Hemorrhagic Transformation Following Ischemic Stroke in Patient with Infective Endocarditis Complicated with Atrial Fibrilation and Rheumatic Heart Disease

Author : P. Setiawan, L.O.S Suastika
Upload Date : 19-04-2018

Background: Infective endocarditis (IE) is a rare infectious disease but has a high rate of morbidity and mortality. Neurological complication in IE is uncommon but has worse prognosis, therefore needs special attention on the management.

Case: A 24 year-old man was consulted by Neurology Departement with fever and decreased consiousness caused by ischemic stroke. Physical examination showed rapid and irregular heart rate. ECG result was atrial fibrillation (AF) with ventricular response 130-186 beats/minute. On echocardiography study, multiple highly-mobile vegetations at posterior mitral leaflet and chordae with the biggest size of 2.5 x 3.3 cm was seen along with severe rheumatic mitral stenosis, mild mitral regurgitation, tricuspid regurgitation and aortic regurgitation, and reduced LV systolic function (LVEF 44%). He was diagnosed with definite IE, severe rheumatic mitral stenosis, congestive heart failure, AF rapid ventricular response and ischemic stroke. He was planned to undergo open heart surgery for vegetation excision and mitral valve replacement. After 6 days of hospitalization, his condition deteriorated, the ischemic stroke transformed into hemorrhagic stroke shown by new intracranial and subarachnoid bleeding on head CT scan.

Discussion: Infective endocarditis is one of ischemic stroke causes that is difficult to determine. Several studies suggest that administration of anticoagulation and antiplatelet agents are contraindicated in such case, at least in acute condition. Anticoagulation, although is suggested in patients with AF, is not recommended in ischemic stroke patients due to IE. Hemorrhagic tranformation may be due to microhemorrhagic consequences of vascular friability, or rupture of infectious aneurysms. The decision to conduct surgical intervention is highly dependent on clinical and postoperative prognostic factors.

Conclusion: Infective endocarditis should be considered as a cause of stroke that occurs in young patients. Hemorrhagic transformation of previously ischemic stroke needs special concern because it worsens the patient prognosis.

KEYWORDS : infective endocarditis, stroke, atrial fibrilation, hemorrhagic transformation

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