Infective Endocarditis Complicated by Acute Ischemic Stroke from Septic Embolus: Successful Solitaire FR Thrombectomy

Liang, Jackson J.; Bishu, Kalkidan; Anavekar, Nandan S.

doi:10.4021/cr235e

Cited by 9 publications

(5 citation statements)

References 15 publications

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“…1,5 To this end, endovascular thrombectomy (EVT) is emerging as a potentially efficacious and safer intervention strategy in this subgroup of patients. 6,7 We recently reported a case study on the usefulness of EVT and clot histopathology in a patient with stroke secondary to IE. 8 EVT also offers further benefit to pursue a thorough histopathologic analysis including routine Gram staining of EVT-retrieved clots, which may provide additional diagnostic/etiologic information in non-IE patients, 9 and in those with suspected IE or prosthetic valvular heart disease.…”

Section: Introductionmentioning

confidence: 99%

Clot Histopathology in Ischemic Stroke with Infective Endocarditis

Bhaskar

Saab

Cappelen‐Smith

et al. 2019

Can. J. Neurol. Sci.

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ABSTRACT:Background: Endovascular thrombectomy (EVT) has shown efficacy in acute ischemic stroke (AIS) patients with infective endocarditis (IE). The possibility to undertake advanced histopathological clot analysis following EVT offers a new avenue to establish the etiological basis of the stroke – which is often labelled “cryptogenic.” In this paper, we present our findings from four consecutive patients with IE who underwent EVT following an AIS at our tertiary referral comprehensive stroke centre. Methods: Comprehensive histopathological analysis of clot retrieved after EVT, including morphology, was undertaken. Results: The consistent observation was the presence of dense paucicellular fibrinoid material mixed/interspersed with clusters of bacterial cocci. This clot morphology may be specific to septic embolus due to IE unlike incidental bacteraemia and could possibly explain the refractoriness of such clots to systemic thrombolysis. Conclusion: Detailed morphological and histopathological analysis of EVT-retrieved clots including Gram staining can assist in etiological classification of the clot. Understanding the composition of the clot may be of clinical value in early diagnostics and mapping treatment planning in IE.

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Section: Introductionmentioning

confidence: 99%

Clot Histopathology in Ischemic Stroke with Infective Endocarditis

Bhaskar

Saab

Cappelen‐Smith

et al. 2019

Can. J. Neurol. Sci.

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“…The database search yielded 431 relevant records published until January 2020. Nineteen articles fulfilled the eligibility criteria [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. Three articles (16%) were case series while sixteen (84%) were single case report.…”

Section: Resultsmentioning

confidence: 99%

Endovascular treatment of ischemic large-vessel stroke due to infective endocarditis: case series and review of the literature

D’Anna

2020

Neurol Sci

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Background Mechanical thrombectomy is the standard of care, in selected patients, for acute ischemic stroke with large vessel occlusion but its use in patients with stroke secondary to infective endocarditis is controversial. We report three cases of acute ischemic stroke treated by mechanical thrombectomy and we propose an extensive review of the literature to evaluate the clinical safety and efficacy of thrombectomy in patients with stroke secondary to infective endocarditis. Methods A comprehensive literature search was performed following a pre-specified protocol of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials were considered that included endocarditis-related acute ischemic stroke patients who underwent mechanical thrombectomy. Results The database search yielded 431 relevant records published until January 2020. Nineteen articles fulfilled the eligibility criteria that described thirty patients. After the thrombectomy, 13.3% of the patients experienced intracranial haemorrhage. After the procedure, the median National Institutes of Health Stroke Scale score dropped from 15 (IQR 7) to 2.5 (IQR 5.75). At 90 days, mortality was 23.3% while 46.7% of the patients were functionally independent (mRS ≤ 2). Discussion Based on our review, the use of mechanical thrombectomy in patients with large vessel occlusion due to endocarditisassociated stroke might improve patient outcome but it should be considered on a case by case base as the safety has not been well established yet. Further research on risk stratification is needed to drive clinician during the decision-making process.

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“…However, there has been no comparative research or clear consensus on how to manage ischemic stroke patients with LVO due to suspected or diagnosed IE. Embolization occurs more frequently with larger (>10 mm), left‐sided vegetations, particularly on the mitral valve, and when antiphospholipid antibodies are present . Furthermore, vegetations comprise inflammatory cells, platelets, and microorganisms in addition to a rich fibrin network, which may explain refractoriness and complications associated with IV‐tPA …”

Section: Discussionmentioning

confidence: 99%

“…The selection strategy for intervention in suspected septic emboli remains elusive with lack of guidelines as to whether to avoid stent retrievers. However, previous case series have not confirmed advantage of aspiration over stent retrievers …”

Section: Discussionmentioning

confidence: 99%

“…Intravenous tissue‐plasminogen activator (IV‐tPA) may potentiate the risk of bleeding . Intra‐arterial endovascular thrombectomy (EVT) potentially offers a safer first‐line treatment strategy to patients with IE . Recent consensus guidelines of thrombus analysis in AIS do not address the need for routine gram staining of clots retrieved post‐EVT .…”

Section: Introductionmentioning

confidence: 99%

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Clarion call for histopathological clot analysis in “cryptogenic” ischemic stroke: implications for diagnosis and treatment

Bhaskar

Cordato

Cappelen‐Smith

et al. 2017

Ann Clin Transl Neurol

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Diagnosis, treatment, and secondary management of cryptogenic stroke patients pose a formidable challenge. The scenario is further complicated in patients with native and prosthetic valvular heart disease. We present a case study of a 36‐year‐old man who received intravenous thrombolysis (IV‐tPA) and endovascular thrombectomy (EVT) for presumed “cryptogenic” complete middle cerebral artery infarction who made a surprisingly excellent clinical recovery despite poor baseline and postintervention neuroimaging. Retrospective gram stain of his clot confirmed a diagnosis of infective endocarditis. This raises an important issue regarding need for more routine histopathological analysis of clot retrieved after EVT in “cryptogenic” stroke patients particularly those with valvular heart disease.

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Infective Endocarditis Complicated by Acute Ischemic Stroke from Septic Embolus: Successful Solitaire FR Thrombectomy

Cited by 9 publications

References 15 publications

Clot Histopathology in Ischemic Stroke with Infective Endocarditis

Clot Histopathology in Ischemic Stroke with Infective Endocarditis

Endovascular treatment of ischemic large-vessel stroke due to infective endocarditis: case series and review of the literature

Clarion call for histopathological clot analysis in “cryptogenic” ischemic stroke: implications for diagnosis and treatment

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