Multimodal Management of Rheumatic Mitral Stenosis with Widespread Cervicocephalic Thromboembolism

Background Rheumatic mitral stenosis, one of the most prevalent valvular heart diseases worldwide, is frequently associated with left atrial enlargement and impaired atrial flow dynamics, predisposing patients to thrombus formation. Left atrial thrombi carry a substantial risk of systemic embolization, which may involve the carotid or vertebral arteries and result in cerebrovascular ischemic events. Antithrombotic therapy remains a cornerstone of management, serving both to mitigate the risk of thromboembolism and to provide a therapeutic bridge to definitive surgical valve intervention. Case Presentation: A 36-year-old woman with rheumatic mitral stenosis complicated by left atrial thrombi presented with multi-vessel occlusion within the cervicocephalic circulation, resulting in cerebellar infarction. Dual antithrombotic therapy achieved partial recanalization, enabling successful mitral valve replacement. Postoperative anticoagulation was maintained and effectively prevented recurrence. Conclusions This case illustrates the challenges of rheumatic mitral stenosis complicated by extensive cervicocephalic thromboembolism. The vascular thrombus within the cervicocephalic circulation emphasized the high embolic risk associated with left atrial appendage thrombosis in young patients. Dual therapy with rivaroxaban and aspirin achieved partial recanalization and neurological stabilization, providing a bridge to surgery. Careful timing of valve replacement—delayed to allow recovery from cerebral infarction—was essential in minimizing perioperative bleeding risk and ensuring a favorable outcome. These findings highlight the value of individualized antithrombotic therapy and judicious surgical planning in complex valvular disease.