Nishino Wataru, Tajima Yosuke, Inoue Toru, Hayasaka Michihiro, Katsu Bi, Ebihara Koichi, Kawauchi Daisuke, Kubota Masaaki, Suda Sumio
Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan.
Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan.
J Stroke Cerebrovasc Dis. 2017 Sep;26(9):e186-e188. doi: 10.1016/j.jstrokecerebrovasdis.2017.06.002. Epub 2017 Jun 29.
Untreated infective endocarditis (IE) often produces infective emboli in major cerebral arteries. We describe a case of middle cerebral artery occlusion due to IE, which caused severe vasospasm and reocclusion after mechanical thrombectomy (MT). We present the pathologic findings of the occluded middle cerebral artery and investigate the precautions to be taken while performing MT due to IE. A 72-year-old man with atrial fibrillation treated with dabigatran presented with right hemiparesis and aphasia. A diffusion-weighted image showed a high-intensity area in the left temporoparietal junction, and magnetic resonance angiography revealed a left M2 occlusion. Because of an elevated activated partial thromboplastin time, the thrombolytic therapy was contraindicated; instead, MT was performed. Just after the withdrawal of a stent retriever, the left M2 segment showed severe vasospasm. The next day, the left M2 segment reoccluded. Transthoracic echocardiogram and blood culture findings revealed IE. On the ninth day, the patient died. According to the autopsy report, the cause of death was pulmonary embolism. Pathologic analysis of the occluded M2 segment revealed fibrin thrombi containing vast amounts of neutrophils and invasion of neutrophils into the internal elastic lamina. Severe vasospasm was thought to have occurred because the vascular injury caused by the stent retriever in the vessel had a marked inflammation background. Our findings suggest that devices that are less invasive to the vascular wall are required for performing MT due to IE. The Penumbra aspiration system is thought to be a suitable device.
未经治疗的感染性心内膜炎（IE）常导致大脑主要动脉出现感染性栓子。我们描述了一例因IE导致大脑中动脉闭塞的病例，该病例在机械取栓术（MT）后出现严重血管痉挛和再闭塞。我们展示了闭塞大脑中动脉的病理结果，并探讨了因IE进行MT时应采取的预防措施。一名72岁接受达比加群治疗的房颤男性患者出现右侧偏瘫和失语。弥散加权成像显示左侧颞顶叶交界处有高强度区域，磁共振血管造影显示左侧M2段闭塞。由于活化部分凝血活酶时间升高，溶栓治疗被禁忌；取而代之的是进行MT。刚取出支架取栓器后，左侧M2段出现严重血管痉挛。第二天，左侧M2段再次闭塞。经胸超声心动图和血培养结果显示为IE。第九天，患者死亡。根据尸检报告，死亡原因是肺栓塞。对闭塞的M2段进行病理分析发现，纤维蛋白血栓中含有大量中性粒细胞，且中性粒细胞侵入内弹力层。认为严重血管痉挛的发生是因为血管内支架取栓器造成的血管损伤有明显的炎症背景。我们的研究结果表明，因IE进行MT时需要使用对血管壁侵袭性较小的器械。Penumbra抽吸系统被认为是一种合适的器械。
