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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
Symptoms may begin quickly or slowly depending on the size of the embolus and how much it blocks the blood flow. Symptoms of embolisation in an organ vary with the organ involved but commonly include:
- Pain in the involved body part
- Temporarily decreased organ function
Later symptoms are closely related to infarction of the affected tissue. This may cause permanently decreased organ function.
For example, symptoms of myocardial infarction mainly include chest pain, dyspnea, diaphoresis (an excessive form of sweating), weakness, light-headedness, nausea, vomiting, and palpitations.
Symptoms of limb infarction include coldness, decreased or no pulse beyond the site of blockage, pain, muscle spasm, numbness and tingling, pallor and muscle weakness, possibly to the grade of paralysis in the affected limb.
Arterial emboli often occur in the legs and feet. Some may occur in the brain, causing a stroke, or in the heart, causing a heart attack. Less common sites include the kidneys, intestines, and eyes.
Subclavian steal syndrome (SSS), also called subclavian steal phenomenon or subclavian steal steno-occlusive disease, is a constellation of signs and symptoms that arise from retrograde (reversed) blood flow in the vertebral artery or the internal thoracic artery, due to a proximal stenosis (narrowing) and/or occlusion of the subclavian artery. The arm may be supplied by blood flowing in a retrograde direction down the vertebral artery at the expense of the vertebrobasilar circulation. This is called the "subclavian steal". It is more severe than typical vertebrobasilar insufficiency.
Cardiac ischemia may be asymptomatic or may cause chest pain, known as angina pectoris. It occurs when the heart muscle, or myocardium, receives insufficient blood flow. This most frequently results from atherosclerosis, which is the long-term accumulation of cholesterol-rich plaques in the coronary arteries. Ischemic heart disease is the most common cause of death in most Western countries and a major cause of hospital admissions.
Reduced blood flow to the skin layers may result in mottling or uneven, patchy discoloration of the skin
CT angiography would be helpful in differentiating occlusive from non-occlusive causes of mesenteric ischaemia.
The eyes may show retinal hemorrhage or an exudate. Papilledema must be present before a diagnosis of malignant hypertension can be made. The brain shows manifestations of increased intracranial pressure, such as headache, vomiting, and/or subarachnoid or cerebral hemorrhage. Patients will usually suffer from left ventricular dysfunction. The kidneys will be affected, resulting in hematuria, proteinuria, and acute renal failure. It differs from other complications of hypertension in that it is accompanied by papilledema. This can be associated with hypertensive retinopathy.
Other signs and symptoms can include:
- Chest pain
- Arrhythmias
- Headache
- Epistaxis
- Dyspnea
- Faintness or vertigo
- Severe anxiety
- Agitation
- Altered mental status
- Paresthesias
- Vomiting
Chest pain requires immediate lowering of blood pressure (such as with sodium nitroprusside infusions), while urgencies can be treated with oral agents, with the goal of lowering the mean arterial pressure (MAP) by 20% in 1–2 days with further reduction to "normal" levels in weeks or months. The former use of oral nifedipine, a calcium channel blocker, has been strongly discouraged as it has led to excessive falls in blood pressure with serious and fatal consequences.
Sometimes, the term hypertensive emergency is also used as a generic term, comprising both hypertensive "emergency", as a specific term for a serious and urgent condition of elevated blood pressure, and hypertensive urgency, as a specific term of a less serious and less urgent condition (the terminology hypertensive "crisis" is usually used in this sense).
The primary symptoms of hypotension are lightheadedness or dizziness.
If the blood pressure is sufficiently low, fainting may occur.
Low blood pressure is sometimes associated with certain symptoms, many of which are related to causes rather than effects of hypotension:
- chest pain
- shortness of breath
- irregular heartbeat
- fever higher than 38.3 °C (101 °F)
- headache
- stiff neck
- severe upper back pain
- cough with sputum
- Prolonged diarrhea or vomiting
- dyspepsia (indigestion)
- dysuria (painful urination)
- adverse effect of medications
- acute, life-threatening allergic reaction
- seizures
- loss of consciousness
- profound fatigue
- temporary blurring or loss of vision
- Black tarry stools
Non-occlusive mesenteric ischemia occurs due to severe vasoconstriction of mesenteric vessels supplying the intestine. Acute abdominal pain is the only early acute symptom in those patients, which makes early diagnosis difficult.
