Recurrent Large‐Vessel Occlusive Stroke Requiring Repeated Mechanical Thrombectomy in Severe Dilated Cardiomyopathy With Extremely Low Left Ventricular Ejection Fraction and HIV Screening Positivity: A Case Report

ABSTRACT

Severe dilated cardiomyopathy with markedly reduced left ventricular ejection fraction can rarely present as recurrent large‐vessel occlusive stroke. This case demonstrates that timely mechanical thrombectomy and sustained anticoagulation are crucial for neurological recovery and secondary prevention, while HIV screening positivity adds complexity but should not independently preclude reperfusion therapy.

Key Clinical Message

In patients with severe dilated cardiomyopathy and extremely low left ventricular ejection fraction, interruption of anticoagulation may precipitate recurrent large‐vessel occlusive stroke. HIV screening positivity should prompt multidisciplinary evaluation but should not independently preclude imaging‐guided mechanical thrombectomy.

1. Introduction

Dilated cardiomyopathy (DCM) is characterized by ventricular dilation and impaired systolic function and may be complicated by heart failure, arrhythmia, intracardiac thrombus formation, and systemic embolism. Stroke associated with DCM is commonly ischemic and is linked to left ventricular dilation, impaired wall motion, blood stasis, atrial arrhythmia, and potential ventricular thrombus formation [1, 2, 3]. Patients with heart failure with reduced ejection fraction have an increased risk of stroke, and stroke in this population is associated with worse clinical outcomes [2].

Human immunodeficiency virus (HIV) infection has become a chronic condition in the era of antiretroviral therapy, and cardiovascular and cerebrovascular complications are increasingly recognized. HIV may contribute to myocardial injury, endothelial dysfunction, chronic inflammation, platelet activation, and coagulation abnormalities [4, 5, 6, 7]. However, when confirmatory HIV staging data are unavailable, causal language should remain cautious.

We report a patient with severe DCM, an LVEF of 19%, recurrent LVO stroke, and HIV screening positivity who underwent two successful mechanical thrombectomy procedures. The case supports an imaging‐guided approach to acute reperfusion while emphasizing anticoagulation adherence and psychosocial support as central components of secondary prevention.

2. Case History and Examination

A 58‐year‐old man had a 3‐year history of DCM and chronic heart failure classified as New York Heart Association Class IV. His long‐term medications included oral furosemide, spironolactone, and sustained‐release metoprolol. No patient name or other direct identifier is reported in this manuscript.

On June 25, 2023, he was admitted to the Department of Neurology at Maanshan People's Hospital with 14 h of dizziness and more than 2 h of slurred speech. Neurological examination showed dysarthria, bilateral horizontal nystagmus, mildly reduced left nasolabial fold excursion, approximately Grade 4 muscle strength in all four limbs, and a positive left Babinski sign. The National Institutes of Health Stroke Scale (NIHSS) score was 5. Non‐contrast cranial computed tomography (CT) showed ischemic white‐matter change. Laboratory testing revealed an N‐terminal pro‐B‐type natriuretic peptide level of 6770.0 pg/mL, whereas routine blood, liver, and kidney function tests showed no major abnormalities. Transthoracic echocardiography showed severe systolic dysfunction with an LVEF of 19%.

At 7:00 a.m. on June 26, 2023, the patient suddenly developed impaired consciousness and quadriplegia, and the NIHSS score increased to 21. Emergency multimodal imaging showed basilar artery occlusion and delayed perfusion in the vertebrobasilar territory that was disproportionate to the infarct core, suggesting salvageable brain tissue.

After the first stroke, the patient recovered well and was discharged on dabigatran etexilate. Follow‐up suggested good functional recovery. However, before the second stroke event, he self‐discontinued dabigatran because of depressive symptoms.

On August 25, 2024, he was readmitted to the Department of Cardiology with a 2‐year history of chest tightness and shortness of breath that had worsened over the preceding 2 weeks. At approximately 5:00 p.m. on September 5, 2024, he suddenly developed slurred speech and an inability to move the left upper and lower limbs. The NIHSS score was 19. Non‐contrast cranial CT showed no intracranial hemorrhage, and cerebral angiography revealed occlusion at the origin of the right internal carotid artery.

3. Timeline

The chronological sequence of the three neurologic events, endovascular interventions, anticoagulation course, HIV screening result, and final disposition is summarized in Table 1.

TABLE 1.

Clinical timeline of recurrent large‐vessel occlusive stroke and major management events.

Date	Clinical event
June 25, 2023	First admission for dizziness and dysarthria; NIHSS Score 5.
June 26, 2023	Neurological deterioration with impaired consciousness and quadriplegia; basilar artery occlusion diagnosed; emergency mechanical thrombectomy performed.
After first discharge	Dabigatran anticoagulation prescribed; good recovery documented during follow‐up.
August 25, 2024	Readmission for worsening heart‐failure symptoms; history revealed self‐discontinuation of dabigatran because of depressive symptoms.
September 5, 2024	Second LVO stroke with right internal carotid artery origin occlusion; emergency mechanical thrombectomy achieved mTICI Grade 3 reperfusion.
September 6, 2024	HIV antibody screening test positive (21.132 COI); confirmatory staging data were not available in the provided record.
September 7, 2024	Recurrent neurological deterioration; CT suggested right middle cerebral artery thrombus and right hemispheric infarction; family declined further endovascular therapy and requested discharge.

