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Images in Neurology
May 29, 2018

Cerebral Embolus From Aortic Valve Fragment

Author Affiliations
  • 1Department of Neurosurgery, MedStar Georgetown University Hospital, Pasquerilla Healthcare Center, Washington, DC
  • 2Department of Cardiology, MedStar Washington Hospital Center, Washington, DC
  • 3Department of Interventional Neuroradiology, MedStar Washington Hospital Center, Washington, DC
JAMA Neurol. Published online May 29, 2018. doi:10.1001/jamaneurol.2018.1178

An African American woman in her early 80s with a history of severe aortic stenosis underwent elective transcatheter aortic valve replacement (TAVR) using a bioprosthetic valve with balloon valvuloplasty. The procedure was performed under conscious sedation that was provided by a cardiovascular anesthesia team. The bioprosthetic valve was deployed with a postdeployment balloon valvuloplasty to expand the bioprosthetic valve. Immediately after the valvuloplasty, the patient developed right-sided hemiplegia, forced left gaze deviation, and aphasia. Her National Institute of Health Stroke score was 31, which was consistent with a severe stroke. An urgent head computed tomography angiography scan demonstrated occlusive thrombus of the distal M1 segment of the left middle cerebral artery (MCA) without intracranial hemorrhage. The patient was not a candidate for intravenous thrombolysis because of a recent retroperitoneal hemorrhage. She was taken immediately to the neurointerventional suite to undergo a mechanical thrombectomy. Digital subtraction angiography results revealed a persistent occlusion of the left MCA (Figure, A). A single pass with a stent retriever resulted in a complete recanalization of the left MCA territory (Figure, B). A white-tan solid piece of tissue that was approximately 0.5 cm was recovered from the stent retriever (Figure, C). The histopathological assessment of the recovered thrombus demonstrated a fibrous stroma with a myxoid appearance that most likely detached from the native aortic valve (Figure, D). The patient had a neurological recovery with a National Institute of Health Stroke score of 5 at 24 hours after undergoing the thrombectomy procedure. She was discharged to short-term rehabilitation in 1 week with no significant neurological deficit (modified Rankin Scale score, 0).

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