Case Report
Endovascular Treatment for Cerebral Septic Embolic Stroke Hadi D. Toeg, MD, MSc,* Talal Al-Atassi, MD, MPH,* Navya Kalidindi, MD,† Daniela Iancu, MD, MSc,‡ Delara Zamani, MD,* Roberto Giaccone, MD,† and Roy G. Masters, MD*
This case demonstrates an alternative approach to cerebral revascularization by performing both intravascular mechanical thrombectomy and local injection of thrombolytics that may reduce mortality, bleeding, and the diminished quality of life experienced by patients following an acute septic embolic stroke. Key Words: Infective endocarditis—stroke—thrombolysis—endovascular therapy. Ó 2014 by National Stroke Association
Clinical Note In October 2012, a 73-year-old man, 8 weeks after undergoing an uneventful bioprosthetic aortic valve replacement (AVR), presented back to hospital with a 1-week history of fevers and chills: he was found to have a new diastolic murmur. Blood cultures were positive for gram-positive cocci; he was, therefore, admitted to hospital and treated empirically for infective endocarditis with intravenous vancomycin and gentamicin.
From the *Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; †Department of Neurology, University of Ottawa, Ottawa, Ontario, Canada; and ‡Department of Radiology, University of Ottawa, Neuro-Interventional Radiology, Ottawa, Ontario, Canada. Received October 2, 2013; revision received November 26, 2013; accepted December 8, 2013. Author contributions: H.D.T.—acquisition of data, analysis, and interpretation, and study supervision; T.A.—Critical revision and acquisition of data; N.K.—acquisition of data; D.I.—acquisition of data; D.Z.—critical revision and writing; R.G.—acquisition of data; and R.G.M.—study supervision. Conflicts of interest and disclosures: All authors have no conflicts of interest to disclose. Address correspondence to Hadi D. Toeg, MD, MSc, Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON K1Y 4W7, Canada. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.12.014
Twelve hours after admission, the patient experienced sudden onset of left-sided facial droop, dysarthria, and dense left-sided whole-body hemiplegia. A stroke code was initiated whereby a neurology resident and staff came to assess the patient and determined whether the patient would benefit from intravenous thrombolysis. The patient’s National Institutes of Health Stroke Scale (NIHSS) score was 11. Within 30 minutes, a computed tomography head angiogram was performed demonstrating a large ‘‘T’’ occlusion of the distal right internal carotid artery with thrombus extending to the right M1 and A1 segments (Fig 1, A,B). Neurology initially felt that this patient had a contraindication to IV thrombolytics because of the patient’s postsurgical status,1 along with the presence of infective endocarditis, perceived albeit without much evidence by a higher likelihood in developing a mycotic aneurysm and rupturing; however, combined with the worsening progression of the patient’s neurologic exam, increasing to NIHSS score of 20, and the extent of thrombus occlusion, it was decided by the team to undergo intra-arterial thrombectomy and thrombolysis. Interventional Neuro-Radiology successfully achieved complete recanalization of the right distal internal carotid artery and M1 and A1 segments with a brisk antegrade flow (Fig 1, C,D). This was achieved by mechanical thrombectomy and intra-arterial administration of tissue plasminogen activator (10 mg). Immediately after recanalization, the patient’s NIHSS score
Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 5 (May-June), 2014: pp e375-e377
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Figure 1. Pre-thrombectomy cerebral angiography demonstrating complete occlusion in the distal right internal carotid artery (ICA) at the M1 and A1 proximal portion with arrows indicating area of occlusion in both coronal (A) and sagittal (C) views. Complete cerebral recanalization of the right ICA after mechanical thrombectomy and intra-arterial thrombolysis demonstrating new blood flow through anterior and middle cerebral circulation in both coronal (B) and sagittal (D) views.
dropped to 2, and repeat computed tomography head 24 hours later demonstrated no hemorrhagic transformation. The patient underwent a redo-AVR because of a para-aortic abscess. After 11 days, he was discharged home on intravenous and oral antibiotics for a total of 6 weeks. Aspirin was used again for postoperative anticoagulation. At 8 months follow-up, the patient is doing well with complete resolution of his neurologic deficits (NIHSS score 5 0) along with no cardiovascular symptoms.
