Year: 2019
Type: article
Study design: Case Report
Abstract: T he morning after celebrating her birthday, a 29-year- old woman with a history of intravenous drug use presented to our facility with acute-onset left middle cerebral artery syndrome and an National Institutes of Health Stroke Scale score of 14.Her recent medical history was notable for polymicrobial (methicillin-resistant Staphylococcus aureus, Enterococcus faecalis, and Candida albicans) tricuspid and aortic valve endocarditis, for which she underwent bioprosthetic tricuspid and aortic valve repair 6 months before admission and remained on suppressive fluconazole.Approximately 1 month before admission, she was evaluated at an outside hospital for recurrent arterial emboli of unclear pathogenesis in her lower extremities.After multiple sets of blood cultures and repeat transesophageal echocardiogram were negative for valvular vegetations, she was started on apixaban at the outside facility for empirical embolic treatment.At the time of presentation to our facility, her deficits included right-sided facial asymmetry, hemiparesis, sensory loss, and aphasia.She was last seen normal 7 hours before admission.Computed tomographic (CT) angiogram of the brain demonstrated left middle cerebral artery occlusion.CT perfusion showed favorable perfusion profile with a small core size and large penumbra.Given the extended time window to presentation and presumed apixaban use, tPA (tissue-type plasminogen activator) was contraindicated, but she was a candidate for mechanical thrombectomy and underwent successful Thrombolysis in Cerebral Infarction 2B/3 recanalization with a single-pass stent retriever within 60 minutes of arrival (Figure 1). Laboratory StudiesComplete blood count was within normal limits, and serum chemistries were the most notable for mild hyponatremia (131 mmol/L) and elevated creatinine (2.13 mg/dL).Coagulation studies showed prothrombin time of 14.9 seconds with international normalized ratio of 1.2 and a partial thromboplastin time of 30 seconds.Given the patient's history of endocarditis, recent arterial emboli of unclear pathogenesis, temperature of 38° at presentation, young age, and occurrence of stroke while reportedly anticoagulated, the clot retrieved during thrombectomy was sent for microbiological analysis.Grossly, the specimen had no unusual morphological characteristics, with a dark red color and gelatinous consistency.Attenuation on CT appeared the most consistent with a red blood cell-rich thrombus.
Source: Stroke
Institution: University of Washington
Language: Slovenian
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2921434496