title: Surgical treatment of nonbacterial thrombotic endocarditis presenting with stroke.
abstract: BACKGROUND
  Necropsy studies have shown that nonbacterial thrombotic endocarditis (NBTE) may be associated with cerebral infarctions and antemortem diagnosis is now possible. However, the best treatment for patients with NBTE presenting with stroke is not known. We describe three patients presenting with an acute embolic stroke secondary to large,mobile vegetations detected by transthoracic (one case) or transesophageal echocardiography (two cases). All patients underwent surgery for removal of the vegetations to prevent recurrent embolic events; valve replacement was necessary in two cases. The sterile nature of the vegetations was confirmed by pathological examination and negative stains and cultures of the surgical samples. A previously unrecognized hypercoagulable condition was diagnosed in all patients (antiphospholipid antibody syndrome in two cases and disseminated adenocarcinoma in one case).
  
  
  CONCLUSIONS
  NBTE should be considered among the possible causes of embolic stroke even in the absence of history of cancer, hypercoagulability, or previous embolic manifestations. If NBTE is diagnosed, the possibility of underlying thrombophilia should be thoroughly investigated. Valvular surgery represents a valuable therapeutic alternative in patients with large mobile vegetations, valvular dysfunction or recurrent embolic events despite anticoagulation.
authors.affiliation: Dept. of Neurology, University of Miami School of Medicine, Miami, FL 33101, USA. arabinstein@med.miami.edu
authors.forename: A A
authors.initials: AA
authors.lastname: Rabinstein
authors.forename: C
authors.initials: C
authors.lastname: Giovanelli
authors.forename: J G
authors.initials: JG
authors.lastname: Romano
authors.forename: S
authors.initials: S
authors.lastname: Koch
authors.forename: A M
authors.initials: AM
authors.lastname: Forteza
authors.forename: M
authors.initials: M
authors.lastname: Ricci
mesh_terms: D000328:Adult; D017548:Echocardiography, Transesophageal / Q000379:methods; D004617:Embolism / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D004696:Endocarditis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D020521:Stroke / Q000150:complications / Q000175:diagnosis / Q000601:surgery*
references.citation: J Am Coll Cardiol. 1991 Oct;18(4):931-6
references.pmid: 1894866
references.citation: Acta Neurol Scand. 1994 Dec;90(6):417-23
references.pmid: 7892761
references.citation: Arch Neurol. 1982 Feb;39(2):95-8
references.pmid: 7059307
references.citation: Circulation. 1990 Aug;82(2):369-75
references.pmid: 2372888
references.citation: Am Heart J. 1987 Mar;113(3):773-84
references.pmid: 3548296
references.citation: Lupus. 1991 Nov;1(1):43-7
references.pmid: 1845363
references.citation: J Am Soc Echocardiogr. 1995 May-Jun;8(3):251-6
references.pmid: 7640017
references.citation: Chest. 1992 Sep;102(3):954-6
references.pmid: 1516432
references.citation: Am J Med. 1987 Oct;83(4):746-56
references.pmid: 3674060
references.citation: Am Heart J. 1996 Jun;131(6):1175-83
references.pmid: 8644598
references.citation: Stroke. 2002 May;33(5):1267-73
references.pmid: 11988602
references.citation: Mayo Clin Proc. 2001 Dec;76(12):1204-12
references.pmid: 11761501