Endocarditis is a common stroke mechanism in hemodialysis patients.
Ishida Koto,Brown Mesha Gay,Weiner Mark,Kobrin Sidney,Kasner Scott E,Messé Steven R
Stroke
BACKGROUND AND PURPOSE:Hemodialysis patients are at high risk for ischemic stroke, and previous studies have noted a high rate of cardioembolism in this population. The aim of this study was to determine ischemic stroke causes among hemodialysis patients and elucidate specific cardioembolic stroke mechanisms. METHODS:This study is a retrospective cross-sectional study of hemodialysis patients admitted with acute stroke to the University of Pennsylvania Health System between 2003 and 2010. Strokes were classified using modified Trial of Org 10,172 in Acute Stroke Treatment (TOAST) criteria as large vessel, cardioembolism, small vessel, atypical, multiple causes, or cryptogenic. Cardioembolic strokes were further characterized for specific mechanism. RESULTS:We identified 52 patients hospitalized with acute stroke while receiving hemodialysis. Mean age was 64±13 years, 56% were female, and 67% were black. Stroke subtypes included 3 (6%) large vessel, 20 (38%) cardioembolism, 6 (11%) small vessel, 3 (6%) other, 4 (8%) with multiple causes, and 16 (31%) were unknown. Among patients who had an echocardiogram performed, 5 of 52 (10%; 95% confidence interval, 1%-18%) had a patent foramen ovale. Cardioembolic stroke mechanisms included 6 with infective endocarditis (accounting for 12% of all strokes). CONCLUSIONS:Cardioembolism and cryptogenic stroke are the predominant stroke mechanisms among hemodialysis patients. Infective endocarditis was identified frequently relative to other stroke cohorts, and a raised index of suspicion is warranted in the hemodialysis population.
10.1161/STROKEAHA.113.003913
Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management.
Novy E,Sonneville R,Mazighi M,Klein I F,Mariotte E,Mourvillier B,Bouadma L,Wolff M
Medecine et maladies infectieuses
Neurological complications are frequent in infective endocarditis (IE) and increase morbidity and mortality rates. A wide spectrum of neurological disorders may be observed, including stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Ischemic lesions account for 40% to 50% of IE central nervous system complications. Systematic brain MRI may reveal cerebral abnormalities in up to 80% of patients, including cerebral embolism in 50%, mostly asymptomatic. Neurological complications affect both medical and surgical treatment and should be managed by an experimented multidisciplinary team including cardiologists, neurologists, intensive care specialists, and cardiac surgeons. Oral anticoagulant therapy given to patients presenting with cerebral ischemic lesions should be replaced by unfractionated heparin for at least 2 weeks, with a close monitoring of coagulation tests. Recently published data suggest that after an ischemic stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Surgery should be postponed for 2 to 3 weeks for patients with intracranial hemorrhage. Endovascular treatment is recommended for cerebral mycotic aneurysms, if there is no severe mass effect. Recent data suggests that neurological failure, which is associated with the location and extension of brain injury, is a major determinant for short-term prognosis.
10.1016/j.medmal.2013.09.010
Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study.
García-Cabrera Emilio,Fernández-Hidalgo Nuria,Almirante Benito,Ivanova-Georgieva Radka,Noureddine Mariam,Plata Antonio,Lomas Jose M,Gálvez-Acebal Juan,Hidalgo-Tenorio Carmen,Ruíz-Morales Josefa,Martínez-Marcos Francisco J,Reguera Jose M,de la Torre-Lima Javier,de Alarcón González Arístides, ,
Circulation
BACKGROUND:The purpose of this study was to assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery. METHODS AND RESULTS:This was a retrospective analysis of prospectively collected data on a multicenter cohort of 1345 consecutive episodes of left-sided infective endocarditis from 8 centers in Spain. Cox regression models were developed to analyze variables predictive of neurological complications and associated mortality. Three hundred forty patients (25%) experienced such complications: 192 patients (14%) had ischemic events, 86 (6%) had encephalopathy/meningitis, 60 (4%) had hemorrhages, and 2 (1%) had brain abscesses. Independent risk factors associated with all neurological complications were vegetation size ≥3 cm (hazard ratio [HR] 1.91), Staphylococcus aureus as a cause (HR 2.47), mitral valve involvement (HR 1.29), and anticoagulant therapy (HR 1.31). This last variable was particularly related to a greater incidence of hemorrhagic events (HR 2.71). Overall mortality was 30%, and neurological complications had a negative impact on outcome (45% of deaths versus 24% in patients without these complications; P<0.01), although only moderate to severe ischemic stroke (HR 1.63) and brain hemorrhage (HR 1.73) were significantly associated with a poorer prognosis. Antimicrobial treatment reduced (by 33% to 75%) the risk of neurological complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% versus 40% in later surgery). CONCLUSIONS:Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of infective endocarditis. Early appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.
