J Cerebrovasc Endovasc Neurosurg.  2020 Sep;22(3):176-181. 10.7461/jcen.2020.22.3.176.

Clinical challenges associated with the endovascular treatment of acute stroke in a patient with infective endocarditis

• Settarzade E
• Peker A
• Topcuoglu MA
• Arsava EM
• Demircin M
• Arat A

• KMID: 2506764
• DOI: http://doi.org/10.7461/jcen.2020.22.3.176

Abstract

Although stroke is common in infective endocarditis (IE), only 26 cases of thrombectomy have been reported to date for IE-related acute stroke. We report a 40-year-old man who presented with left middle cerebral artery occlusion of unknown cause. Multiple attempts of mechanical aspiration thrombectomy and stentrievers failed to recanalize the artery. Effective revascularization was eventually achieved by placing a self-expanding intracranial stent. Post-procedurally the patient was diagnosed with IE with mitral valve insufficiency, mandating emergent valvular replacement while the patient was still on tirofiban infusion. On follow-up, the patient had a modified Rankin’s score of 0, had no recurrent stroke, and the intracranial stent remained patent yet stenosed. Based on the use of a self-expanding intracranial stent in the setting of IE, we discuss the consequences of the fibrotic and inflammatory content of the embolus and the associated high risk of intracranial hemorrhage which complicates clinical decision making.

Figure

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  Fig. 1 In coronal (A) and axial (B) planes CT-angiography showing occlusion of the superior trunk of the left middle cerebral artery.

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  Fig. 2 The cerebral angiogram in the AP (A) and lateral views (B) confirming the total occlusion of the superior trunk of the left middle cerebral artery (MCA).

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  Fig. 3 Just after replacement of stent, AP (A) and lateral view (B) angiography showing a Thrombolysis in Cerebral Infarction (TICI) score 3 reperfusion of the left middle cerebral artery territory.

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  Fig. 4 After the procedure, non-enhanced brain computed tomography images passing through the level of thalamus (A) and sylvian fissures (B) revealing bilateral small intraparenchymal hemorrhagic lesions and a focal subarachnoid hemorrhage.

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  Fig. 5 The AP (A) and lateral views (B, C) of the control angiogram obtained at 6 months demonstrating stent patency with persistent residual stenosis.

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  Fig. 6 Color perfusion maps obtained at the level of basal ganglia (A–E) and corona radiata (F) show no significant asymmetry between the two hemispheres except sequelae changes of chronic infarct in the left putamen on MR perfusion imaging obtained after 10 months.

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