Effectiveness of Mechanical Embolectomy for Septic Embolus in the Cerebral Artery Complicated with Infective Endocarditis
A 39-yr-old woman without any underlying medical conditions including heart problems visited the emergency department with ten minutes of right hemiparesis and aphasia on April 23, 2012. Her National Institutes of Health stroke scale (NIHSS) score was 16.\nOn presentation, she has been often febrile for 1 month. Her pulse was regular, blood pressure was 124/67 mm Hg and temperature was 37.1℃. Laboratory tests upon admission disclosed mild normocytic anemia (hemoglobin, 11 g/dL), a normal leukocyte count (8,600/mL), and a platelet count of 193,000/µL. The serum C-reactive protein level was 3.48 mg/dL and an erythrocyte sedimentation rate was 53 mm/h. The initial electrocardiogram showed a right bundle branch block. Results of other routine laboratory tests were within normal limits. A chest film was normal.\nThe brain computed tomography (CT) showed no abnormal findings. The diffusion-weighted magnetic resonance (MR) images and corresponding apparent diffusion coefficient maps revealed hyperacute infarction of left insula cortex, corona radiata, centrum semiovale and posterior inferior cerebellar artery territory of right side cerebellum. The MR angiography showed left MCA proximal segment (M1) occlusion. The diffusion-perfusion mismatch was found in the mean transit time & time to peak perfusion maps. (, ) She was not given an intravenous tissue plasminogen activator because of the unclear onset time of the neurological deficits. Considering the time window, diffusion-perfusion mismatch and the patient's young age, we decided to perform intra-arterial thrombolysis. The patient received urokinase 150,000 units and tirofiban (Aggrastat; Merck) 100 micrograms intra-arterially. However, there was no flow restoration of the left MCA. After the second trial of mechanical thrombectomy with retrievable stent Solitaire AB 4×15 mm (ev3/Covidien Vascular Therapies, Mansfield, Massachusetts, USA), the MCA was recanalized to the thromobolysis in cerebral infarction (TICI) grade 2b (). (, ) After 36-hr procedure, her right side motor power was almost fully recovered. The patient improved greatly and had only right hemifacial palsy and aphasia, which also improved gradually. A postoperative CT scan obtained 24 hr later showed no evidence of infarct or hemorrhage.\nUnfortunately, we had not detected early on, but a cardiac examination revealed a regular heart beat with pansystolic murmur on apex. A transthoracic echocardiogram showed a mass like-lesion on the anterior mitral valve (1.07×0.59 cm) and moderate mitral regurgitation without any functional problems and the evidence of heart failure. Ceftriaxone and gentamicin treatment for IE started immediately. On the third day, Streptococcus gordonii was subsequently grown from the initial blood culture sets. With the patient fulfilled clinical Duke criteria for definite IE (), she was treated with parenteral penicillin and gentamicin. The patient's NIHSS score was 7 at this time. We underwent a sequential echocardiography once a week during hospitalization. The volume of mitral regurgitation and the size of vegetation on echocardiography did not increase. After two weeks, the size of vegetation on echocardiography was decreased to about 0.7×0.5 cm. During the four weeks of her antibiotics course, the patient's hemiparesis and aphasia improved (NIHSS score of 3). She has had no recurrent infarction and congestive heart failure and has been recovering well at home.