Emergency Department Management of Infective Endocarditis-Associated Stroke (Stroke CME) -
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Publication Date: March 2023 (Volume 25, Number 3)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 03/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke CME credits, subject to your state and institutional approval.

Authors

Lauren Gillespie, MD

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH

Natalie Kreitzer, MD

Associate Professor, Emergency Medicine and Neurocritical Care, University of Cincinnati College of Medicine, Cincinnati, OH

Peer Reviewers

Jeffrey Miller, MD

Vascular and Inpatient Neurologist, Atrium Health, Carolinas Medical Center, Charlotte, NC

Vasisht Srinivasan, MD

Acting Assistant Professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA

Editor-in-Chief

Rhonda Cadena, MD, FNCS, FCCM

Neurocritical Care, Atrium Health, Carolinas Medical Center, Charlotte, NC

Abstract

Stroke in patients with endocarditis is a unique, highly morbid condition requiring a high index of suspicion for diagnosis. This issue reviews the historical and physical examination factors that can provide clues to the etiology. The workup of these patients, involving both infection-focused and stroke-focused laboratory testing and neuroimaging, is discussed. The mainstay of treatment is empiric antibiotics, as thrombolytics are contraindicated. Recent evidence regarding the use of mechanical thrombectomy in large-vessel occlusion strokes is discussed, as well as surgical options and consultation strategies with stroke, neurocritical care, infectious disease, and neurosurgery teams.

Case Presentations

CASE 1

A 65-year-old man with a history of aortic valve repair 2 years ago presents via EMS with concern for stroke….

He has right facial droop, difficulty speaking, and is unable to move the right side of his body.
The patient is ill-appearing. His vital signs are: temperature, 39°C; heart rate, 115 beats/min; blood pressure, 98/55 mm Hg; respiratory rate, 30 breaths/min; and oxygen saturation, 91% on room air. There are small areas of hyperpigmentation on his nail beds, and he has a palmar rash.
On neurological examination, he has an initial NIHSS score of 10. He has an IV/VI systolic murmur best heard in the second left intercostal space, and diffuse crackles on lung auscultation. His point-of-care glucose is 195 mg/dL.
What should your initial resuscitation steps be? If this were a thromboembolic stroke, what considerations regarding management should you have? How does the physical examination narrow the differential?

CASE 2

A 25-year-old woman with fever and altered mental status is brought to the ED by a friend…

The patient is obtunded and unable to provide any meaningful history. She has no known medical history, but her friend reports that the patient uses heroin, has been trying to quit, and is interested in suboxone. The friend said the patient last used intravenous heroin 3 days ago, but started to act confused and was difficult to wake up from sleep tonight.
She feels hot to the touch. Her vital signs are: temperature, 38.5°C; heart rate, 140 beats/min; blood pressure, 82/40 mm Hg; respiratory rate, 27 breaths/min; and oxygen saturation, 80% on room air.
She withdraws in all 4 extremities, has nuchal rigidity, is making incomprehensible sounds, and is not following commands. There is no evidence of trauma. Her blood glucose is 211 mg/dL.
She was intubated for airway protection and hypoxemia prior to obtaining imaging. CT of the head without contrast demonstrates moderate-volume subarachnoid hemorrhage.
What are the differential diagnoses that should be considered for this patient? What central nervous system infectious sources should be included?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.