E-223 Atypical delayed mechanical thrombectomy for calcified cardiac emboli. (23rd July 2022) - Pandhi, A
Abstract : Background: Calcified cardiac embolism to the brain requiring mechanical thrombectomy is a rare entity. Calcified cardiac emboli (CCE) are small, few millimeter particles, usually originating from calcific aortic stenosis or mitral annular calcification, either spontaneously or following cardiac valve or coronary surgery. Calcified non-cardiac emboli have also been described from cervical large vessel plaques. We present a unique case of CCE causing recurrent stroke symptoms requiring atypical delayed mechanical thrombectomy. Methods: Case description and literature review: Results: A patient in their late 50's with prior bioprosthetic aortic valve replacement presented with concerns for valve dysfunction. Workup revealed prosthetic aortic stenosis with a large mobile calcified echodensity on the valve. The patient developed recurrent, fluctuating symptoms of left facial droop, dysarthria, and left-sided weakness over several days with a return to no neurologic deficits between the 10–15 minute long spells. EEG was negative for seizures. Noncontrast head CT showed a small hyperdense lesion in the right sylvian fissure. Brain CTA was suggestive of a subocclusive right M2 thrombus. MRI confirmed small punctate infarcts in the corresponding right middle cerebral artery distribution. The pathomechanism was presumed to be a combined 'valve-like' hemodynamic effect and microembolism from CCE. After extensive discussions of risks and benefits with the patient and cardiology, the patient was taken for an angiogram. Successful mechanical thrombectomy of the subocclusive calcified material at the origin of the superior M2 division was performed with a combination of an Embotrap stentriever and local aspiration. Pathology confirmed calcified debris, most likely originating from the patient's degenerating prosthetic aortic valve. The patient made a full recovery without further recurrent symptoms. The literature search reviewed revealed a rare phenomenon with a reportedly low chance of successful thrombectomy. The use of local aspiration, stentriever with a 'cage' design, and even microsurgical resection have been reported. Conclusion: Mechanical thrombectomy for intermittent stroke symptoms due to CCE was successfully achieved using an Embotrap device despite several days of relapsing-remitting symptoms with full neurologic recovery. Regardless of prior reports showing a low success rate, with the advent and availability of advanced thrombectomy devices, tailored endovascular treatment for patients with CCE to the brain should be strongly considered. Disclosures: A. Pandhi: None. A. Alrohimi: None. A. Mahapatra: None. A. Russman: None. G. Toth: None.