Classically, SSS is a consequence of a redundancy in the circulation of the brain and the flow of blood.
SSS results when the short low resistance path (along the subclavian artery) becomes a high resistance path (due to narrowing) and blood flows around the narrowing via the arteries that supply the brain (left and right vertebral artery, left and right internal carotid artery). The blood flow from the brain to the upper limb in SSS is considered to be "" as it is blood flow the brain must do without. This is because of collateral vessels.
As in vertebral-subclavian steal, coronary-subclavian steal may occur in patients who have received a coronary artery bypass graft using the internal thoracic artery (ITA), also known as internal mammary artery. As a result of this procedure, the distal end of the ITA is diverted to one of the coronary arteries (typically the LAD), facilitating blood supply to the heart. In the setting of increased resistance in the proximal subclavian artery, blood may flow backward away from the heart along the ITA, causing myocardial ischemia due to coronary steal. Vertebral-subclavian and coronary-subclavian steal can occur concurrently in patients with an ITA CABG.
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120 mmHg or systolic blood pressure greater than or equal to 180 mmHg. Hypertensive emergency differs from hypertensive crisis in that, in the former, there is evidence of acute organ damage.
A paradoxical embolism, also called a crossed embolism, refers to an embolus which is carried from the venous side of circulation to the arterial side, or vice versa. It is a kind of stroke or other form of arterial thrombosis caused by embolism of a thrombus (blood clot), air, tumor, fat, or amniotic fluid of venous origin, which travels to the arterial side through a lateral opening in the heart, such as a patent foramen ovale, or arteriovenous shunts in the lungs.
The opening is typically an atrial septal defect, but can also be a ventricular septal defect.
Paradoxical embolisms represent two percent of arterial emboli.
The symptoms of pulmonary hypertension include the following:
Less common signs/symptoms include non-productive cough and exercise-induced nausea and vomiting. Coughing up of blood may occur in some patients, particularly those with specific subtypes of pulmonary hypertension such as heritable pulmonary arterial hypertension, Eisenmenger syndrome and chronic thromboembolic pulmonary hypertension. Pulmonary venous hypertension typically presents with shortness of breath while lying flat or sleeping (orthopnea or paroxysmal nocturnal dyspnea), while pulmonary arterial hypertension (PAH) typically does not.
Other typical signs of pulmonary hypertension include an accentuated pulmonary component of the second heart sound, a right ventricular third heart sound, and parasternal heave indicating a hypertrophied right atrium. Signs of systemic congestion resulting from right-sided heart failure include jugular venous distension, ascites, and hepatojugular reflux. Evidence of tricuspid insufficiency and pulmonic regurgitation is also sought and, if present, is consistent with the presence of pulmonary hypertension.
The carotid artery is the large artery whose pulse can be felt on both sides of the neck under the jaw. On the right side it starts from the brachiocephalic trunk (a branch of the aorta) as the common carotid artery, and on the left side the common carotid artery comes directly off the aortic arch. At the throat it forks into the internal and external carotid arteries. The internal carotid artery supplies the brain, and the external carotid artery supplies the face. This fork is a common site for atherosclerosis, an inflammatory buildup of atheromatous plaque that can narrow the lumen of the common or internal carotid arteries.
The plaque can be stable and asymptomatic, or it can be a source of embolization. Emboli break off from the plaque and travel through the circulation to blood vessels in the brain. As the vessel gets smaller, they can lodge in the vessel wall and restrict blood flow to parts of the brain which that vessel supplies. This ischemia can either be temporary, yielding a transient ischemic attack, or permanent resulting in a thromboembolic stroke.
Clinically, risk of stroke from carotid stenosis is evaluated by the presence or absence of symptoms and the degree of stenosis on imaging.
Transient ischemic attacks (TIAs) are a warning sign, and may be followed by severe permanent strokes, particularly within the first two days. TIAs by definition last less than 24 hours and frequently take the form of a weakness or loss of sensation of a limb or the trunk on one side of the body, or the loss of sight (amaurosis fugax) in one eye. Less common symptoms are artery sounds (bruits), or ringing in the ears (tinnitus).
Embolism can be classified as to where it enters the circulation either in arteries or in veins. Arterial embolism are those that follow and, if not dissolved on the way, lodge in a more distal part of the systemic circulation. Sometimes, multiple classifications apply; for instance a pulmonary embolism is classified as an arterial embolism as well, in the sense that the clot follows the pulmonary artery carrying deoxygenated blood away from the heart. However, pulmonary embolism is generally classified as a form of venous embolism, because the embolus forms in veins, e.g. deep vein thrombosis.