4. Differential Diagnosis, Investigations, and Treatment

4.1. First LVO Stroke: Basilar Artery Occlusion

Given the acute clinical deterioration and the mismatch between delayed perfusion and infarct core, emergency endovascular therapy was performed for basilar artery occlusion. Emergency multimodal imaging and digital subtraction angiography demonstrated delayed vertebrobasilar perfusion and confirmed basilar artery occlusion (Figure 1A–C). Post‐thrombectomy angiography showed restoration of basilar artery flow, and postoperative CT demonstrated a left cerebellar hypodensity consistent with posterior‐circulation infarction (Figure 1D,E). Neurological function improved markedly. Cranial magnetic resonance imaging (MRI) could not be performed because of metal artifacts in the head. Severe DCM with an LVEF of 19% made cardioembolism a strongly suspected mechanism. Dabigatran etexilate was prescribed after discharge for secondary prevention.

FIGURE 1.

Imaging and endovascular findings during the first stroke episode. (A) Three‐dimensional angiographic reconstruction of the head and neck. (B) CT perfusion demonstrating delayed perfusion within the vertebrobasilar territory. (C) Digital subtraction angiography confirming basilar artery occlusion. (D) Final angiography after mechanical thrombectomy showing restoration of basilar artery flow. (E) Postprocedural cranial CT demonstrating left cerebellar infarction.

4.2. Second LVO Stroke: Right Internal Carotid Artery Occlusion

The second event occurred after self‐discontinuation of dabigatran. Cerebral angiography confirmed occlusion at the origin of the right internal carotid artery (Figure 2A). Persistent right middle cerebral artery occlusion remained after the first thrombectomy pass (Figure 2B). Repeat angiography demonstrated complete reperfusion of the right internal carotid artery and right middle cerebral artery, corresponding to modified Thrombolysis in Cerebral Infarction (mTICI) Grade 3 reperfusion (Figure 2C). Postoperatively, left limb strength improved to Grade 3 and the NIHSS score decreased from 19 to 4. Diffusion‐weighted MRI showed scattered acute infarcts in the right cerebral hemisphere (Figure 2D).

FIGURE 2.

Imaging and reperfusion findings during the second stroke episode. (A) Initial angiography showing occlusion of the right internal carotid artery at its origin. (B) Persistent right middle cerebral artery occlusion after the first thrombectomy pass. (C) Repeat angiography showing complete reperfusion of the right internal carotid artery and right middle cerebral artery, corresponding to modified Thrombolysis in Cerebral Infarction Grade 3 reperfusion. (D) Postprocedural diffusion‐weighted MRI demonstrating acute infarcts in the right cerebral hemisphere.

4.3. HIV Screening Positivity and Third Neurological Event

On September 6, 2024, HIV antibody screening was positive at a cutoff index (COI) of 21.132. Confirmatory HIV testing, CD4 cell count, HIV RNA viral load, and antiretroviral treatment status were not available in the record used to prepare this report. Therefore, this case is described as HIV screening positivity or HIV seropositivity rather than fully staged HIV disease.

On September 7, 2024, the patient developed recurrent impaired consciousness, right gaze deviation, and left‐sided limb paralysis. Cranial CT showed a hyperdense right middle cerebral artery sign and findings consistent with infarction in the right cerebral hemisphere, suggesting recurrent right anterior‐circulation LVO (Figure 3). After discussion of potential benefits and risks, the family declined further mechanical thrombectomy and requested discharge.

FIGURE 3.

Non‐contrast cranial CT obtained during the third neurological deterioration. The image demonstrates right hemispheric infarction and a hyperdense right middle cerebral artery sign, suggesting recurrent right anterior‐circulation large‐vessel occlusion.

5. Outcome and Follow‐Up

Both mechanical thrombectomy procedures were followed by short‐term neurological improvement. After the first basilar artery occlusion, the patient recovered well and received oral anticoagulation. After the second right internal carotid artery occlusion, mTICI Grade 3 reperfusion was achieved, left limb strength improved, and the NIHSS score decreased to 4. The subsequent event on September 7, 2024, was not treated endovascularly because the family declined further intervention. Long‐term functional outcome after discharge was not available in the clinical record used for manuscript preparation.

