Downloaded from http://jnis.bmj.com/ on November 18, 2015 - Published by group.bmj.com

Ischemic stroke

CASE REPORT

Complex decision-making in stroke: preoperative
mechanical thrombectomy of septic embolus for
emergency cardiac valve surgery
Travis R Ladner,1 Brandon J Davis,1 Lucy He,1 Howard S Kirshner,2
Michael T Froehler,3 J Mocco1
1

Department of Neurosurgery,
Vanderbilt University, Nashville,
Tennessee, USA
2
Department of Neurology,
Vanderbilt University, Nashville,
Tennessee, USA
3
Department of Neurology,
Vanderbilt University Medical
Center, Nashville, Tennessee,
USA
Correspondence to
Travis R Ladner,
Department of Neurosurgery,
Vanderbilt University, T 4224
Medical Center North, 1161
21st Ave, Nashville, TN
37232-2380, USA;
travis.r.ladner@vanderbilt.edu
Republished with permission
from BMJ Case Reports
Published 19 November 2014;
doi: 10.1136/bcr-2014011488

ABSTRACT
Stroke is a common and devastating embolic
manifestation of infective endocarditis. We report a case
of cardioembolic stroke in a patient with enterococcal
endocarditis, with National Institutes of Health Stroke
Scale score of 3. 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. Cerebrovascular
imaging revealed a partially occlusive thrombus in the M1
segment of the right middle cerebral artery, which
became symptomatic during relative hypotension. Given
the expected hypotension during the urgently needed
aortic valve replacement, there was a significant risk of
infarction of most of the right hemisphere. Thus,
mechanical thrombectomy was performed immediately
prior to thoracotomy, and the patient awoke
neurologically intact. This case demonstrates avoidance of
a large stroke due to a subocclusive thrombus and
anticipated intraoperative hypotension with preoperative
mechanical thrombectomy.

Accepted 27 October 2014

BACKGROUND
Stroke is a common and devastating embolic manifestation of infective endocarditis (IE).1 Cardiac
surgery for IE requires induced hypotension,
placing hypoperfused cerebral tissue at risk for
infarction. Patients presenting with large vessel
occlusion without severe neurological deficit
(National Institutes of Health Stroke Scale (NIHSS)
score <7) are frequently felt to be inappropriate
for neurointervention due to relatively good neurologic status. However, with known induced hypotension, preoperative mechanical thrombectomy
(MT) of embolized vegetations may make early
cardiac surgery safer by restoring normal cerebral
hemodynamic physiology. We report a case of preoperative MT followed by immediate cardiac valve
surgery in a patient with recent cardioembolism
from enterococcal endocarditis.

speech. The NIHSS score was 3. Identical episodes
were reported during the previous 3 days.

INVESTIGATIONS
CT angiography demonstrated partial occlusion of
the distal right M1 segment (figure 1), with prolonged mean transit time throughout most of the
right middle cerebral artery (MCA) territory on CT
perfusion (figure 2), placing extensive MCA territory at risk. MRI demonstrated multiple small areas
of infarction of various ages scattered predominantly throughout the right cerebral hemisphere in
the MCA territory and watershed areas (figure 3).
These findings were thought to be due to both
embolic events from cardiac vegetations, but with a
partially occlusive thrombus in the MCA resulting
in hypoperfusion whenever the patient’s blood
pressure dropped.
At initial evaluation by the stroke and interventional services, the patient was felt to be neither a
candidate for tissue plasminogen activator nor MT,
given the low NIHSS score. Furthermore, the
symptoms subsequently resolved when the patient
was consistently autopressing to maintain a systolic
blood pressure of 170 mm Hg. Cardiac surgery was
undertaken to evaluate the patient and emergency
aortic valve replacement and mitral valve repair

CASE PRESENTATION

To cite: Ladner TR,
Davis BJ, He L, et al. J
NeuroIntervent Surg 2015;7:
e41.

A patient (age in the 40s) with a history of intravenous opiate use and a new diagnosis of
Enterococcus faecalis endocarditis presented with
severe dyspnea prompting a transthoracic echocardiogram which confirmed aortic insufficiency with
extensive aortic valve vegetations. Overnight the
patient had three intermittent 30 min episodes of
left hand weakness, left facial droop, and slurred

Figure 1 CT angiography showing segmental occlusion
of the right M1 segment just proximal to its trifurcation
(arrowheads) in (A) coronal and (B) axial planes.

