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Infarction

Infarctions

Infarction is defined as the obstruction of a local blood supply which results in a lack of oxygen (ischemia) and possibly the death of the local tissue.


Presentation

Infarction might be classified according to its location. 8 main types of infarctions are distinguished:

  • Heart infarction: Commonly known as myocardial infarction or heart attack, it is the most common and best known of the infarctions. The death of the cells is due to occlusion occurring in the coronary arteries which takes place soon after the rupture of a vulnerable atherosclerotic plaque. The rupture is due to the instability of the plaque itself, as consequence of an unstable collection or storage of lipids and white blood cells along the coronary wall. This type is also one of the most dangerous, since its consequences, the impaired activity of the heart, and has a systemic effect involving the whole body.
  • Brain infarction: In this case the blockage appears in a vessel supplying blood to the brain. The blockage might be both atherothrombotic or embolic in origin [17], and it results in a stroke. It is important to remember that a stroke may be not only the result of an infraction, but also of a cerebral hemorrhage, usually due to increased exertion, tension and stress [18], or a subarachnoid hemorrhage, much less common [19] but always equally dangerous and fatal. One third of the cases of this type of infarction result in death.
  • Pulmonary infarction: Due to the occurrence of a blockage of arteries running to the lungs causing the death of part of the pulmonary structure [20]. 
  • Spleen infarction: This occurs when the splenic artery or one of its branches becomes blocked. It is often asymptomatic, but may also cause an intense pain interesting the left quadrant of the abdomen, which might even radiate to the left shoulder. These signs can be coupled with fever and chills [21].
  • Limb infarction: This type interests arms and legs and its causes include diabetes mellitus and its complications like skeletal muscle infarction [22]. The infarction is usually characterized by painful thighs and leg swelling.
  • Bone infarction: This type is famous for resulting in avascular necrosis, that is the death of the bone components and bone collapse [23]. 
  • Testicular infarction: The main cause of this infarction is the previously mentioned testicular torsion, and it is particularly frequent in people under 25 years of age [24] [25].
  • Ocular infarction: This infarction frequently involves the central retinal artery which supplies the retina, and it is famous for causing a sudden loss of sight. 
Fever
  • The symptoms of infarcts are generally spitting up of blood, coughing, fever, moderate difficulty in breathing, increased heartbeat, pleural rubbing, diminished breath sounds, and a dull sound heard when the chest is tapped.[britannica.com]
  • Fever and chills develop in some cases. [8] It has to be differentiated from other causes of acute abdomen . Limb : Limb infarction is an infarction of an arm or leg .[en.wikipedia.org]
  • […] an aseptic fever caused by liberation of pyrogens from damaged tissue. intestinal infarction a common occurrence in horses due to occlusion of arteries by larvae of Strongylus vulgaris.[medical-dictionary.thefreedictionary.com]
  • These signs can be coupled with fever and chills. Limb infarction: This type interests arms and legs and its causes include diabetes mellitus and its complications like skeletal muscle infarction.[symptoma.com]