6. Discussion

This case illustrates recurrent LVO stroke in a patient with severe DCM, extremely low LVEF, interruption of anticoagulation, and newly identified HIV screening positivity. The central clinical lesson is that severe left ventricular systolic dysfunction may represent a persistent and dynamic embolic‐risk state. In this patient, the LVEF of 19%, severe chronic heart failure, recurrent embolic‐appearing occlusions in different vascular territories, and temporal association with dabigatran discontinuation made a cardioembolic mechanism highly plausible. Nevertheless, direct proof, such as documented left ventricular thrombus, atrial fibrillation, or transesophageal echocardiographic findings, was not available. For this reason, the mechanism should be described as strongly suspected cardioembolism rather than definitive attribution.

The relationship between DCM and ischemic stroke is biologically plausible. Ventricular dilation and reduced wall motion may promote intraventricular blood stasis and thrombus formation, and patients with heart failure with reduced ejection fraction have an increased stroke burden [1, 2, 3]. The educational value of the present case is not simply that DCM may be associated with stroke, but that recurrent LVO can occur across different vascular territories in a patient with profoundly reduced LVEF and that clinically meaningful short‐term improvement may follow reperfusion when imaging supports intervention.

The acute treatment course has practical relevance. Despite severe heart failure and complex comorbidity, the patient benefited from two mechanical thrombectomy procedures, one for posterior‐circulation LVO and one for anterior‐circulation LVO. These observations do not prove that thrombectomy is universally safe or effective in patients with severe DCM and HIV seropositivity. Rather, they support an individualized approach guided by the clinical syndrome, vascular imaging, infarct‐core and penumbral assessment, prestroke function, perioperative risk, and patient or family preferences [8, 9]. HIV screening positivity itself should not be considered an absolute contraindication to endovascular reperfusion when standard eligibility criteria are otherwise met.

HIV‐related information should be interpreted cautiously in this case. HIV has been associated with cardiomyopathy, chronic inflammation, endothelial dysfunction, vascular injury, coagulation abnormalities, and increased cardiovascular and cerebrovascular risk [4, 5, 6, 7]. However, the available record contained only a positive antibody screening result and did not include confirmatory testing, CD4 cell count, HIV RNA viral load, opportunistic infection assessment, or antiretroviral therapy status. Therefore, HIV should be presented as a factor that increased diagnostic and management complexity rather than as a proven causal driver of the recurrent strokes. The screening result should prompt infectious‐disease consultation, confirmatory testing, immune and virological staging, and careful review of potential interactions between anticoagulants, heart‐failure therapies, and antiretroviral agents.

The second major lesson concerns secondary prevention. The patient recovered well while receiving anticoagulation after the first event but self‐discontinued dabigatran because of depressive symptoms before the second LVO. This sequence shows that prescribing an anticoagulant is insufficient when adherence barriers remain unrecognized. In patients with severe DCM and suspected cardioembolism, prevention requires shared decision‐making, medication education, depression and anxiety screening, family support, follow‐up reinforcement, and coordination between neurology and cardiology. When HIV infection is suspected or confirmed, infectious‐disease involvement and drug‐interaction review become additional components of safe long‐term care.

This report has limitations. First, HIV was identified by antibody screening, but confirmatory test results, CD4 count, viral load, opportunistic infection assessment, and antiretroviral therapy status were not available. Second, the presumed cardioembolic mechanism was supported by severe DCM, very low LVEF, imaging pattern, and anticoagulation interruption, but not by direct visualization of intracardiac thrombus or documented atrial fibrillation. Third, thrombectomy procedural details, anticoagulant dose, complete vascular risk‐factor profile, and long‐term functional follow‐up were incomplete. Finally, as a single case, this report cannot estimate the safety or efficacy of thrombectomy in the broader population of patients with severe DCM and HIV screening positivity.

7. Conclusion

In patients with severe DCM and very low LVEF, recurrent LVO stroke may occur, particularly after interruption of anticoagulation. HIV screening positivity may increase the need for multidisciplinary evaluation, but it should not by itself preclude mechanical thrombectomy when imaging and clinical criteria support reperfusion. Long‐term anticoagulation adherence, psychosocial support, heart‐failure optimization, infectious‐disease assessment, and family‐centered communication are central to secondary prevention.

Author Contributions

Jing Xu: writing – review and editing, conceptualization, funding acquisition, writing – original draft, formal analysis, validation, investigation. Liangxu Xiang: conceptualization, methodology, validation, resources. Yanghua Tian: validation, project administration, resources, funding acquisition, writing – review and editing, supervision, visualization.

Funding

The authors have nothing to report.

Disclosure

Reporting Guidelines: This manuscript was prepared in accordance with the CARE reporting principles for case reports and the Clinical Case Reports emphasis on a concise Key Clinical Message [10].

Ethics Statement

The requirement for formal ethics approval was waived by the Ethics Committee of Maanshan People's Hospital because this was a retrospective single‐patient case report using anonymized clinical information.

Consent

Written informed consent for publication of anonymized clinical details and accompanying imaging materials was obtained from the patient or legally authorized representative.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data are not publicly available because of patient privacy protection but are available from the corresponding author on reasonable request, subject to institutional and ethical restrictions.