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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 239-240

Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis


Department of Neurology, Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Submission15-Feb-2012
Date of Decision29-Feb-2012
Date of Acceptance11-Mar-2012
Date of Web Publication19-May-2012

Correspondence Address:
P N Sylaja
Department of Neurology, Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96424

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How to cite this article:
Sukumaran S, Jayadevan E R, Mandilya A, Sreedharan SE, Harikrishnan S, Radhakrishnan N, Sylaja P N. Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis. Neurol India 2012;60:239-40

How to cite this URL:
Sukumaran S, Jayadevan E R, Mandilya A, Sreedharan SE, Harikrishnan S, Radhakrishnan N, Sylaja P N. Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis. Neurol India [serial online] 2012 [cited 2015 Jul 30];60:239-40. Available from: http://www.neurologyindia.com/text.asp?2012/60/2/239/96424


Sir,

The safety and efficacy of thrombolysis in acute ischemic stroke due to infective endocarditis is not well established and case reports have shown conflicting results. [1],[2],[3],[4],[5] The risk of precipitating a hemorrhage following thrombolytic therapy in patients with infective endocarditis and possible mycotic aneurysms must be weighed against the benefit of the treatment. We report successful mechanical recanalization of middle cerebral artery (MCA) occlusion by vegetation using solitaire device with pathological demonstration of gram-positive cocci in the vegetation.

A 33-year-old male, a known case of rheumatic mitral stenosis, presented with fever and malaise of 1 month duration. On examination, he was febrile, pulse was regular, and blood pressure was 124/80 mm Hg. Cardiac examination revealed a mid-diastolic murmur. Erythrocyte sedimentation rate was 58 mm in the first hour, and C-reactive protein was 101 ng/L. Echo showed severe mitral stenosis (mitral orifice 2 cm 2 ) and 14 × 4 mm mobile mass attached to the anterior mitral leaflet. Blood culture yielded alpha hemolytic streptococci. With a diagnosis of infective endocarditis, he was started on parenteral penicillin and gentamicin. On the third day, he developed right hemiplegia with motor aphasia. On examination, his National Institute of Health Stroke Scale (NIHSS) score was 14. Emergent non-enhanced head computed tomography (CT) scan within 45 min of symptom onset revealed hyperdense MCA sign with early ischemic changes in left lentiform nucleus (ASPECTS 9) [Figure 1]a and CT angiogram revealed occlusion of left M1 segment of MCA. In view of the high possibility of septic embolic M1 occlusion, he was shifted for emergent intra-arterial treatment. Catheter angiogram showed left M1 occlusion. Mechanical thrombectomy was attempted with solitaire device. The left M1 recanalized fully with complete recanalization of its anterior division and partial recanalization of the posterior division [Figure 1]b and c. Recanalization occurred 2 h 30 min after the stroke onset. Post procedure, NIHSS improved to 4 at 24 h and to 0 on day 4 after the stroke. Histopathology of the retrieved embolic material showed eosinophilic fibrinoid material with scanty infiltrating inflammatory cells. Gram staining showed clusters of gram-positive cocci [Figure 1]d.
Figure 1: (a) Pre-procedure axial non-contrast enhanced CT showing relative hyperdensity of the M1 segment of left middle cerebral artery. (b) Pre-procedure angiogram shows complete cutoff of M1 segment of left middle cerebral artery. (c) Post-procedure angiogram shows successful recanalization of anterior division of middle cerebral artery. (d) Gram's stain ×400. Fibrinoid material containing gram-positive cocci in sheets

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Acute treatment of a patient with ischemic stroke due to infective endocarditis is a challenge. Few case reports have shown increased risk of intracerebral bleeding after intravenous tissue plasminogen activator (tPA) in infective endocarditis related strokes. [4],[6] There may be a role for interventional therapy in these patients, but sufficient evidence supporting this therapy is lacking. In our patient since the stroke occurred in the presence of infective endocarditis, it was clear that the vegetation is the most likely cause for the stroke. Though the patient was seen within 1 h of stroke, considering the reports of increased risk of hemorrhage with intravenous tPA in infective endocarditis-related strokes and lesser chance of recanalization of major vessel occlusion with intravenous thrombolysis, we decided for mechanical thrombectomy.

The pathological demonstration of fibrin, microorganisms, and inflammatory cells in the retrieved material is suggestive of septic emboli. Though fibrin is present in the vegetations, the physiological and mechanical properties of vegetations may be different from an intracardiac thrombus. [7] Therefore, whether fibrinolytic therapy is helpful in thrombus resolution by its action on the fibrin present in the vegetation is not clear. So, mechanical revascularization is a better option in these patients. The excellent recovery after thrombolysis in our patient is mostly related to the good CT ASPECTS of 9 and the recanalization that could be attained within 3 h of stroke onset.

Though current evidence is lacking regarding the best option of thrombolysis in patients with infective endocarditis, endovascular mechanical revascularization should probably be the first choice in patients with documented infective endocarditis and ischemic stroke due to the following reasons: vegetations are less likely to be amendable to pharmacological lysis, mycotic aneurysms can be ruled out, and theoretically it reduces the risk of hemorrhage.

 
  References Top

1.Tan M, Armstrong D, Birken C, Bitnun A, Caldarone CA,Cox P, et al. Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: Should thrombolytic therapy be absolutely contraindicated? Dev Med Child Neurol 2009:51:151-4.  Back to cited text no. 1
    
2.Siccoli M, Benninger D, Schuknecht B, Jenni R, Valavanis A, Bassetti C. Successful intra-arterial thrombolysis in basilar thrombosis secondary to infectious endocarditis. Cerebrovasc Dis 2003;16:295-7.   Back to cited text no. 2
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3.Junna M, Lin CC, Espinosa RE, Rabinstein AA. Successful intravenous thromobolysis in ischemic stroke caused by infective endocarditis. Neurocrit Care 2007;6:117-20.  Back to cited text no. 3
    
4.Bhuva P, Kuo SH, Claude Hemphill J, Lopez GA. Intracranial hemorrhage following thrombolytic use for stroke caused by infective endocarditis. Neurocrit Care 2010;12:79-82.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Sontineni SP, Mooss AN, Andukuri VG, Schima SM, Esterbrooks D. Effectiveness of thrombolytic therapy in acute embolic stroke due to infective endocarditis. Stroke Res Treat 2010;2010. pii: 841797.  Back to cited text no. 5
    
6.Di Salvo TG, Tatter SB, O'Gara PT, Nielsen GP, DeSanctis RW. Fatal intracerebral hemorrhage following thrombolytic therapy of embolic myocardial infarction in unsuspected infective endocarditis. Clin Cardiol 1994;17:340-4.  Back to cited text no. 6
[PUBMED]    
7.Thiene G, Basso C. Pathology and pathogenesis of infective endocarditis in native heart valves. Cardiovasc Pathol 2006;15:256-3.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  


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