Introduction: Stroke is a common and devastating embolic manifestation of infective endocarditis. We report a case of cardioembolic stroke in a patient with enterococcal endocarditis requiring emergent cardiac valve surgery who was treated successfully with mechanical thrombectomy prior to planned intraoperative hypotension.
Methods: A middle-aged patient with bacterial endocarditis exhibited mild intermittent left hemiparesis and dysarthria in the setting of severe aortic insufficiency requiring urgent aortic valve replacement. NIH stroke scale (NIHSS) was 3. Cerebrovascular imaging revealed a partially occlusive thrombus in the M1 segment of the right middle cerebral artery (MCA), which became symptomatic during relative hypotension (Figure 1). Given the expected hypotension during the urgently needed aortic valve replacement, there was significant risk of infarction of most of the right hemisphere. Thus, mechanical thrombectomy was performed immediately prior to thoracotomy (Figure 2).
The patient was transferred from the angiography suite to the cardiac surgery suite under the same anesthesia and underwent a median sternotomy with aortic valve replacement and mitral valve repair. The procedures were tolerated well, and the patient was transferred to the cardiac intensive care unit in stable condition.
Results: The patient returned to neurological baseline immediately after surgeries and was extubated the following day. The patient remained hemodynamically and neurologically stable throughout post-operatively, with no new stroke episodes. The patient was discharged to home on postoperative day 13 in excellent neurological condition (NIHSS=0; modified Rankin Scale=0).
Conclusions: For our patient, MT was a favorable option to avoid a large stroke during emergent cardiac valve surgery. MT might be considered in the rare circumstance of partially occlusive thrombus prior to anticipated hypotension, even in the setting of minimal deficits (NIHSS <7).
Patient Care: Mechanical thrombectomy for patients with NIHSS <7 is controversial. This case demonstrates the value of a multidisciplinary approach to complex patients. This case also demonstrates avoidance of a large stroke due to a subocclusive thrombus and anticipated intraoperative hypotension with pre-operative mechanical thrombectomy.
Learning Objectives: By the conclusion of this session, participants should be able to:
1. Discuss complex decision making in the care of stroke patients requiring anticipated hypotension