Ladner TR, et al. J NeuroIntervent Surg 2015;7:e41. doi:10.1136/neurintsurg-2014-011488.rep

1 of 4

Downloaded from http://jnis.bmj.com/ on November 18, 2015 - Published by group.bmj.com

Ischemic stroke

Figure 2 CT perfusion maps showing prolonged mean transit time with tissue at risk throughout the greater part of the right middle cerebral
artery territory.
were recommended due to the high risk of a recurrent thromboembolic event or stroke progression. The procedure would
require a significant decrease in blood pressure while on-pump
during bypass. Therefore, after direct personal consultation
among the cardiac surgery, vascular neurology, and endovascular
neurosurgery attendings, the decision was made to offer MT
followed by cardiac valve surgery immediately after stroke
intervention.

TREATMENT
Upon consultation among the surgical services and anesthesiology, general endotracheal anesthesia was preferred as the
patient was planned for immediate cardiac surgery following
neurointervention. It was desired to use the same anesthesia
to reduce the complications of reversal and induction, including
intubation risks and potential volatile hemodynamic changes
in a patient with a blood pressure-dependent neurological
status. Under general endotracheal anesthesia, angiography confirmed right MCA occlusion with a Thrombolysis in Cerebral
Infarction (TICI) 2 flow into the superior division and TICI 0
flow into the posterior inferior division (figure 4). A 5Max ACE
(Penumbra, Alameda, California, USA) was advanced over a
Penumbra 3Max, which was advanced over a Fathom-16 microwire (Boston Scientific, Boston, Massachusetts, USA) to selectively catheterize the right MCA. Once the clot was reached, the

3Max and Fathom-16 were withdrawn and aspiration was
undertaken at the site of occlusion for 3 min using the 5Max
ACE, which was then withdrawn on aspiration to remove the
2×10 mm clot (figure 5). Immediate angiographic run demonstrated complete TICI 3 reperfusion of the right MCA territory
with robust recanalization without complication (figure 4).
Some spasm of the supraclinoid internal carotid artery was
observed (figure 4B/D), which had resolved on the final angiographic run without need for further intervention (not shown).
Given the excellent angiographic result, without flow limitation or evidence of hemorrhage, and the well-controlled hemodynamics of the patient, the decision was made to proceed
under the same general anesthesia for the cardiac procedure
without wake-up neurologic examination or repeat head
imaging. 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 a
stable condition.

OUTCOME AND FOLLOW-UP
The patient returned to neurological baseline immediately after
the surgeries and was extubated the following day. The patient
remained
hemodynamically
and
neurologically
stable

Figure 3 MRI showing multiple foci
of infarction scattered throughout
primarily the right cerebral hemisphere,
although some evidence of left-sided
disease is present. Multiple areas with
restricted diffusion (A) were
hyperintense on FLAIR imaging
(B). The right basal ganglia in
particular was hyperintense on FLAIR,
suggesting an older infarct as well. No
areas were hemorrhagic. There is also
a remote right cerebellar hemisphere
infarct (not shown).

2 of 4

Ladner TR, et al. J NeuroIntervent Surg 2015;7:e41. doi:10.1136/neurintsurg-2014-011488.rep

Downloaded from http://jnis.bmj.com/ on November 18, 2015 - Published by group.bmj.com

Ischemic stroke

Figure 4 Diagnostic angiography demonstrating an occluding thrombus in the distal right M1 segment which is partially occlusive of the superior
division of the middle cerebral artery (MCA) with Thrombolysis in Cerebral Infarction score (TICI) 2 flow through that branch, but is completely
occlusive of the inferior division with a TICI 0 perfusion of the posterior and inferior branches in (A) anteroposterior and (C) lateral views. Follow-up
angiogram through the existing catheter after mechanical thrombectomy showing complete restoration of flow through the MCA branches in (B)
anteroposterior and (D) lateral views. The images show no evidence of thrombus formation or any other untoward occurrence and excellent TICI 3
perfusion of the MCA territory.
throughout the postoperative period with no new stroke episodes. On postoperative day 6 the patient developed a right leg
deep vein thrombosis and was started on heparin and warfarin.
The patient was discharged to home on postoperative day 13 in

an excellent neurological condition (NIHSS score 0; modified
Rankin Scale score 0).

