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A Puzzling Case of Cryptogenic Stroke
Marisa Distefano1, Rosalinda Calandrelli2, Vincenzo Arena3
1UOC Neurologia, Dipartimento di scienze dell'invecchiamento, neurologiche, ortopediche e della testa-collo; Fondazione Policlinico Universitario A. Gemelli - IRCCS, Roma, Italy.
Insights
Infective endocarditis (IE) stroke is challenging to diagnose. Analyzing clots from mechanical thrombectomy aids early IE diagnosis and treatment, improving outcomes for stroke patients.
Area of Science:
- Neurology
- Infectious Diseases
- Cardiology
Background:
- Stroke is a frequent and severe complication of infective endocarditis (IE).
- Diagnosing IE in patients presenting with acute stroke is clinically challenging.
- IE significantly increases stroke-related morbidity and mortality.
Observation:
- A 75-year-old male presented with acute left hemiparesis and dysarthria.
- Initial symptoms included fatigue, fever, and weight loss over three months.
- Neurological examination confirmed left hemiparesis and dysarthria.
Findings:
- Brain imaging revealed a right M1 segment occlusion, treated with thrombolysis and mechanical thrombectomy.
- Clot analysis showed bacterial colonies consistent with septic emboli.
- Post-procedure, the patient developed fever and intracranial hemorrhage.
- Blood cultures identified Enterococcus faecalis, leading to antibiotic treatment.
Implications:
- Early diagnosis of IE in acute stroke is critical for effective management.
- Mechanical thrombectomy allows direct analysis of embolic material for rapid IE diagnosis.
- Prompt identification and appropriate antibiotic therapy are essential for improving outcomes in IE-related stroke.
Background:
Stroke is a common neurological complication of infective endocarditis (IE) and it is associated with increased morbidity and mortality but infective endocarditis in acute stroke setting is hard to discover.
Material And Methods:
A 75-year-old man referred to hospital for the onset of left hemiparesis and dysarthria. His past medical history included hypertension. He had 3 months history of fatigue, fever, and weight loss. Neurological examination revealed left hemiparesis and dysarthria.
Findings:
Brain CT and CT angiography revealed a right M1 segment occlusion. Thrombolysis was delivered followed by mechanical thrombectomy by clot aspiration and recanalization was achieved. Anatomopathological analysis of the clot showed necrotic material and bacterial colonies consistent with septic emboli. The day after he developed fever and brain CT revealed a right parieto-occipital intraparenchymal and subarachnoid hemorrhage. Blood cultures demonstrated growth of Enterococcus faecalis. Treatment with vancomycin and ampicillin was started.
Conclusion:
Management of acute ischemic stroke related to IE is difficult. The great clinical challenge for the physician is recognizing the signs suggestive of IE in the acute stroke setting. Anatomo-pathological and bacteriological analysis of the clot in patients eligible to mechanical thrombectomy can provide the remarkable advantage to analyse directly the extracted material, allowing an early diagnosis and appropriate antibiotic therapies and treatments.
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