Clarion call for histopathological clot analysis in "cryptogenic" ischemic stroke: implications for diagnosis and treatment

Sonu Bhaskar; Dennis Cordato; Cecilia Cappelen-Smith; Andrew Cheung; David Ledingham; David Celermajer; Christopher Levi

doi:10.1002/acn3.500

Clarion call for histopathological clot analysis in "cryptogenic" ischemic stroke: implications for diagnosis and treatment

Ann Clin Transl Neurol. 2017 Nov 12;4(12):926-930. doi: 10.1002/acn3.500. eCollection 2017 Dec.

Authors

Sonu Bhaskar^{1

2

3

4

5

6}, Dennis Cordato^{1

4

7}, Cecilia Cappelen-Smith^{1

4

7}, Andrew Cheung^{4

8

9}, David Ledingham¹, David Celermajer¹⁰, Christopher Levi^{1

2

3

4

5

7}

Affiliations

¹ Department of Neurology & Neurophysiology Liverpool Hospital Liverpool New South Wales Australia.
² Translational Health Research Institute (THRI) South West Sydney Clinical School School of Medicine Western Sydney University (WSU) Sydney New South Wales Australia.
³ The Sydney Partnership for Health, Education Research & Enterprise (SPHERE) Sydney New South Wales Australia.
⁴ Ingham Institute for Applied Medical Research Sydney New South Wales Australia.
⁵ Department of Neurology John Hunter Hospital Newcastle New South Wales Australia.
⁶ School of Medicine & Public Health, Faculty of Health & Medicine University of Newcastle Callaghan New South Wales Australia.
⁷ South Western Sydney Clinical School University of New South Wales (UNSW) Sydney New South Wales Australia.
⁸ Department of Interventional Neuroradiology Liverpool Hospital Liverpool New South Wales Australia.
⁹ Department of Interventional Neuroradiology Prince of Wales Hospital Randwick New South Wales Australia.
¹⁰ Department of Cardiology Royal Prince Alfred Hospital Heart Research Institute (HRI) the University of Sydney Sydney New South Wales Australia.

Abstract

Diagnosis, treatment, and secondary management of cryptogenic stroke patients pose a formidable challenge. The scenario is further complicated in patients with native and prosthetic valvular heart disease. We present a case study of a 36-year-old man who received intravenous thrombolysis (IV-tPA) and endovascular thrombectomy (EVT) for presumed "cryptogenic" complete middle cerebral artery infarction who made a surprisingly excellent clinical recovery despite poor baseline and postintervention neuroimaging. Retrospective gram stain of his clot confirmed a diagnosis of infective endocarditis. This raises an important issue regarding need for more routine histopathological analysis of clot retrieved after EVT in "cryptogenic" stroke patients particularly those with valvular heart disease.