Vegetations and cerebral emboli of non-bacterial thrombotic endocarditis are overwhelmingly platelet-dominant: A possible histological clue for the diagnosis from an autopsy study

As endovascular therapy for ischemic stroke has advanced, we are getting increasing opportunities to study cerebral thromboemboli histologically. These opportunities have not been fully exploited, but some reports suggest that thromboemboli retrieved from cancer patients with stroke are platelet-richer than those from non-cancer patients. Nonbacterial thrombotic endocarditis (NBTE) is an important cause of ischemic stroke in cancer patients. In this study, we analyzed 20 autopsy cases of NBTE (13 of which had advanced cancer), along with cases of cerebral embolism associated with atrial fibrillation (AF, n = 11) and infective endocarditis (IE, n = 7). The histological features of NBTE vegetations (n = 20) were fairly consistent among cases: they were overwhelmingly platelet-dominant and spatially homogeneous, containing few erythrocytes or inflammatory cells. They were little organized, if at all, and were not associated with valvular destruction. Cerebral emboli associated with NBTE (n = 7) were also platelet-dominant. Intracardiac thrombi/vegetations and cerebral emboli associated with AF and IE, in contrast, contained variable amounts of platelets and erythrocytes. NBTE vegetations/emboli, compared with AF thrombi/emboli, had significantly higher %platelet area (intracardiac vegetations/thrombi: 70 ± 15 % vs 33 ± 20 %, p < 0.001; cerebral emboli: 65 ± 16 % vs 25 ± 22 %, p < 0.001) and lower %erythrocyte area (vegetations/thrombi: 9 ± 7 % vs 61 ± 21 %, p < 0.001; emboli: 20 ± 11 % vs 70 ± 9 %, p < 0.001). These results suggest that some platelet-rich thrombi retrieved during mechanical thrombectomy for ischemic stroke in cancer patients are likely to have originated from NBTE. Clinical diagnosis of NBTE is often difficult, but histological analysis of retrieved thrombi may help identify this underdiagnosed condition.