The Case

A 50-year-old male with no known past medical history is brought to the emergency department by EMS after his wife found him down with right-sided flaccidity and aphasia. A prehospital stroke code was called in the field. Upon arrival, the patient is found to have no movement in the right upper or lower extremity, a left sided gaze, and complete aphasia. Computed tomography (CT) without contrast was performed and revealed a large left middle cerebral artery (MCA) thrombosis with infarct and bilateral subarachnoid hemorrhages. Tissue plasminogen activator (tPA) is not given due to subarachnoid hemorrhage. Neuro-intervention is consulted and brings the patient to the angiography suite to perform an endovascular thrombectomy extending from the terminus of the left internal carotid artery (ICA) to the left MCA. Following thrombectomy, the patient has good blood flow to left ICA and MCA.

Slam-dunk stroke code with resolution of the cause?

Axial nonenhanced CT of the head shows acute middle cerebral artery infarction.
Medical Body Scans/Science Source

History obtained from the wife shortly after the patient’s admission reveals that, over the previous six months, the patient had experienced intermittent fevers, night sweats, and a 25-pound weight loss. She adds that the patient recently emigrated from the Dominican Republic, where he had been evaluated for these symptoms, though he was never given a definitive diagnosis.

The patient subsequently receives a transesophageal echocardiogram, which reveals a bicuspid aortic valve with vegetations and mitral valve abscess. He is started on empiric antibiotics for endocarditis. Blood cultures grow Streptococcus mitis. The patient has a complicated recovery requiring percutaneous endoscopic gastrostomy tube placement, physical therapy, and daily intravenous antibiotics. Despite a complicated course over the period of a month, the patient has relative improvement in symptoms, begins to move his right upper and lower extremities, and regains his speech, but with dysphasia. He is discharged to a subacute rehabilitation facility with the diagnosis of a left MCA stroke secondary to septic embolus from infective endocarditis. 

Causes of Stroke

Stroke is a common presentation to the emergency department. Most emergency physicians are well versed with the presentation and are trained to think stroke with thrombus means give tPA (controversy aside). However, the presumption of traditional ischemic stroke in all patients with stroke-like symptoms can result in disastrous consequences.

Ischemic strokes can be subdivided:

1. Thrombotic
   1. Local obstruction of an artery that can be due to a variety of causes, most commonly atherosclerosis
   2. Most commonly occur in older patients
2. Embolic
   1. Refers to a stroke that presents after an obstruction from particles or clot that originated in a different part of the body

Cardiac ultrasound of infectious endocarditis. Note the vegetation in the trunk of the pulmonary artery.
James Cavallini

Clinically, both of these ischemic entities are treated similarly in the emergency department. If there is an occlusion and the patient has no signs of bleeding and falls into the appropriate time frame, tPA should be strongly considered. Depending on your institution, there should also be consultation with neurosurgery and neuro-intervention for potential thrombolysis, but that’s not the end of the evaluation.

Embolic stroke has multiple causes and can arise from the heart, aorta, or any large vessel. In this subset, we have the opportunity for further investigation and potential early intervention. Factors that suggest embolic stroke, triggering us to begin thinking of other causes, include:¹