  • In the evening, she developed a mild fever. On the following day, she awoke early in the morning because of a severe precordial pain. She stated that the pain felt like a weight pushing on her chest.[pediatrics.aappublications.org]
Sepsis
  • […] citing sepsis as the etiology for T2MI ( 20 , 22 , 24 ).[clinchem.aaccjnls.org]
  • Associated diseases [ edit ] Diseases commonly associated with infarctions include: Peripheral artery occlusive disease (the most severe form of which is gangrene ) Antiphospholipid syndrome Sepsis Giant-cell arteritis (GCA) Hernia Volvulus Sickle-cell[en.wikipedia.org]
  • A rapid increase in copeptin can be associated with stroke, sepsis, or acute myocardial injury. In conjunction with troponin, copeptin has high negative predictive value to rule out myocardial injury. References Anversa P, Sonnenblick EH.[library.med.utah.edu]
  • […] tachycardic and bradycardic) Heart block Takotsubo Infiltrative diseases Inflammatory diseases Drugs and toxins Troponin elevation in non-cardiac conditions Pulmonary diseases Pulmonary embolism Pulmonary hypertension (HTN) Respiratory failure Renal failure Sepsis[clinicaladvisor.com]
  • Nonatherosclerotic causes of MI include the following: Coronary occlusion secondary to vasculitis Ventricular hypertrophy (eg, left ventricular hypertrophy, hypertrophic cardiomyopathy) Coronary artery emboli, secondary to cholesterol, air, or the products of sepsis[emedicine.medscape.com]
Anemia
  • In hospital, a full blood count might be useful to rule out other possible conditions such as anemia. It is also important to analyze key enzymes like troponins or myocardial muscle creatine kinase.[symptoma.com]
  • […] where a condition without an acute atherothrombotic event contributes to an imbalance between myocardial oxygen supply and/or demand, such as coronary endothelial dysfunction, coronary artery spasm, coronary embolism, tachyarrhythmias, bradyarrhythmias, anemia[clinchem.aaccjnls.org]
  • Examples include coronary vasospasm. coronary artery embolus, anemia, arrhythmias, respiratory failure and hemodynamic instability.[clinicaladvisor.com]
  • Type 2 (MI secondary to an ischemic imbalance): MI consequent to increased oxygen demand or a decreased supply (eg, coronary endothelial dysfunction, coronary artery spasm, coronary artery embolus, tachyarryhthmias/bradyarrhythmias, anemia, respiratory[emedicine.medscape.com]
Leg Swelling
  • Causes include arterial embolisms and skeletal muscle infarction as a rare complication of long standing, poorly controlled diabetes mellitus . [9] A major presentation is painful thigh or leg swelling. [9] Bone : Infarction of bone results in avascular[en.wikipedia.org]
  • The infarction is usually characterized by painful thighs and leg swelling. Bone infarction: This type is famous for resulting in avascular necrosis, that is the death of the bone components and bone collapse. [symptoma.com]
Gangrene
  • Similar occlusion to blood flow and consequent necrosis can occur as a result of severe vasoconstriction as illustrated in severe Raynaud's phenomenon that can lead to irreversible gangrene .[en.wikipedia.org]
  • […] myocardial (acute) (with stated duration of 4 weeks or less) - I21.9 non-Q wave - I21.4 non-ST elevation(NSTEMI) - I21.4 nontransmural - I21.4 nontransmural - I21.4 subendocardial(acute) (nontransmural) - I21.4 Necrosis, necrotic(ischemic) — See also Gangrene[icd10coded.com]
Withdrawn
  • In other types of infarction, like cerebral infarction, the clinician can also use a corkscrew-like device to ensnare the blood clot, which is then withdrawn from the body while removing the catheter.[symptoma.com]