DISCUSSION

Figure 5 Extracted M1 segment embolus beside 5Max ACE clot
extraction device. This embolus appeared to morphologically retain the
shape of the middle cerebral artery bifurcation it was occluding.

Cerebral embolization is a common occurrence in IE, with
ischemic stroke present in 18% of all IE cases.1 Antibiotics are
standard, but early surgery is indicated in cases of heart failure,
uncontrolled infection, or high thromboembolic risk.2
While anecdotal, our case suggests that preoperative mechanical removal of large vessel embolic vegetations may be beneficial in situations where patients have a ‘pressure-dependent’
neurologic examination. Several other case reports suggest that
this paradigm is both safe and effective in the setting of septic
cardiac emboli (table 1). This case is unique in that the NIHSS
score was below typical thresholds for MT, and symptomatology
was subacute with MRI evidence of established small infarcts.
Intervention was undertaken in a semi-elective manner because
of the emergency need for cardiac surgery. Optimal cardiac
surgery timing is driven by the risk of further neurological
sequelae and the urgency of valve replacement. Early surgery is
generally regarded as safe, although opinions differ.1 3 The rate
of neurological deterioration is 15–35% for cardiac surgery
within 72 h of stroke.4 Previous reports of early versus late

Ladner TR, et al. J NeuroIntervent Surg 2015;7:e41. doi:10.1136/neurintsurg-2014-011488.rep

3 of 4

Downloaded from http://jnis.bmj.com/ on November 18, 2015 - Published by group.bmj.com

Ischemic stroke
Table 1 Outcomes of mechanical thrombectomy in stroke-associated infectious endocarditis
Author

Cardiac disease

NIHSS

Location

NIS

Thrombolysis

Angio outcome

Clinical outcome

Bain et al5

18 months s/p LVAD c/b sepsis

18

L ICA terminus

MT+IBAS

IA tPA

Sukumaran et al6

Rheumatic mitral stenosis

14

L M1

MT

None

M1: TICI 3
A1: TICI 0
TICI 2a

Dababneh et al7

6 months s/p MVR c/b line infection

Unknown

L M2

MT

None

TICI 2–3

Kan et al8
Kang et al9

MVP
None

16
16

R M2
L M1

MT
MT

None
IA urokinase and tirofiban

TICI 3
TICI 2b

Toeg et al10

s/p AVR

20

R ICA terminus

MT

IV tPA

TICI 3

Post-op NIHSS 7
NIHSS 2 @ 2 months
Post-op NIHSS 4
NIHSS 0 @ 4 days
PE w/DNR
Elected for hospice
Post-op NIHSS 12
Post-op NIHSS 7
NIHSS 3 @ 4 weeks
Post-op NIHSS 2
Re-AVR for abscess
NIHSS 0 @ 8 weeks

AVR, aortic valve replacement; c/b, complicated by; DNR, do not resuscitate; IA, intra-arterial; IBAS, intracranial balloon angioplasty and stenting; IV, intravenous; LVAD, left ventricular
assist device; MT, mechanical thrombectomy; MVP, mitral valve prolapse; MVR, mitral valve repair; NIHSS, National Institutes of Health Stroke Scale; NIS, neurointerventional surgery
intervention; PE, pulmonary embolism; s/p, status post; TICI, Thrombolysis in Cerebral Infarction score; tPA, tissue plasminogen activator.

cardiac surgery are limited because it is unclear how preoperative factors (especially vegetation size, hemodynamic instability,
and infarct size) and postoperative outcome (especially intracerebral hemorrhage and reinfarction) varied between groups.
There is little information reported on how neurointervention
modifies the risks of cardiac surgery, although we expect this
could improve outcomes for selected patients. Certainly the
management paradigm presented here is unproven; however, we
hope this report provides a reference for others who find themselves in this challenging scenario.
In general, the performance of MT for embolic vegetations
without urgent cardiac surgery is rarely reported. Our review
yielded six previous reports (table 1).5–10 Including the current
case, the proximal MCA was the most common thrombus location (3/7, 42.9%). Three cases (42.9%) have reported using MT
with thrombolytics whereas four (57.1%) have reported MT
alone. In a single case, MT failed due to adherence of the vegetation to the endothelium, requiring a balloon-assisted stent.5
No cases reported postoperative hemorrhage. Postoperative
revascularization has been exceptional in all cases (between

