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Images in Neurology |

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

Hirokuni Sakima, MD; Katsunori Isa, MD, PhD; Kazuhito Kokuba, MD; Koh Nakachi, MD; Hidekazu Ikemiyagi, MD; Kanako Shiroma, MD; Satoshi Ishihara, MD; Takashi Tokashiki, MD, PhD; Takanori Yasu, MD, PhD; Yusuke Ohya, MD, PhD
Arch Neurol. 2011;68(12):1604-1605. doi:10.1001/archneurol.2011.687.
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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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Figure 1. Diffusion-weighted images of the lateral ventricle (A) and the corona radiata (B) on the first day and of the lateral ventricle (C) and the corona radiata (D) 15 days after stroke onset. Multiple recent small and large stroke lesions (arrows on the first day, arrowheads on day 15) increased in bilateral middle cerebral arterial territories despite anticoagulation.

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Graphic Jump Location

Figure 2. Transverse (A) and longitudinal (B) transesophageal echocardiographic images on the second day after stroke onset, and transverse (C) and longitudinal (D) transesophageal echocardiographic images 11 days after stroke onset. Transesophageal echocardiography revealed that the mobile isoechoic mass (arrows) on the left and noncoronary cusp of the aortic valve had shrunk from 7 to 5 mm.

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