TITLE:
A cardioembolic stroke
AUTHORS:
N. Benyounes, R. Blanc, S. Welschbillig, M. Obadia, G. Chevalier, A. Cohen
KEYWORDS:
Stroke; Echocardiography; Cardio-Embolic; Congenital Heart Disease; Infective Endocarditis
JOURNAL NAME:
World Journal of Cardiovascular Diseases,
Vol.4 No.1,
January
17,
2014
ABSTRACT: A 76-year-old woman with unspecified congenital
heart disease was admitted on April 25th for TIA. She had a possible
history of atrial fibrillation. A slight fever was noted on admission. Her ECG
was abnormal, as well as her transthoracic echocardiography (TTE). Troponin I
was slightly increased. On May 11th, a stroke occurred, in relation
with an occlusion of the basilar artery. The patient was transferred to our institution for an emergency desobstruction. A
dramatic improvement allowed her to be discharged to a rehabilitation
center on May 18th. However, she was re-hospitalized on June 5th,
due to sepsis and neurological worsening. MRI showed new ischemic brain
lesions. Several episodes of paroxysmal atrial fibrillation were documented, as
well as pulmonary hypertension. Effective heparin therapy was initiated and
transesophageal echocardiography (TEE) was requested this time. It revealed a
congenital valvular heart disease (a subaortic membrane), complicated by
infective endocarditis. Despite a monitoring of aPTT, a fatal hemorrhagic shock
occurred. We report this unfortunately remarkable case to address the following
important points: 1) In the setting of a neurological event, abnormal ECG
and/or abnormal TTE and/or Troponin I elevation may indicate a cardioembolic
mechanism and therefore seek a cardiac source of embolism. 2) When TTE fails to
identify a cardiac source of embolism, TEE should be performed, especially when
a preexisting heart disease is suspected or known. 3) The multiplicity in space
(infarcts in both the anterior and posterior circulation, or bilateral) and/or
the multiplicity in time (infarcts of different age) may indicate a
cardioembolic stroke. 4) Congenital subaortic membrane predisposes to infective
endocarditis. 5) When anticoagulant therapy is initiated on strong arguments in
a septic patient (much discussed in infective endocarditis), aPTT monitoring
alone may not be enough. An anti-Xa monitoring may be more appropriate.