Workup

As for etiology, the diagnosis of infarction depends on the type concerned. Let us consider yet again the cases of myocardial and cerebral infarction, the most frequent and widespread among patients:

  • Diagnosis for myocardial infarction: Electrocardiogram is highly advised, especially in a pre-hospital setting when diagnosis is uncertain. Typical features include new ST segment elevations and T-wave inversions. In hospital, a full blood count might be useful to rule out other possible conditions such as anemia. It is also important to analyze key enzymes like troponins or myocardial muscle creatine kinase. Imaging studies, instead, like echocardiography or X-rays, might be useful to analyse other parameters like heart’s size and the extent of the infarction itself. 
  • Cerebral Infarction: CT and MRI scans are paramount. In addition, other important tests are carried out, like the test for sickle cell disease, hypoglycemia and hypertension, to exclude other possible pathological conditions.

Treatment

There are two main interventions used to remove a blockage in the blood vessels causing an episode of infarction: breaking down the blood clot using an appropriate drug or removing the clot mechanically. The more rapidly the clot is removed and the flow is restored, the lower the final level of damage.

A classic example of intervention aimed at mechanically removing the blood clot responsible for the episode of infarction is percutaneous coronary intervention, commonly known as coronary angioplasty, used to treat the coronary arteries in coronary heart disease. The operation is often performed by inserting a deflated balloon on a catheter in the femoral artery and push it through the blood vessels until it reaches the site of blockage. Once reached the blockage, the balloon is then inflated to re-open the artery and a stent may be placed there to hold open the blood vessel and prevent re-narrowing. The stent stays in place permanently as the blood vessel lining heals over it. While performing the delicate intervention, the clinician uses X-ray imaging to guide the movements of the catheter. In other types of infarction, like cerebral infarction, the clinician can also use a corkscrew-like device to ensnare the blood clot, which is then withdrawn from the body while removing the catheter.

The blood clot can also be chemically dissolved by using thrombolytic drugs. These agents mostly work by activating the enzyme plasminogen, famous for degrading many blood plasma proteins including fibrin clots. The plasmonigen so activated clears the cross-linked fibrin mesh (the core of the clot) which in turns becomes soluble and subject to further proteolysis by other enzymes, until it is completely dissolved and the blood flow is entirely restored.

Prognosis

The short term prognosis of infarction might be very poor involving the perennial damage of the local tissue, if the problem is not promptly treated. On the long run, survival rate has increased dramatically over the last two decades. In fact, the prognosis is very good for most people that reach the hospital soon after the appearance of the symptoms. However, the cases of subjects experiencing sudden death, that do not even make it to the hospital, still remains relatively frequent. Therefore, prevention is paramount to effectively treat infarction and its long and short term side effects.

Etiology

The other most common causes of infarction include thrombosis and embolism in the artery nearby the site of the infarction itself. Thrombosis is defined as the formation of a blood clot which obstructs the blood flow, and this usually occurs when a vessel is injured. In fact, after an injury the platelets and fibrin form a clot to prevent blood loss. This clot might break free and begin to travel as a solid mass which blocks local blood vessels (especially small sized ones like capillaries). The floating mass might be gaseous or liquid in nature and is called embolus [4] and its formation embolism. An embolus generally goes away from the site of formation to reach distant sites. In both case, this occlusion of local blood vessels provokes a decreased blood supply which eventually results in infarction and the death of the local tissue.

Other less common causes of infarction include:

  • Local vessel spasm (or vasospasm): The blood vessels might locally narrow, reducing the lumen diameter and resulting in a diminished blood flow.
  • Compression of arteries by a tumor: A tumor can be present in the close vicinity of an important artery. As it grows it can compress the artery concerned leading to its forced occlusion [5] [6].
  • Torsion of artery: An event that can happen in testicular torsion, particularly frequent soon after birth and during puberty [7], or volvulus, which occurs with the formation of a loop around a focal point along the mesentery attached to the intestinal tract [8]. 
  • Rupture of blood vessel: This is usually due to a trauma and might also result in infarction.

Furthermore, infarction should not be confused with congestion. In fact, congestion usually occurs when veins are occluded. An occluded vein always results in ischemia, but the common outcome of this condition is the formation of some bypass channels which helps the blood flood and improves vein drainage with the blood moving away from the site of congestion. However, sometime infarction might result from congestion, and this happens when congestion occurs in those organs with a single efferent vein such as ovaries. Thus, the only outcome possible for the blockage of that single efferent vein is inevitably infarction.

Epidemiology

The etiology of infarction depends on the type taken into consideration. Let us consider the most important types, myocardial infarction and cerebral infarction:

  • Etiology of myocardial infarction: In 2004, the World Health Organization estimated that 12,2 % of the deaths worldwide were due to ischemic heart disease [9]. It is one of the world’s most common causes of death, especially in rich countries, followed by other dangerous diseases or conditions such as cancer and stroke. Although the rates of death have slightly decreased over the last decades in high-income countries, myocardial infarction was still responsible for one in three deaths in the United States in 2008 [10] [11]. The trend is also seen in developing countries like India, where myocardial infarction still accounts for 1.46 millions of deaths (14% of the total) each year, attesting itself as one of the most common cause death [12].
  • Etiology of cerebral infarction: Stroke is also one of the most important causes of death in rich countries like the United States [13], where it is responsible for approximately 795,000 cases. According to the World Health Organization, around 15 millions of people suffer from stroke worldwide each year, 5 millions of whom die and the remaining 10 millions left permanently disabled [14]. Furthermore, stroke appears to be more frequent in blacks [15], males and elderly [16].
Sex distribution
Age distribution

