Embolization of Endocardial Vegetation With Stroke Presentation.

This case report details the unique cause of death of a 37-year-old Caucasian woman with a history significant for intravenous drug abuse. Before her death, she complained of extremity weakness and pain. Although her death was discovered to be the result of endocarditis, her symptoms were similar to that of a stroke. Autopsy revealed a large endocardial vegetation infecting both the tricuspid and mitral valves and a patent foramen ovale. The subsequent embolization of this vegetation caused blockages in the lungs, liver, and brain. An acute embolization of these vegetations to the bilateral middle cerebral arteries is the cause of the stroke presentation. Other comorbidities, such as cardiomegaly, microscopic evidence of myocardial infarction, and atherosclerotic disease, also contributed to the cause of death. As the opioid crisis continues in the United States, it is important to review cases involving the effects of drug use. The multiple interactions between endocarditis and the aforementioned conditions are documented to not only serve as references for future autopsies but also for the treatment of patients who have similar symptoms and comorbidities.

An unusual ischaemic presentation of thrombosed intracranial mycotic aneurysm with subsequent subarachnoid haemorrhage.

We present an unusual case of acute ischaemic stroke secondary to thrombosed mycotic aneurysm with subsequent early aneurysmal rupture and subarachnoid haemorrhage, successfully treated with endovascular coil embolisation of the thrombosed segment. Imaging correlates are presented demonstrating successful endovascular management despite vessel occlusion precluding angiographic visualisation of the aneurysmal segment. Imaging and clinical follow-up is provided demonstrating durable occlusion and excellent clinical outcome with full functional recovery.

Middle cerebral artery territory infarct due to Cryptococcus infectionstitle: an uncommon indication for cerebrospinal fluid analysis in stroke patients.

Cryptococcal meningitis is the most common manifestation of cryptococcosis and is caused by the encapsulated yeast organism Cryptococcus neoformans. It occurs most commonly in patients with impaired cell-mediated immunity such as in HIV infection; patients with hematological malignancies; patients post solid-organ transplantation; on chronic steroids or immunosuppressants. Clinically, stroke can arise as a complication of cryptococcal meningitis. While cerebrospinal fluid (CSF) examination is usually not indicated for evaluation of stroke patients, demonstration of cryptococcal yeast forms in CSF is valuable in guiding appropriate therapy in arterial stroke caused by Cryptococci. Herein, we describe the CSF and radiologic correlation in a female patient who presented with disseminated cryptococcosis, cryptococcal meninigitis and a middle cerebral artery infarct.

Chlamydia pneumoniae in atherosclerotic middle cerebral artery.

BACKGROUND AND PURPOSE: Atherosclerotic middle cerebral arteries are frequent sites of thrombosis, leading to stroke. Previous studies have suggested a role for Chlamydia pneumoniae in the pathogenesis of atherosclerosis. However, the presence of this pathogen in atherosclerotic middle cerebral arteries has heretofore not been documented. In the present study, we analyzed atheromatous plaques from middle cerebral arteries for the presence of C pneumoniae. METHODS: Atherosclerotic middle cerebral arteries from 15 cadavers who died of natural causes and corresponding nonatherosclerotic arteries from 4 otherwise healthy trauma victims were examined. Assays for C pneumoniae DNA were carried out by nested polymerase chain reaction (nPCR) specific for the C pneumoniae ompA gene. The presence of the bacterium was assessed by transmission electron microscopy. RESULTS: Five of the 15 atherosclerotic arterial samples and none of the control tissues were positive for C pneumoniae by nPCR. Particles similar in morphology and size to C pneumoniae elementary bodies were detected by transmission electron microscopy in 4 of the 5 nPCR-positive atherosclerotic samples. CONCLUSIONS: The demonstration of C pneumoniae in atherosclerotic middle cerebral arteries is consistent with the hypothesis that this bacterium is involved in acute and chronic cerebrovascular diseases.

Complex decision-making in stroke: preoperative mechanical thrombectomy of septic embolus for emergency cardiac valve surgery.

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.

Early atherosclerotic plaques show evidence of infection by Chlamydia pneumoniae.

Chlamydia pneumoniae (Cpn) could play an important role in the development of atherosclerosis. Cpn interferes with HIF-1alpha regulation in infected host cells during intracellular replication in hypoxia. We obtained carotid artery specimens with low (n=38), high (n=25) levels of stenosis and 10 middle cerebral arteries. Fifty eight percent of the carotids with low levels of stenosis showed evidence of the viable organism. Ninety one percent of the positive results were derived from pre-atheromatous lesions. Only 12 percent of plaques removed at endarterectomy showed the presence of Cpn DNA. All middle cerebral arteries failed to show evidence of live Chlamydia. Ninety one percent of sera from 22 endarterectomy patients failed to show the presence of Cpn antibodies. Immunohistology of carotid arteries with low levels of stenosis was used to confirm the presence of HIF-1alpha in infected specimens and showed a correlation between the over-expression of HIF-1alpha and Cpn in the plaque (p less than 0.05). Cpn might play an important role in activation and development of the initial stages of atherosclerotic lesions.

Percutaneous transluminal angioplasty in a patient with vasospasm secondary to coccidioidal meningitis: case report and review of the literature.

INTRODUCTION: Coccidioidomycosis is secondary to infection with fungal species Coccidioides immitis or Coccidioides posadasii. One consequence of extrapulmonary coccidioidomycosis dissemination is meningitis, which is associated with high rates of morbidity and mortality if left untreated. Intracranial vasospasm, although rarely described, can occur and may be a result of vasculitic or subacute fibrotic changes. We describe a case of successful percutaneous transluminal angioplasty (PTA) in a patient with severe vasospasm related to coccidioidal meningitis. This is the first report of this endovascular treatment used to treat coccidioidal vasospasm. CLINICAL PRESENTATION: A patient with a history of pulmonary coccidioidomycosis presented with acute confusion, blurry vision and headache. Serology confirmed basilar meningitis and magnetic resonance angiography demonstrated severe symptomatic vasospasm. INTERVENTION: Emergent cerebral angiography confirmed severe vasospasm in the right middle cerebral artery and moderate vasospasm in the left middle cerebral artery. Successful PTA was performed under general anesthesia. The patient demonstrated postprocedural angiographic and clinical improvement. CONCLUSION: We report the first case of successful PTA performed to treat vasospasm related to coccidioidal meningitis. When vasospasm is clinically symptomatic, PTA is a safe and feasible procedure.