• HPI: 54 year old female presents with the sudden onset visual difficulty 

    PMH: Mechanical mitral valve on coumadin anticoagulation, Atrial fibrillation, Hypertension, Hyperlipidemia, Previous ischemic stroke, History of septic shock episodes from mitral valve endocarditis over last 10 year period 

    Neurologic exam: Awake, alert and oriented x 3; Cranial nerves II-XII intact except for right inferior quadrantanopsia; Motor / Sensory exam WNL 

    Blood culture: Gram positive cocci 

    Echocardiogram: No valvular vegetations

    Figure 1. Non-contrast, axial CT scan demonstrates a left parietal intraparenchymal hemorrhage

    Figure 2. Digital subtraction arteriography: left vertebral artery injection demonstrates a 8mm distal posterior cerebral artery aneurysm

    1. What aneurysm characteristic would NOT suggest a mycotic aneurysm?

    2. What is the optimal treatment for this patient?

    3. After aneurysm rupture and SAH in a patient with a mechanical mitral valve, when would you resume anticoagulation?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:

    • Ability to safely stop anticoagulation depends on type of valve.
    • Would need clipping/trapping if not improved onfollow up angio after antibiotics.
    • Worth knowing how to deal though not so common.
    • I am in the opinion of medical management.If facilities available coiling and medical management are standard in Indian subcontinent, in my opinion
    • This particular patient must be treated in the most conservative way possible, endovascular plus antibiotic.
    • If you didn't have to re-start anticoagulation, then antibiotics alone would be reasonable choice; with the mechanical heart valve though requiring anticoags, you should get rid of the aneurysm and will likely have to trap or sacrifice the vessel.
    • Student, MS3
    • Excellent classic case
    • I've never had a simillar situation, so ive left q.3 unanswered.can u elaborate on the proper use of anticoagulation in pt with stent or mechanical valves having acute cerebral bleeds
    • 1 wel sen this case for more specilised center

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