10.1161/CIRCULATIONAHA.112.000813
Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients.
Misfeld Martin,Girrbach Felix,Etz Christian D,Binner Christian,Aspern Konstantin V,Dohmen Pascal M,Davierwala Piroze,Pfannmueller Bettina,Borger Michael A,Mohr Friedrich-Wilhelm
The Journal of thoracic and cardiovascular surgery
OBJECTIVE:To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE). METHODS:From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis. RESULTS:Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis (P = .69). Three versus 4 had severe postoperative intracerebral bleeding (P = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% (P = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years (P = .83) and 40% ± 6% versus 32% ± 5% at 10 years (P = .86). Independent risk factors of mortality were age at surgery (P < .01), chronic obstructive pulmonary disease (P = .01), preoperative requirement of catecholamines (P = .02), dialysis (P < .01), and duration of cardiopulmonary bypass (P < .01). CONCLUSIONS:Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism--which appears to be equally as dangerous as symptomatic embolism.
10.1016/j.jtcvs.2013.10.076
Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke.
Barsic Bruno,Dickerman Stuart,Krajinovic Vladimir,Pappas Paul,Altclas Javier,Carosi Giampiero,Casabé José H,Chu Vivian H,Delahaye Francois,Edathodu Jameela,Fortes Claudio Querido,Olaison Lars,Pangercic Ana,Patel Mukesh,Rudez Igor,Tamin Syahidah Syed,Vincelj Josip,Bayer Arnold S,Wang Andrew,
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
BACKGROUND:The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. METHODS:Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. RESULTS:Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). CONCLUSIONS:There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.
10.1093/cid/cis878
Infective endocarditis-related stroke: diagnostic delay and prognostic factors.
Epaulard Olivier,Roch Nathalie,Potton Leila,Pavese Patricia,Brion Jean-Paul,Stahl Jean-Paul
Scandinavian journal of infectious diseases
Infective endocarditis is frequently revealed by complications such as stroke, but the diagnostic delay between stroke and infective endocarditis may be long. We retrospectively reviewed all cases of infective endocarditis-associated stroke referred to our institution from 2000 to 2007, with special attention to diagnostic delay and survival. Most (26) of the 34 studied patients presented with stroke before diagnosis of infective endocarditis. The median delay before infective endocarditis diagnosis was 8 d (0-40 d), and was longer in cases with negative blood cultures. Diagnostic delay had no influence upon survival. When diagnosis of infective endocarditis occurred first, stroke developed in 3 patients during the first week of antibiotic therapy; in 3 patients, stroke occurred after valvular surgery. Overall survival was 67.6%; a small vegetation and non-staphylococcal aetiology were associated with a better outcome. In conclusion, infective endocarditis diagnosis is frequently delayed in patients presenting with stroke, particularly if blood cultures are sterile. The risk of delayed stroke after valvular surgery must be considered.
10.1080/00365540902984701
Age, creatinine and ejection fraction (ACEF) score: a simple risk-stratified method for infective endocarditis.