Discussion Most clinicians believe that infective endocarditis is considered a relative contraindication to thrombolytic therapy even though there is no conclusive evidence that this is the case. The main treatment modality entails supportive therapy: maintaining normal blood pressure, minimizing the use of anticoagulants or antiplatelets, and continuing intravenous antibiotics leaving less than one third of patients alive with functional independence.2 It is clear that patients undergoing a conservative treatment approach can suffer from significant irreversible neurologic damage while alternative therapies including intravenous thrombolysis,3 mechanical thrombectomy, or adjuncts have demonstrated mixed results.4-8 This is further confounded by dissimilar patient
characteristics, timing of treatment, and follow-up time.3-8 Our post-AVR patient had a large septic emboli removed via a stent retriever and aspiration catheter followed by local administration of 10 mg of tissue plasminogen activator. Neurologic recovery and cerebral revascularization was instantaneous, with NIHSS scores dropping from 20 to 2, which improved with time to a nadir of 0. In summary, this case demonstrates an alternative approach to cerebral revascularization by performing both intravascular mechanical thrombectomy and local injection of thrombolytics that may reduce mortality, bleeding, and the diminished quality of life experienced by patients following an acute septic embolic stroke.
References 1. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947. 2. Sonneville R, Mirabel M, Hajage D, et al. Neurologic complications and outcomes of infective endocarditis in critically ill patients: the ENDOcardite en REAnimation prospective multicenter study. Crit Care Med 2011; 39:1474-1481.
ENDOVASCULAR TREATMENT FOR CEREBRAL SEPTIC EMBOLIC STROKE 3. Sontineni SP, Mooss AN, Andukuri VG, et al. Effectiveness of thrombolytic therapy in acute embolic stroke due to infective endocarditis. Stroke Res Treat 2010. 4. Bain MD, Hussain MS, Gonugunta V, et al. Successful recanalization of a septic embolus with a balloon mounted stent after failed mechanical thrombectomy. J Neuroimaging 2011;21:170-172. 5. Sukumaran S, Jayadevan ER, Mandilya A, et al. Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis. Neurol India 2012;60:239-240.
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6. Kang G, Yang TK, Choi JH, et al. Effectiveness of mechanical embolectomy for septic embolus in the cerebral artery complicated with infective endocarditis. J Korean Med Sci 2013;28:1244-1247. 7. Kan P, Webb S, Siddiqui AH, et al. First reported use of retrievable stent technology for removal of a large septic embolus in the middle cerebral artery. World Neurosurg 2012;77:591.e591-591.e595. 8. Dababneh H, Hedna VS, Ford J, et al. Endovascular intervention for acute stroke due to infective endocarditis: case report. Neurosurg Focus 2012;32:E1.
Endovascular Treatment for Cerebral Septic Embolic Stroke Hadi D. Toeg, MD, MSc,* Talal Al-Atassi, MD, MPH,* Navya Kalidindi, MD,† Daniela Iancu, MD, MSc,‡ Delara Zamani, MD,* Roberto Giaccone, MD,† and Roy G. Masters, MD*
This case demonstrates an alternative approach to cerebral revascularization by performing both intravascular mechanical thrombectomy and local injection of thrombolytics that may reduce mortality, bleeding, and the diminished quality of life experienced by patients following an acute septic embolic stroke. Key Words: Infective endocarditis—stroke—thrombolysis—endovascular therapy. Ó 2014 by National Stroke Association
Clinical Note In October 2012, a 73-year-old man, 8 weeks after undergoing an uneventful bioprosthetic aortic valve replacement (AVR), presented back to hospital with a 1-week history of fevers and chills: he was found to have a new diastolic murmur. Blood cultures were positive for gram-positive cocci; he was, therefore, admitted to hospital and treated empirically for infective endocarditis with intravenous vancomycin and gentamicin.
From the *Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; †Department of Neurology, University of Ottawa, Ottawa, Ontario, Canada; and ‡Department of Radiology, University of Ottawa, Neuro-Interventional Radiology, Ottawa, Ontario, Canada. Received October 2, 2013; revision received November 26, 2013; accepted December 8, 2013. Author contributions: H.D.T.—acquisition of data, analysis, and interpretation, and study supervision; T.A.—Critical revision and acquisition of data; N.K.—acquisition of data; D.I.—acquisition of data; D.Z.—critical revision and writing; R.G.—acquisition of data; and R.G.M.—study supervision. Conflicts of interest and disclosures: All authors have no conflicts of interest to disclose. Address correspondence to Hadi D. Toeg, MD, MSc, Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON K1Y 4W7, Canada. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.12.014
Twelve hours after admission, the patient experienced sudden onset of left-sided facial droop, dysarthria, and dense left-sided whole-body hemiplegia. A stroke code was initiated whereby a neurology resident and staff came to assess the patient and determined whether the patient would benefit from intravenous thrombolysis. The patient’s National Institutes of Health Stroke Scale (NIHSS) score was 11. Within 30 minutes, a computed tomography head angiogram was performed demonstrating a large ‘‘T’’ occlusion of the distal right internal carotid artery with thrombus extending to the right M1 and A1 segments (Fig 1, A,B). Neurology initially felt that this patient had a contraindication to IV thrombolytics because of the patient’s postsurgical status,1 along with the presence of infective endocarditis, perceived albeit without much evidence by a higher likelihood in developing a mycotic aneurysm and rupturing; however, combined with the worsening progression of the patient’s neurologic exam, increasing to NIHSS score of 20, and the extent of thrombus occlusion, it was decided by the team to undergo intra-arterial thrombectomy and thrombolysis. Interventional Neuro-Radiology successfully achieved complete recanalization of the right distal internal carotid artery and M1 and A1 segments with a brisk antegrade flow (Fig 1, C,D). This was achieved by mechanical thrombectomy and intra-arterial administration of tissue plasminogen activator (10 mg). Immediately after recanalization, the patient’s NIHSS score
Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 5 (May-June), 2014: pp e375-e377
e375
H.D. TOEG ET AL.