Pathophysiology

The pathophysiology of the most common type of infarction, the type due to the formation of an atherosclerotic plaque, is described here. In this case the blood flow is blocked, and this causes the damage of the tissue nearby because, as previously said, it no longer gets an adequate amount of oxygen from the blood. In the case of a myocardial infarction, the blockage affects usually the coronary arteries, even though occlusions and spasms are also frequent enough. The inside of the blood vessel narrows and hardens, because of the buildup of the plaque of fatty material, and the blood flood to the heart muscles is decreased. If the plaque cracks or breaks open, a blood clot forms on the surface of the plaque itself, and the latter, also called thrombus, completely blocks the blood flow in the artery. Once the blood flow is blocked, infarction takes place, as a part of the surrounding tissue becomes damaged. In the case of myocardial infarction, the damage of the heart muscles that might finally result in the impaired activity of the heart, which can no longer pump blood into the body in a proper manner, if not completely becoming unable to do so. If the block is not promptly removed, the damaged tissue will begin to die and be replaced by scar tissue. It is important to remember that this damage might not be obvious and might cause severe and long-lasting symptoms.

Prevention

Prevention is mainly based on avoiding the formation of a build-up of fatty materials in the blood vessels, which is the primary cause of all types of infarction. This can be achieved through a series of important changes in lifestyle, like stopping the use of tobacco, performing physical exercise on a daily basis (at least 30 minutes a day, five times a week), following an healthy die, and avoiding stress.

Summary

The key event underlying infarction is the block of the local blood supply which comes as consequence of different circumstances. For example, the obstruction might be caused by the presence of a block which prevents the blood from flowing, like an embolus (gaseous or liquid mass), a thrombus (a compact mass of other blood elements) or an atherosclerotic plaque, or it might be caused by a mechanical compression (tumor or hernia), a trauma or a vasoconstriction.

The most frequent of these causes is undoubtedly the development of an atherosclerotic plaque, in other words the accumulation of degenerative material in the tunica intima which mainly consists of macrophage cells [1] [2], debris, lipids, calcium and fibrous connective tissue. Eventually, the plaque is degraded by metalloproteinases or by the sheer force of the blood flow, and the subendothelial thrombogenic material, that is the collection of extracellular molecules providing structural and biochemical support to surrounding cells [3], is exposed to circulating platelets and provokes thrombus formation.

Patient Information

Infarction is defined as the obstruction of a local blood supply which results in a lack of oxygen (ischemia) and possibly the death of the local tissue. The main causes of infarction include the formation on an embolus (a gaseous or liquid mass), a thrombus (a compact mass of blood elements), and an atherosclerotic plaque. Other possible but less common causes include vessel spasm, compression by a nearby tumor, artery torsion, and vessel rupture.

Infarction is usually classified according to the site of the blockage. The main ones include: heart infarction, cerebral infarction, and pulmonary infarction. The treatment of this pathological condition basically involves the mechanical removal of the blockage or its chemical dissolution through thrombolytic drugs. Since the formation of the blockage is a long term event, largely based on an unhealthy lifestyle, prevention is paramount and include changes like stopping the use of tobacco, performing physical exercise, following an healthy diet, and avoiding stress

