• 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
    • EXELLENTE EXERCISE
    • 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

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site here. Privacy Policy