Cerebrovascular Accident in a Young Patient With Infective Endocarditis With Known Mitral Valve Vegetation, Patent Foramen Ovale, and DVT: An Anticoagulation Conumdrum; a Case Report

Abstract

SESSION TITLE: Nervous System Disorders in the ICU 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: This is case of a young patient who presented with a cerebrovascular accident (CVA) in the presence of a patent foramen ovale (PFO), a deep venous thrombosis (DVT), and infective endocarditis (IE) with known vegetation on the mitral valve (MV). The need for anticoagulation in this setting was unclear as the etiology of the CVA may have been thrombotic or septic. CASE PRESENTATION: 29 year old female with a history of intravenous drug use, IE with Streptococcus bacteremia, and MV vegetation was admitted for CVA symptoms and subsequent unresponsiveness and hypoxia prompting intubation. The patient was receiving Rocephin for IE as an outpatient and was scheduled to have MV repair due to severe MV regurgitation. The patient presented prior to the scheduled MV repair with a CVA from an unknown etiology as the patient had a PFO, DVT, and IE with vegetation that was 1.2 cm in diameter. CT head did not show hemorrhage or old infarction. MRA head showed occlusion of the left MCA 7-10 mm beyond the bifurcation of the left ICA. Brain MRI showed probable 5-6 mm long embolus in proximal left MCA and infarction of the caudate nucleus and putamen without hemorrhage. Given thrombocytopenia, patient was not a good candidate for tPA. Neurosurgery did not recommend intervention. The patient did not receive anticoagulation. The family chose comfort measures and hospice. DISCUSSION: Current standard treatment for IE is against routine anticoagulant and antiplatelet therapy, unless a separate indication exists. Neurological complications (intracerebral infarction and hemorrhage) are a major determinant of poor outcome in IE.1 Mortality rates with CVA can reach up to 50% and worse prognosis if aortic and MV are involved with Staphylococcus aureus bactermia.4 The mechanisms of brain hemorrhage have been related to ruptured mycotic aneurysms, arterial rupture due to arteritis, and hemorrhagic transformation of an ischemic infarction. Mortality was higher in patients with prosthetic valve IE on anticoagulation than in naïve valve IE without anticoagulation (71% vs 37%; P=0.02) due to CNS complications.4 However, others reported the incidence of CNS complications and mortality were higher if anticoagulant therapy was discontinued.3 There was no difference in the number of CNS complication among those with and without anticoagulation, and the probability of these complications rapidly decreases after antimicrobial therapy has been started.2 CONCLUSIONS: There are currently no direct guidelines when to anticoagulate patients with concurrent IE/PFO/CVA/DVT. Anticoagulation will need to be individualized, remain within therapeutic range, along with frequent serial use of CT/MRI scan and clinical signs to decrease the frequency and severity of CNS complications.8 Reference #1: Delahaye JP. et al. Cerebrovascular accidents in infective endocarditis: role of anticoagulation. European Heart Journal (1990) 11, 1074-1078 DISCLOSURE: The following authors have nothing to disclose: Jennifer Treece, Vandana Pai, Kim Phung Nguyen, Girendra Hoskere No Product/Research Disclosure Information