References

Article

  1. Hotamisligil GS. Endoplasmic reticulum stress and atherosclerosis. Nature Medicine 2010 16 (4): 396–9.
  2. Oh J, Riek AE, Weng S, Petty M, Kim D, Colonna M, Cella M, Bernal-Mizrachi C. Endoplasmic reticulum stress controls M2 macrophage differentiation and foam cell formation. Journal of Biological Chemistry 2012 287 (15): 11629–41.
  3. Gurvan M, Tonon T, Scornet D, Cock MJ, Kloareg B. The cell wall polysaccharide metabolism of the brown alga Ectocarpus siliculosus. Insights into the evolution of extracellular matrix polysaccharides in Eukaryotes. New Phytologist 210 188 (1): 82–97.
  4. Dorland's. Dowland's Illustrated Medical Dictionary 2012 (32nd ed.). Elsevier. p. 606.
  5. Katz ES, Shah A, Rosenzweig BP, Tunick PA, Kronzon I. Bilateral pulmonary artery compression and obstruction by tumor: diagnosis by unusual Doppler flow patterns. J Am Soc Echocardiogr. 2003 Feb;16(2):185-7.
  6. Takefumi Ozaki, MD, PhD, Satoru Chiba, MD, PhD, Kazuya Annen, MD, PhD, Yuji Kawamukai, MD, PhD, Nobuyuki Kohno, RT, Masashi Horimoto, MD, PhD, FJCC. Acute coronary syndrome due to coronary artery compression by a metastatic cardiac tumor. Journal of Cardiology Cases, Volume 1, Issue 1, February 2010, Pages e52–e55.
  7. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. American family physician 2013 88 (12): 835–40.
  8. Wedding ME, Gylys BA. Medical Terminology Systems: A Body Systems Approach (Medical Terminology (W/CD & CD-ROM) (Davis)). Philadelphia, Pa: F. A. Davis Company. 2004
  9. World Health Organization. The Global Burden of Disease: 2004 Update. Geneva: World Health Organization.
  10. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB et al. Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 2012 125 (1): 188–97.
  11. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. American Heart Association Statistics Committee and Stroke Statistics, Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 2015 131 (4): e29–322.
  12. Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S. Epidemiology and causation of coronary heart disease and stroke in India. Heart 2008 94 (1): 16–26.
  13. Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead. Stroke. 2011 Aug. 42(8):2351-5.
  14. MacKay J, Mensah GA. World Health Organization. Global Burden of Stroke. The Atlas of Heart Disease and Stroke
  15. Schneider AT, Kissela B, Woo D, Kleindorfer D, Alwell K, Miller R, et al. Ischemic stroke subtypes: a population-based study of incidence rates among blacks and whites. Stroke. 2004 Jul. 35(7):1552-6.
  16. Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead. Stroke. 2011 Aug. 42(8):2351-5.
  17. Ropper AH, Adams RD, Brown RF, Victor M. Adams and Victor's principles of neurology. New York: McGraw-Hill Medical Pub. 2005 Division. pp. 686–704.
  18. Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A. Endoscopic management of hypertensive intraventricular haemorrhage with obstructive hydrocephalus. BMC Neurol 2007 7: 1.
  19. Feigin VL, Rinkel GJ, Lawes CM et al.. Risk factors for subarachnoid hemorrhage: an updated systematic review of epidemiological studies. Stroke 2005 36 (12): 2773–80.
  20. Cagle PT. Color atlas and text of pulmonary pathology (2 ed.). Philadelphia: Lippincott Williams & Wilkins. 2008 p. 291.
  21. Nores M, Phillips EH, Morgenstern L, Hiatt JR. The clinical spectrum of splenic infarction. The American surgeon 1998 64 (2): 182–8.
  22. Grigoriadis E, Fam AG, Starok M, Ang LC. Skeletal muscle infarction in diabetes mellitus. The Journal of rheumatology 2000 27 (4): 1063–8.
  23. Digiovanni CW, Patel A, Calfee R, Nickisch F. Osteonecrosis in the foot. The Journal of the American Academy of Orthopaedic Surgeons 2007 15 (4): 208–17.
  24. Wampler SM, Llanes M. Common scrotal and testicular problems. Prim. Care 2010 37 (3): 613–26, x.
  25. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician 2006 74 (10): 1739–43.

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