TICI 2 and 3). All patients had a decrease in NIHSS score and
5/7 (71.4%) had an NIHSS score <4 at follow-up.
For our patient, MT was a favorable option to avoid a large
stroke during emergency 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).
Competing interests JM is a consultant for Lazarus Effect, Medina Medical,
Pulsar Vascular, Reverse Medical, Edge Therapeutics; an investor in Blockade
Medical, Medina Medical; and serves on the advisory board for Codman
Neurovascular.
Patient consent None.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1

2
3

4

Key messages

5

▸ The cerebral vasculature is a common distal embolic site in
infective endocarditis.
▸ Early cardiac surgery is generally regarded as safe in the
setting of endocarditis-related stroke, although optimal
cardiac surgery timing is driven by the risk of further
neurological sequelae and urgency of valve replacement.
▸ Mechanical thrombectomy might be considered in the rare
circumstance of partially occlusive thrombus prior to
anticipated hypotension, even in the setting of minimal
deficits.

6

4 of 4

7
8

9

10

Barsic B, Dickerman S, Krajinovic V, et al. Influence of the timing of cardiac surgery
on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis
2013;56:209–17.
Habib G, Avierinos J-F, Thuny F. Aortic valve endocarditis: is there an optimal
surgical timing? Curr Opin Cardiol 2007;22:77–83.
Rossi M, Gallo A, Silva RJD, et al. What is the optimal timing for surgery in
infective endocarditis with cerebrovascular complications? Interact CardioVasc
Thorac Surg 2012;14:72–80.
Angstwurm K, Borges AC, Halle E, et al. Timing the valve replacement in infective
endocarditis involving the brain. J. Neurol 2004;251:1220–6.
Bain MD, Hussain MS, Gonugunta V, et al. Successful recanalization of a septic
embolus with a balloon mounted stent after failed mechanical thrombectomy.
J Neuroimaging 2011;21:170–2.
Sukumaran S, Jayadevan ER, Mandilya A, et al. Successful mechanical
thrombectomy of acute middle cerebral artery occlusion due to vegetation from
infective endocarditis. Neurol India 2012;60:239–40.
Dababneh H, Hedna VS, Ford J, et al. Endovascular intervention for acute stroke
due to infective endocarditis: case report. Neurosurg Focus 2012;32:E1.
Kan P, Webb S, Siddiqui AH, et al. First reported use of retrievable stent technology
for removal of a large septic embolus in the middle cerebral artery. World
Neurosurg 2012;77:591.e1–e5.
Kang G, Yang TK, Choi JH, et al. Effectiveness of mechanical embolectomy for
septic embolus in the cerebral artery complicated with infective endocarditis.
J Korean Med Sci 2013;28:1244–7.
Toeg HD, Al-Atassi T, Kalidindi N, et al. Endovascular treatment for cerebral septic
embolic stroke. J Stroke Cerebrovasc Dis 2014;23:e375–7.

Ladner TR, et al. J NeuroIntervent Surg 2015;7:e41. doi:10.1136/neurintsurg-2014-011488.rep

Downloaded from http://jnis.bmj.com/ on November 18, 2015 - Published by group.bmj.com

Complex decision-making in stroke:
preoperative mechanical thrombectomy of
septic embolus for emergency cardiac valve
surgery
Travis R Ladner, Brandon J Davis, Lucy He, Howard S Kirshner, Michael
T Froehler and J Mocco
J NeuroIntervent Surg 2015 7: e41 originally published online November
24, 2014

doi: 10.1136/neurintsurg-2014-011488.rep
Updated information and services can be found at:
http://jnis.bmj.com/content/7/12/e41

These include:

References
Email alerting
service

This article cites 10 articles, 2 of which you can access for free at:
http://jnis.bmj.com/content/7/12/e41#BIBL
Receive free email alerts when new articles cite this article. Sign up in the
box at the top right corner of the online article.

Notes

To request permissions go to:
http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to:
http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to:
http://group.bmj.com/subscribe/