e376
Figure 1. Pre-thrombectomy cerebral angiography demonstrating complete occlusion in the distal right internal carotid artery (ICA) at the M1 and A1 proximal portion with arrows indicating area of occlusion in both coronal (A) and sagittal (C) views. Complete cerebral recanalization of the right ICA after mechanical thrombectomy and intra-arterial thrombolysis demonstrating new blood flow through anterior and middle cerebral circulation in both coronal (B) and sagittal (D) views.
dropped to 2, and repeat computed tomography head 24 hours later demonstrated no hemorrhagic transformation. The patient underwent a redo-AVR because of a para-aortic abscess. After 11 days, he was discharged home on intravenous and oral antibiotics for a total of 6 weeks. Aspirin was used again for postoperative anticoagulation. At 8 months follow-up, the patient is doing well with complete resolution of his neurologic deficits (NIHSS score 5 0) along with no cardiovascular symptoms.
Discussion Most clinicians believe that infective endocarditis is considered a relative contraindication to thrombolytic therapy even though there is no conclusive evidence that this is the case. The main treatment modality entails supportive therapy: maintaining normal blood pressure, minimizing the use of anticoagulants or antiplatelets, and continuing intravenous antibiotics leaving less than one third of patients alive with functional independence.2 It is clear that patients undergoing a conservative treatment approach can suffer from significant irreversible neurologic damage while alternative therapies including intravenous thrombolysis,3 mechanical thrombectomy, or adjuncts have demonstrated mixed results.4-8 This is further confounded by dissimilar patient
characteristics, timing of treatment, and follow-up time.3-8 Our post-AVR patient had a large septic emboli removed via a stent retriever and aspiration catheter followed by local administration of 10 mg of tissue plasminogen activator. Neurologic recovery and cerebral revascularization was instantaneous, with NIHSS scores dropping from 20 to 2, which improved with time to a nadir of 0. In summary, this case demonstrates an alternative approach to cerebral revascularization by performing both intravascular mechanical thrombectomy and local injection of thrombolytics that may reduce mortality, bleeding, and the diminished quality of life experienced by patients following an acute septic embolic stroke.
References 1. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947. 2. Sonneville R, Mirabel M, Hajage D, et al. Neurologic complications and outcomes of infective endocarditis in critically ill patients: the ENDOcardite en REAnimation prospective multicenter study. Crit Care Med 2011; 39:1474-1481.
ENDOVASCULAR TREATMENT FOR CEREBRAL SEPTIC EMBOLIC STROKE 3. Sontineni SP, Mooss AN, Andukuri VG, et al. Effectiveness of thrombolytic therapy in acute embolic stroke due to infective endocarditis. Stroke Res Treat 2010. 4. Bain MD, Hussain MS, Gonugunta V, et al. Successful recanalization of a septic embolus with a balloon mounted stent after failed mechanical thrombectomy. J Neuroimaging 2011;21:170-172. 5. Sukumaran S, Jayadevan ER, Mandilya A, et al. Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis. Neurol India 2012;60:239-240.
e377
6. Kang G, Yang TK, Choi JH, et al. Effectiveness of mechanical embolectomy for septic embolus in the cerebral artery complicated with infective endocarditis. J Korean Med Sci 2013;28:1244-1247. 7. Kan P, Webb S, Siddiqui AH, et al. First reported use of retrievable stent technology for removal of a large septic embolus in the middle cerebral artery. World Neurosurg 2012;77:591.e591-591.e595. 8. Dababneh H, Hedna VS, Ford J, et al. Endovascular intervention for acute stroke due to infective endocarditis: case report. Neurosurg Focus 2012;32:E1.