Arterial stiffness occurs as a consequence of biological aging and arteriosclerosis. Inflammation plays a major role in arteriosclerosis development, and consequently it is a major contributor in large arteries stiffening. Increased arterial stiffness is associated with an increased risk of cardiovascular events such as myocardial infarction and stroke, the two leading causes of death in the developed world. The World Health Organisation predicts that in 2010, cardiovascular disease will also be the leading killer in the developing world and represents a major global health problem.
Several degenerative changes that occur with age in the walls of large elastic arteries are thought to contribute to increased stiffening over time, including the mechanical fraying of lamellar elastin structures within the wall due to repeated cycles of mechanical stress; changes in the kind and increases in content of arterial collagen proteins, partially as a compensatory mechanism against the loss of arterial elastin and partially due to fibrosis; and crosslinking of adjacent collagen fibers by advanced glycation endproducts (AGEs).
Arterial embolism can cause occlusion in any part of the body. It is a major cause of infarction, tissue death due to the blockage of blood supply.
An embolus lodging in the brain from either the heart or a carotid artery will most likely be the cause of a stroke due to ischemia.
An arterial embolus might originate in the heart (from a thrombus in the left atrium, following atrial fibrillation or be a septic embolus resulting from endocarditis). Emboli of cardiac origin are frequently encountered in clinical practice. Thrombus formation within the atrium occurs mainly in patients with mitral valve disease, and especially in those with mitral valve stenosis (narrowing), with atrial fibrillation (AF). In the absence of AF, pure mitral regurgitation has a low incidence of thromboembolism.
The risk of emboli forming in AF depends on other risk factors such as age, hypertension, diabetes, recent heart failure, or previous stroke.
Thrombus formation can also take place within the ventricles, and it occurs in approximately 30% of anterior-wall myocardial infarctions, compared with only 5% of inferior ones. Some other risk factors are poor ejection fraction (<35%), size of infarct, and the presence of AF. In the first three months after infarction, left-ventricle aneurysms have a 10% risk of emboli forming.
Patients with prosthetic valves also carry a significant increase in risk of thromboembolism. Risk varies, based on the valve type (bioprosthetic or mechanical); the position (mitral or aortic); and the presence of other factors such as AF, left-ventricular dysfunction, and previous emboli.
Emboli often have more serious consequences when they occur in the so-called "end circulation": areas of the body that have no redundant blood supply, such as the brain and heart.
Hypotension is low blood pressure, especially in the arteries of the systemic circulation. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. A systolic blood pressure of less than 90 millimeters of mercury (mm Hg) or diastolic of less than 60 mm Hg is generally considered to be hypotension. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.
Hypotension is the opposite of hypertension, which is high blood pressure. It is best understood as a physiological state, rather than a disease. Severely low blood pressure can deprive the brain and other vital organs of oxygen and nutrients, leading to a life-threatening condition called shock.
For some people who exercise and are in top physical condition, low blood pressure is a sign of good health and fitness.
For many people, excessively low blood pressure can cause dizziness and fainting or indicate serious heart, endocrine or neurological disorders.
Treatment of hypotension may include the use of intravenous fluids or vasopressors. When using vasopressors, trying to achieve a mean arterial pressure (MAP) of greater than 70 mmHg does not appear to result in better outcomes than trying to achieve a MAP of greater than 65 mm Hg in adults.
Carotid stenosis is a narrowing or constriction of the inner surface (lumen) of the carotid artery, usually caused by atherosclerosis.