Wei X-B,Su Z-D,Liu Y-H,Wang Y,Huang J-L,Yu D-Q,Chen J-Y
QJM : monthly journal of the Association of Physicians
BACKGROUND:Older age, renal dysfunction and low left ventricular ejection fraction are accepted predictors of poor outcome in patients with infective endocarditis (IE). This study aimed to investigate the prognostic significance of the age, creatinine and ejection fraction (ACEF) score in IE. METHODS:The study involved 1019 IE patients, who were classified into three groups according to the tertiles of ACEF score: low ACEF (<0.6, n = 379), medium ACEF (0.6-0.8, n = 259) and high ACEF (>0.8, n = 381). The ACEF score was calculated as follows: age (years)/ejection fraction (%)+1 (if serum creatinine value was >2 mg/dL). The relationship between ACEF score and adverse events was analyzed. RESULTS:In-hospital mortality was 8.2%, which increased with the increase of ACEF score (4.2% vs. 5.0% vs. 14.4% for the low-, medium- and high-ACEF groups, respectively; P < 0.001). ACEF score had a good discriminative ability for predicting in-hospital death [areas under the curve (AUC), 0.706, P < 0.001]. The predictive value of ACEF score in surgical treatment was significantly higher than in conservative treatment for predicting in-hospital death (AUC, 0.812 vs. 0.625; P = 0.001). Multivariable analysis revealed that ACEF score was independently associated with in-hospital mortality (adjusted odds ratio, 2.82; P < 0.001) and long-term mortality (adjusted hazard ratio, 2.51; P < 0.001). CONCLUSION:ACEF was an independent predictor for in-hospital and long-term mortality in IE patients, and it could be considered as a useful tool for risk stratification. ACEF score was more suitable for surgical patients in terms of assessing the risk of in-hospital mortality.
10.1093/qjmed/hcz191
Clinical Presentation and Multi-Parametric Screening Surrogates of Ischemic Stroke Patients Suffering from Infective Endocarditis.
Hobohm Carsten,Hagendorff Andreas,Schulz Sandra,Fritzsch Dominik,Budig Sarah,Stöbe Stephan,Michalski Dominik
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:Infective endocarditis (IE) represents a life-threatening condition due to complications like cardiac failure and thromboembolism. In ischemic stroke, IE formally excludes patients from approaches addressing the recanalization of occluded vessels, challenging decision-making in the early phase of hospitalization. This study aimed at the rate and clinical course of stroke patients with IE and explored clinical, imaging-based and serum parameters, which would allow early identification. METHODS:A hospital-based registry containing 1,531 ischemic stroke patients was screened for IE identified by echocardiography. In addition to clinical parameters, patterns of cerebral manifestation as well as a variety of inflammatory serum and myocardial markers were analyzed concerning their predictive impact for identifying affected patients. RESULTS:IE was found in 26 patients (1.7%) and was associated with an increased body temperature and cardiac murmurs. Patients suffering from IE demonstrated a more severe clinical affection at hospital discharge and an impaired symptom decline during hospitalization, further deteriorated by the use of systemic thrombolysis. Distribution of cerebral infarction patterns did not differ between the groups. C-reactive protein (CRP) and leukocyte count as well as troponin and myoglobin, taken at hospital admission, were found to be significantly associated with IE. CONCLUSIONS:IE in stroke patients is associated with worse clinical outcome, complicated by intravenously applied thrombolysis, and therefore needs to be screened during the early phase of hospitalization. Increased serum levels of CRP and leukocyte count in combination with an increased body temperature or abnormal cardiac murmurs should entail rapid initiation of further diagnostics, that is, transoesophageal echocardiography.
10.1159/000442005
Outcomes after early or late timing of surgery for infective endocarditis with ischaemic stroke: a retrospective cohort study.
