Multidisciplinary Approach to Cardioembolic Stroke Due to Infectious Endocarditis in the Neurocritical Care Unit
Year: 2024
Type: article
Study design: Case Report
Abstract: Objective We present a case of infectious endocarditis complicated by ischemic stroke and acute limb ischemia, requiring a multidisciplinary stepwise treatment approach. Background By The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) group, the annual incidence of stroke, and stroke-related mortality, increased significantly from 1990 to 2019. Moreover, one of the most common mechanisms for stroke is cardioembolic, accounting for 20-30% of all ischemic stroke, usually due to atrial fibrillation but also associated with more atypical sources, such as septic emboli. Design/Methods Case report and review of the literature Results 56 year-old man with Hypertension, uncontrolled Diabetes Mellitus type 2, and gastric bypass surgery presented to the ED with fevers and chills. He was found to have acute left leg critical limb ischemia and underwent emergent thromboembolectomy, fasciotomy and stent placement with vascular surgery, later requiring an above-knee amputation. Transesophageal echocardiography showed mitral valve endocarditis and blood cultures revealed Streptococcus agalactiae bacteremia. Brain MRI showed scattered bilateral cerebral and right cerebellar infarcts with hemorrhagic components. A diagnostic cerebral angiogram ruled out mycotic aneurysms. After a multidisciplinary discussion between neurocritical care, neurosurgery, cardiology and cardiothoracic surgery, the patient underwent a successful percutaneous aspiration of a large mitral valve vegetation using angiovac system with cerebral embolic protection filter. Intraoperative bivalirudin was required. Post-operative intracranial imaging remained stable. The patient thereafter was primarily managed for refractory atrial flutter with multiple agents, subsequently requiring electrical cardioversion, and remained on anticoagulation with apixaban after confirming stability of cerebral infarcts. Conclusions Among cardioembolic sources, infective endocarditis is one of the most lethal etiologies due to associated complications such as brain mycotic aneurysms, intracranial hemorrhage, and other systemic emboli. This oftentimes requires a multidisciplinary approach to create a tailored treatment plan individualized to every patient.
Source: Neurology
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4403207065