According to WHO classification there are 5 groups of PH, where Group I (pulmonary arterial hypertension) is further subdivided into Group I' and Group I" classes. The most recent WHO classification system (with adaptations from the more recent ESC/ERS guidelines shown in italics) can be summarized as follows:
WHO Group I – Pulmonary arterial hypertension (PAH)
- Idiopathic
- Heritable (BMPR2, ALK1, SMAD9, caveolin 1, KCNK3 mutations)
- Drug- and toxin-induced (e.g., methamphetamine use)
- Associated conditions:Connective tissue disease, HIV infection, Portal hypertension, Congenital heart diseases, Schistosomiasis
WHO Group I' – Pulmonary veno-occlusive disease (PVOD), pulmonary capillary hemangiomatosis (PCH)
- Idiopathic
- Heritable (EIF2AK4 mutations)
- Drugs, toxins and radiation-induced
- Associated conditions:connective tissue disease, HIV infection
WHO Group I" – Persistent pulmonary hypertension of the newborn
WHO Group II – Pulmonary hypertension secondary to left heart disease
- Left ventricular Systolic dysfunction
- Left ventricular Diastolic dysfunction
- Valvular heart disease
- Congenital/acquired left heart inflow/outflow tract obstruction and congenital cardiomyopathy
- Congenital/acquired pulmonary venous stenosis
WHO Group III – Pulmonary hypertension due to lung disease, chronic hypoxia
- Chronic obstructive pulmonary disease (COPD)
- Interstitial lung disease
- Mixed restrictive and obstructive pattern pulmonary diseases
- Sleep-disordered breathing
- Alveolar hypoventilation disorders
- Chronic exposure to high altitude
- Developmental abnormalities
WHO Group IV – chronic arterial obstruction
- Chronic thromboembolic pulmonary hypertension (CTEPH)
- Other pulmonary artery obstructions
- Angiosarcoma or other tumor within the blood vessels
- Arteritis
- Congenital pulmonary artery stenosis
- Parasitic infection (hydatidosis)
WHO Group V – Pulmonary hypertension with unclear or multifactorial mechanisms
- Hematologic diseases: chronic hemolytic anemia (including sickle cell disease)
- Systemic diseases: sarcoidosis, pulmonary Langerhans cell histiocytosis: lymphangioleiomyomatosis, neurofibromatosis, vasculitis
- Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid diseases
- Others: pulmonary tumoral thrombotic microangiopathy, fibrosing mediastinitis, chronic kidney failure, segmental pulmonary hypertension (pulmonary hypertension restricted to one or more lobes of the lungs)
Characteristic symptoms are:
- Sudden penetrating pain in the legs, lower back or abdomen
- Confusion, psychosis, slurred speech
- Severe lethargy
- Convulsions
- Fever
- Hyperkalemia (elevated potassium level in the blood)
- Hypercalcemia (elevated calcium level in the blood): the cause of hypercalcemia is a combination of increased calcium input into the extracellular space and reduced calcium removal by the kidney, this last caused by decreased glomerular filtration and increased tubular calcium reabsorption. Both renal factors are secondary to volume depletion and, in fact, improve rapidly during rehydration with saline infusion.
- Hypoglycemia (reduced level of blood glucose)
- Hyponatremia (low sodium level in the blood)
- Hypotension (low blood pressure)
- Hypothyroid (low T4 level)
- Severe vomiting and diarrhea, resulting in dehydration
- Syncope (loss of consciousness and ability to stand)
Because pulmonic regurgitation is the result of other factors in the body, any noticeable symptoms are ultimately caused by an underlying medical condition rather than the regurgitation itself. However, more severe regurgitation may contribute to right ventricular enlargement by dilation, and in later stages, right heart failure. A diastolic decrescendo murmur can sometimes be identified,( heard best) over the left lower sternal border.
Symptoms of aortic insufficiency are similar to those of heart failure and include the following:
- Dyspnea on exertion
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Palpitations
- Angina pectoris
- Cyanosis (in acute cases)
Cavernous sinus thrombosis is a specialised form of cerebral venous sinus thrombosis, where there is thrombosis of the cavernous sinus of the basal skull dura, due to the retrograde spread of infection and endothelial damage from the danger triangle of the face. The facial veins in this area anastomose with the superior and inferior ophthalmic veins of the orbit, which drain directly posteriorly into the cavernous sinus through the superior orbital fissure. Staphyloccoal or Streptococcal infections of the face, for example nasal or upper lip pustules may thus spread directly into the cavernous sinus, causing stroke-like symptoms of double vision, squint, as well as spread of infection to cause meningitis.
Arterial thrombosis is the formation of a thrombus within an artery. In most cases, arterial thrombosis follows rupture of atheroma (a fat-rich deposit in the blood vessel wall), and is therefore referred to as "atherothrombosis". Arterial embolism occurs when clots then migrate downstream, and can affect any organ.
Alternatively, arterial occlusion occurs as a consequence of embolism of blood clots originating from the heart ("cardiogenic" emboli). The most common cause is atrial fibrillation, which causes a blood stasis within the atria with easy thrombus formation, but blood clots can develop inside the heart for other reasons too.