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Images in Neurology
Dec 2011

Recurrent Embolic Stroke Due to Nonbacterial Thrombotic Endocarditis Followed by Transesophageal Echocardiography

Author Affiliations

Author Affiliations: Department of Cardiovascular Medicine, Nephrology, and Neurology, University of the Ryukyus Graduate School of Medicine, Okinawa, Japan.

Arch Neurol. 2011;68(12):1604-1605. doi:10.1001/archneurol.2011.687

A 44-year-old man with advanced gastric cancer visited our hospital because of a sudden onset of difficulty in speaking. He was diagnosed as having recent embolic strokes of bilateral middle cerebral artery territories (Figure 1A and B). Elevated plasma levels of D-dimer indicated ongoing hypercoagulation. Electrocardiography showed normal sinus rhythm. Transesophageal echocardiography revealed a 7-mm mobile isoechoic mass broadly attached to the left and noncoronary cusp of the aortic valve (Figure 2A and B). Infective endocarditis was ruled out by negative results in repeated blood cultures and by a normal inflammatory index. The patient developed nonbacterial thrombotic endocarditis (NBTE). Subsequently, anticoagulation was initiated with continuous intravenous infusion of heparin. On day 11, follow-up transesophageal echocardiography demonstrated that the mobile vegetation had shrunk to 5 mm with a decreased whole volume (Figure 2C and D and videos 1, 2, 3, and 4). At the same time, recurrent embolic stroke without symptoms was documented by follow-up magnetic resonance imaging (Figure 1C and D).

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