Dr. Ambekar Sudheer
Neurosurgery
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I have a question about my father. He is 75 years old, eats healthy, and drinks at least two liters of water daily. He has had atrial fibrillation for the past five years, and for that, he takes Xarelto 15 mg and Amlodipine accord 5 mg. He takes them in the morning, and that is always good. Unfortunately, he had a brain stroke on the left part. He walked to the ambulance. On the next day, he had lesser movement on the left side (mouth, arm, leg, and difficulties with swallowing). Yesterday, it was worse, and the doctors say he had a stuttering stroke because the situation is getting worse. Because of a little fever and high cholesterol, he gets something for cholesterol and an antibiotic called Ceftriaxone. The doctors think the worse is now over, but still a little risk for the next 48 hours. My question is that we see on the monitor every day fewer peaks in his heartbeat. Please see the pictures, the doctors say that it is an extra heartbeat and does not matter, his regular heartbeat is around sixty, and now it is around 80. Could it be his heart is weakening?
Hello, Welcome to icliniq.com.
In atrial fibrillation, the heart beats can vary in frequency and height (amplitude). What is more important in these patients is that the rate needs to be controlled and not above 100 beats per minute. Also, one must make sure that no clot forms in the heart due to the abnormal heartbeats. I have seen the monitor pictures (attachment removed to protect patient identity) and they do not look concerning. One must make sure that there is no clot forming in the heart which can give rise to the stuttering nature of the stroke as in his case. I would recommend a transesophageal echocardiogram to detect the presence of thrombus in the left atrium. If the thrombus is present, he requires anticoagulation with heparin. If the thrombus is absent, oral anticoagulants are enough.
Patient's Query
Hello doctor, Thanks for your reply.
They did scan twice his main arteries through the neck up to the brain, and they were clear. Would you suggest still that they control the heart with a transesophageal echocardiogram? If there are still blood clots in the heart, is the only way to see them through the scan you mention? And would they not resolve because of the medication he gets? They also saw on the CT (computed tomography) scan yesterday where the damaged area is, but they did not see the blood clot. So, is it gone? And would it not be good to give it, for now, heparin due to its side effects?
Hello, Welcome back to icliniq.com.
Yes, I recommend doing a transesophageal echocardiogram to detect any clot in the heart. The CT (Computed tomography) scan that the patient has undergone is the scan of the brain which may or may not to take the clot because the clots in the brain are too tiny to be able to be seen on the CT scan. I recommend we do an echo to look for clots in the heart. If there are clots in the heart, the patient will need to be on intravenous anticoagulants like heparin. If there are no clots in the heart the patient needs to be on oral anticoagulants.
Patient's Query
Hello doctor,
Thanks for the reply. I will ask the doctor that, and come back to you.
Hello,
Welcome back to icliniq.com.
Alright.
Patient's Query
Hello doctor,
They think the brain infarct is unrelated to his heart fibrillation. Would that be logical? Can you explain where do blood clots start? Is that always in the heart? I just spoke to the doctor. They do not think the clot came from the heart but say because he already has Xeralto there is no need for a second or different one like Heparin. He has a little fever because of a bladder infection and gets for that also medication. What is your advice about that?
Hello, Welcome back to icliniq.com.
The blood clot can originate in the heart or in the carotid arteries in the neck. In a patient with atrial fibrillation, it is logical to suspect that the blood clot originated in the heart. Xarelto does thin the blood. But, it Is not necessary that the blood clot cannot form if someone is on Xeralto. I would do a transesophageal echocardiogram and an MRI of the brain along with MR angiography of the neck and the brain to look for the source of the blood clot.
Patient's Query
Hello doctor,
They did a CT scan on two separate days and they did also MRI brain and the MR angiography of the neck. The arteries in the neck were very good they say and they cannot see the blood clot in the brain but just the damaged area. The cause of all this they think is from his heart abnormality but they never do an esophageal echocardiogram they say. I will receive copies of the scans and will send them to you for a second review. Unfortunately, I will get them not before next week but will call in then again. I have a last question, my father gets now therapy for his left arm and left leg and this will continue in the recovery clinic where he is going next week. Should the heartbeat stay then also under the 100, or is this just for now? Because to practice some movements you see his face gets a little bit red and that costs him a lot of energy. I would also like to mention that I am grateful that you take the time for this and that an app like this exists. It gives a good second view of what is happening and also the doctors here take their time but many things go too fast and now I can read it back with you.
Thank you.
Hello,
Welcome back to icliniq.com.
In chronic atrial fibrillation, the heart rate needs to be controlled and needs to be monitored periodically. Despite being on physical therapy the heart rate needs to be below 100. I still feel that a transesophageal echocardiogram will be of benefit especially if the MRA of the neck does not show any blockages. I wish your father a speedy recovery.
Patient's Query
Hello doctor,
One more question. If there still are blood clots in the heart, how long do they pose a risk? Do they go dissolve after some time or with the current medication? I mean does the human body not break them down with time? They did make a lung photo because they think he might have a lung infection and they make that conclusion because he has no fever but still in the blood they see infection levels in the blood. The lung photo will be ready in a few hours but in no lung infection could there be somewhere else an infection? Because beginning this week they say he had a urine infection and know it is clear that that was not the case, can the brain or the heart also have an infection? Strange is that since two days there is no fever. So, that is good.
Hello, Welcome back to icliniq.com.
Blood clots may dissolve on their own if the medications are continued. But, there is a chance of them going into the brain again. The common sources of infection are lung and urine. Make sure he drinks a lot of water.
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