding the R renal artery with renal infarction.

Image on the right is the MRI of brain (diffusion weighted imaging - DWI) 

GREEN CIRCLE - showing an infarct on the L cerebellum

Back to the case

So, there are embolic events in the superior mesenteric artery, renal artery and the brain due to the atrial fibrillation. Thrombolysis was done on the superior mesenteric artery. Patient was also started on heparin bridge and coumadin anticoagulation. Nephrology was on-board for the renal failure (increasing creatinine). Patient was later discharged with therapeutic INR.

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