title: Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated?
abstract: Thrombolysis is considered to be contraindicated in acute ischemic stroke secondary to infective endocarditis (IE). We report a 12-year-old female who presented with acute dense right hemiparesis and aphasia. Cranial magnetic resonance imaging and angiography showed multiple diffusion-restricted lesions in the left hemisphere and absence of flow in the left internal carotid artery. She was treated with intra-arterial tissue plasminogen activator within 6 hours of her presentation. Subsequently she was diagnosed with pneumococcal endocarditis and underwent debridement of vegetations and patch repair of the mitral valve. The patient did not have hemorrhagic complications following thrombolytic therapy or surgery. Pathological analysis of the mitral valve vegetations revealed mostly fibrin thrombus. Follow-up imaging showed complete recanalization of the left internal carotid artery, and the patient had a remarkable neurological recovery. This is the first case report of successful intra-arterial thrombolytic therapy in childhood IE-related stroke. We believe that thrombolytic therapy contributed to a favorable outcome in our patient and may be safe in selected patients with childhood IE-related acute ischemic stroke.
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, Toronto, Canada.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Tan
authors.forename: Derek
authors.initials: D
authors.lastname: Armstrong
authors.forename: Catherine
authors.initials: C
authors.lastname: Birken
authors.forename: Ari
authors.initials: A
authors.lastname: Bitnun
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Caldarone
authors.forename: Peter
authors.initials: P
authors.lastname: Cox
authors.forename: Walter
authors.initials: W
authors.lastname: Kahr
authors.forename: Daune
authors.initials: D
authors.lastname: Macgregor
authors.forename: Rand
authors.initials: R
authors.lastname: Askalan
mesh_terms: D002340:Carotid Artery Diseases / Q000150:complications* / Q000188:drug therapy*; D002648:Child; D004697:Endocarditis, Bacterial / Q000150:complications*; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods; D020521:Stroke / Q000150:complications* / Q000473:pathology; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000652:urine*
chemical_list: D010959:Tissue Plasminogen Activator