Emergency Department Management of Infective Endocarditis-Associated Stroke (Stroke CME)

Table of Contents

 

About This Issue

The treatment of patients with infective endocarditis-associated stroke (IEAS) differs greatly from that of other types of stroke, with thrombolytics contraindicated, so it is essential that emergency clinicians maintain a high index of suspicion for early identification of this highly morbid condition. In this issue, you will learn:

The patient risk factors, history, and physical examination findings that will help flag an infectious etiology of stroke symptoms.

The most likely neurologic complications of infective endocarditis: ischemic stroke, hemorrhagic complications, and infectious intracranial aneurysms.

Other neurologic complications, including bacterial meningitis, encephalitis, and encephalopathy, as well as mimics such as brain abscess, spinal epidural abscess, and seizure.

Neuroimaging – CT, CTA, CT perfusion, diffusion-weighted MRI, POCUS – that will be most useful in diagnosing IEAS.

The appropriate consultations to obtain in managing these complex patients: the stroke team, neurosurgery, infectious disease, and neurointensivists.

The empiric antibiotic therapies to use for ED patients with suspected endocarditis.

When mechanical thrombectomy and neurosurgery may be options.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Ischemic Stroke
   2. Hemorrhagic Complications
   3. Infectious Intracranial Aneurysms
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Initial Stabilization
   2. History
   3. Physical Examination
10. Diagnostic Studies
    1. Laboratory Testing
    2. Neuroimaging
    3. Point-of-Care Ultrasound
    4. Duke Criteria
11. Treatment
    1. Stroke Therapies
    2. Consultation
    3. Antibiotic Therapies
    4. Source Control and Cardiac Surgery
12. Special Populations
13. Controversies and Cutting Edge
    1. Endovascular Therapy and Clot Retrieval for Treatment of Ischemic Stroke Secondary to Septic Emboli
    2. Addiction and Drug Rehabilitation Services in Emergency and Acute Care Settings
14. Disposition
15. Risk Management Pitfalls in Emergency Department Management of Infective Endocarditis-Associated Stroke
16. 5 Things That Will Change Your Practice
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Emergency Department Management of Ischemic Stroke in Infective Endocarditis
21. Tables and Figures
22. References

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

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?

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?

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Clinical Pathway for Emergency Department Management of Ischemic Stroke in Infective Endocarditis

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

10. * Garcia-Cabrera E, Fernandez-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation. 2013;127(23):2272-2284. (Retrospective analysis; 1345 cases) DOI: 10.1161/CIRCULATIONAHA.112.000813

18. * Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation. 2015;132(15):1435-1486. (Review, guideline) DOI: 10.1161/CIR.0000000000000296

49. * Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke. Stroke. 2019;50(12). (Guidelines) DOI: 10.1161/STR.0000000000000211

59. * Marquardt RJ, Cho SM, Thatikunta P, et al. Acute ischemic stroke therapy in infective endocarditis: case series and systematic review. J Stroke Cerebrovasc Dis. 2019;28(8):2207-2212. (Retrospective study; 8 patients; systematic review, 24 publications, 32 participants) DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.039

74. * Bettencourt S, Ferro JM. Acute ischemic stroke treatment in infective endocarditis: systematic review. J Stroke Cerebrovasc Dis. 2020;29(4):104598. (Systematic review; 37 articles, 52 patients) DOI: 10.1016/j.jstrokecerebrovasdis.2019.104598

87. * Ruttmann E, Willeit J, Ulmer H, et al. Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke. 2006;37(8):2094-2099. (Epidemiological study; 65 patients) DOI: 10.1161/01.STR.0000229894.28591.3f

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Keywords: endocarditis, ischemic stroke, marantic, ICH, septic embolic stroke, IV drug use, thrombolytic, thrombectomy, hemorrhage, infectious intracranial aneurysm, antibiotics