We also present pathologic findings

of the retrieved clots and we review currently available literature on this issue. CASE REPORT A 40-year-old right-handed woman presented with fever and general malaise for a few days. During her hospital stay, she was found to be aphasic and right hemiparetic by her husband, and he notified our on-call Neurology reference 4 resident. She was febrile (37.6℃), blood pressure was 140/80 mm Hg, and her pulse was regular (120 bpm). The initial neurological examination revealed expressive aphasia, right homonymous hemianopia, and right hemiparesis including facial paresis with a National Institutes of Health Stroke Scale (NIHSS) score of 15. An electrocardiogram showed sinus tachycardia without T wave changes. The white blood cell count was 15,410/µL, the erythrocyte sedimentation rate was 48 mm/hr and the C-reactive protein level was 3.93 mg/dL. Systolic murmur could be heard in the apex area. A diffusion-weighted image revealed subtle early ischemic changes in the periinsular area, and a perfusion-weighted image showed mean transition time delays on the left MCA M2 inferior trunk territory (Fig. 1A, B), and magnetic resonance angiography showed a left MCA M1 cut-off sign (Fig. 1C). IA mechanical thrombectomy

using the FAST technique was performed on the left MCA occlusion after 5 hours from symptom onset (Fig. 1E). The procedure was initiated by placing the coaxialguiding system into the internal carotid artery, and then the 041 F Penumbra reperfusion catheter (Penumbra Inc., Alameda, CA, USA) was advanced to the area of occlusion over a 1.7 F microcatheter (Excelsior SL-10; Boston Scientific, Fremont, CA, USA) and microwire (synchro 14; Boston Scientific, Natick, MA, USA). After removal of the microcatheter and microwire, manual aspiration was performed with a 50 ml syringe. The

Penumbra reperfusion catheter was slowly withdrawn, while maintaining pulling forces [6]. A complete recanalization was achieved, and multiple fragmented clots were retrieved through the reperfusion catheter tip (Fig. 1F, G). Fig. 1 Summary of brain images and angiographic findings in a 40-year-old woman. A-C. Initial magnetic resonance image and angiography showed acute ischemic change in the left peri-insula area, delayed mean transition time Drug_discovery of the left MCA partial territory and … Pathologic analysis of the retrieved clots revealed septic thrombi containing gram-positive cocci (Fig. 1H). Diagnosis of an infective endocarditis was confirmed thereafter using transthoracic echocardiography. It showed mitral valve vegetation and severe mitral valve regurgitation with valve perforation. Blood cultures were positive for streptococcus mitis. Intravenous antibiotic treatment was started with ceftriaxone and gentamicin. She recovered to mild right hemiparesis and mild expressive aphasia with an NIHSS score of 3 at 2 days after onset.