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Anticoagulation Therapy in a Patient who had two Consecutive Strokes After Antibiotic Therapy for Infective
Abdalla Jamal Albanna1, Ammar Jumah1, Utkarsh Agarwal1
1Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
Abstract:
A 77-year-old male presented with altered mentation and was diagnosed with infective endocarditis. Echocardiography revealed aortic valve vegetations. While receiving inpatient antibiotic therapy, the patient experienced an acute ischemic stroke. Magnetic resonance imaging of the brain showed punctate embolic-appearing infarcts in the right cerebellum and in the left occipital, frontal, and parietal lobes. Anticoagulation was not initiated due to a high risk of hemorrhagic transformation. He was readmitted after being discharged due to another episode of altered mentation. Repeat echocardiography indicated increased size of aortic valve vegetations. The patient was then transferred to our hospital for surgical intervention of enlarging vegetations, however was deemed unsuitable for surgery. During hospitalization, he suffered another embolic stroke in the right frontal lobe. By this time, the patient had completed a full course of antibiotics for infective endocarditis, and additional antibiotics were deemed unnecessary by our infectious disease specialists. Literature review highlighted that residual vegetations carry a higher risk for stroke, but no clear guidelines were found on how to intervene or assess the risk of hemorrhage with anticoagulation in this population. Consequently, a decision was made to initiate anticoagulation, Follow-up imaging revealed no evidence of hemorrhagic transformation. Subsequently, the patient remained stable and was discharged to a rehabilitation center, where he did not experience any further events.
Insights
Infective endocarditis with aortic valve vegetations can lead to stroke. Anticoagulation was safely initiated in a high-risk patient with residual vegetations, preventing further embolic events.
Area of Science:
- Cardiology
- Neurology
- Infectious Diseases
Background:
- Infective endocarditis (IE) is a serious infection affecting heart valves.
- Aortic valve vegetations in IE pose a significant risk for systemic embolization, including ischemic stroke.
- Management of IE with residual vegetations and stroke risk is complex, especially when surgery is contraindicated.
Observation:
- A 77-year-old male with IE and aortic valve vegetations experienced multiple embolic strokes despite antibiotic therapy.
- The patient was deemed unsuitable for surgical intervention due to his condition.
- Residual vegetations persisted, and anticoagulation was cautiously initiated after a thorough risk-benefit assessment.
Findings:
- Initiation of anticoagulation in a patient with IE, residual aortic valve vegetations, and a history of stroke did not result in hemorrhagic transformation.
- The patient remained clinically stable after anticoagulation, with no further embolic events observed.
- This case suggests a potential role for anticoagulation in select IE patients with residual vegetations when surgery is not an option.
Implications:
- This case highlights the challenges in managing IE patients with persistent vegetations and embolic risk.
- It suggests that anticoagulation may be a viable therapeutic option in carefully selected patients, warranting further investigation.
- Further research is needed to establish clear guidelines for anticoagulation in IE patients with residual vegetations and high embolic risk.
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