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Severe Vasospasm of the Middle Cerebral Artery after Mechanical Thrombectomy Due to Infective Endocarditis: An
Wataru Nishino1, Yosuke Tajima1, Toru Inoue2
1Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan.
Abstract:
Untreated infective endocarditis (IE) often produces infective emboli in major cerebral arteries. We describe a case of middle cerebral artery occlusion due to IE, which caused severe vasospasm and reocclusion after mechanical thrombectomy (MT). We present the pathologic findings of the occluded middle cerebral artery and investigate the precautions to be taken while performing MT due to IE. A 72-year-old man with atrial fibrillation treated with dabigatran presented with right hemiparesis and aphasia. A diffusion-weighted image showed a high-intensity area in the left temporoparietal junction, and magnetic resonance angiography revealed a left M2 occlusion. Because of an elevated activated partial thromboplastin time, the thrombolytic therapy was contraindicated; instead, MT was performed. Just after the withdrawal of a stent retriever, the left M2 segment showed severe vasospasm. The next day, the left M2 segment reoccluded. Transthoracic echocardiogram and blood culture findings revealed IE. On the ninth day, the patient died. According to the autopsy report, the cause of death was pulmonary embolism. Pathologic analysis of the occluded M2 segment revealed fibrin thrombi containing vast amounts of neutrophils and invasion of neutrophils into the internal elastic lamina. Severe vasospasm was thought to have occurred because the vascular injury caused by the stent retriever in the vessel had a marked inflammation background. Our findings suggest that devices that are less invasive to the vascular wall are required for performing MT due to IE. The Penumbra aspiration system is thought to be a suitable device.
Insights
Infective endocarditis (IE) can cause cerebral artery occlusion. Mechanical thrombectomy (MT) for IE-related stroke may lead to vasospasm and reocclusion, suggesting less invasive devices are needed.
Area of Science:
- Neurology
- Cardiology
- Pathology
Background:
- Infective endocarditis (IE) is a significant cause of embolic stroke, particularly affecting major cerebral arteries.
- Middle cerebral artery (MCA) occlusion presents with acute neurological deficits, necessitating timely intervention.
Observation:
- A case of a 72-year-old man with atrial fibrillation presenting with aphasia and hemiparesis due to left M2 MCA occlusion.
- Mechanical thrombectomy (MT) was performed due to contraindications for thrombolytic therapy.
- Severe vasospasm and reocclusion of the M2 segment occurred immediately after MT, despite successful initial reperfusion.
Findings:
- Pathologic analysis of the occluded MCA revealed fibrin thrombi with extensive neutrophil infiltration and invasion of the internal elastic lamina.
- The severe vasospasm was attributed to heightened inflammation in the vessel wall, exacerbated by stent retriever injury.
- The patient ultimately died due to pulmonary embolism, with IE confirmed as the underlying condition.
Implications:
- Standard MT devices may cause significant vascular injury in the context of IE due to underlying inflammation.
- Less invasive devices, such as the Penumbra aspiration system, are recommended for MT in IE patients to minimize vascular trauma.
- Further research into device selection and procedural modifications is crucial for improving outcomes in stroke secondary to IE.