Morita Kojiro,Sasabuchi Yusuke,Matsui Hiroki,Fushimi Kiyohide,Yasunaga Hideo
Interactive cardiovascular and thoracic surgery
OBJECTIVES:The timing of cardiac surgery for infective endocarditis with ischaemic stroke remains controversial. METHODS:Using a nationwide inpatient database in Japan, we conducted a retrospective observational study. We identified patients aged 20 years or older with ischaemic stroke on admission who were diagnosed with infective endocarditis and underwent cardiac surgery during the initial hospitalization between July 2010 and March 2013. In-hospital mortality and perioperative complications were compared between the early (≤7 days) and late (>7 days) surgery groups using logistic regression analyses with adjustment for propensity scores and inverse probability of treatment weighting. RESULTS:We identified 253 patients who underwent cardiac valve surgery for infective endocarditis with ischaemic stroke on admission. In-hospital mortality rates were 8.6 and 9.5% in the early (n = 105) and late (n = 148) surgery groups, respectively. There were no significant differences in the in-hospital mortality between the early and late surgery groups in the propensity score-adjusted model [odds ratio (OR), 0.95; 95% confidence interval (CI), 0.35-2.54] and inverse probability-weighted model (risk difference, -0.82%; 95% CI, -6.43 to 4.84%). The perioperative complication rates were 42.9 and 37.8% in the early and late surgery groups, respectively, and showed no significant differences in the propensity score-adjusted model (OR, 1.11; 95% CI, 0.63-1.97) and inverse probability-weighted model (risk difference, 1.54%; 95% CI, -7.13 to 10.2%). CONCLUSIONS:Early timing of surgery for infective endocarditis patients with ischaemic stroke was not associated with higher in-hospital mortality or complications after admission. Early timing of surgery may not be contraindicated for infective endocarditis patients with ischaemic stroke.
10.1093/icvts/ivv235
Embolic phenomena to the limbs are an independent predictor of in-hospital mortality from infective endocarditis.
ANZ journal of surgery
BACKGROUND:Infective endocarditis (IE) is a morbid condition with high mortality. We investigated predictors of in-hospital mortality and embolic phenomena in a contemporary Australasian cohort. METHODS:We identified all patients with IE admitted between January 2017 and 30th April 2020 (40 months). Patient characteristics, risk factors and clinical outcomes were retrospectively collected and analysed. RESULTS:One hundred and seventy-two consecutive patients (mean age: 56.8 ± 17.9 years, male: 63%, 114/172) were included. Causative organisms were Staphylococcus aureus (44%, 75/172), Enterococcus faecalis (15%, 26/172), Streptococcus mitis (6%, 10/172) and Staphylococcus epidermidis (3%, 6/172). In-hospital mortality was 15% (25/172). Embolic complications were found among 57% (98/172) of patients, the most common being stroke (23%, 40/172), septic pulmonary emboli (17%, 29/172), splenic and/or renal emboli (17%, 26/172) and peripheral limb emboli (15%, 25/172). Sixty (35%, 60/172) patients underwent cardiac surgery. On multivariable analysis, independent predictors of in-hospital mortality were: increased age (odds ratio: 1.064, per year older, P = 0.001), ICU admission independent of cardiac surgery (OR 9.81, P < 0.001), moderate or severe LV impairment (OR 5.19, P = 0.012) and any sign of embolic phenomena to limbs (OR 5.02, P = 0.006). Multivariable predictors of embolic complications were S. aureus bacteraemia (OR 3.22, P = 0.001) and large vegetation >10 mm (OR 3.04, P = 0.002). CONCLUSION:We demonstrate predictors of in-hospital mortality and embolic phenomena in our cohort. Though age remains a consistent predictor of mortality, surprisingly, signs of embolic phenomena to the limbs was established as an independent predictor of mortality. The mechanism of this is unclear and warrants further evaluation.
10.1111/ans.17907
Risk factors of early mortality after surgical treatment for infective endocarditis.
Ling Youpeng,Chen Xuliang,Chen Yingji,Sa Mi,Luo Wangjun
Zhong nan da xue xue bao. Yi xue ban = Journal of Central South University. Medical sciences
OBJECTIVES:To explore the basic clinical characteristics and relevant factors affecting the early postoperative prognosis in patients with infective endocarditis (IE). METHODS:A total of 702 patients with IE, who underwent surgery in Xiangya Hospital, Central South University from January 1981 to June 2019, were studied and the data were collected through the paper records and the hospital information system. The patients from January 1981 to June 2010 served as an early group (=224), and other patients from July 2010 to June 2019 served as a recent group (=478). Independent risk factors for early postoperative death were determined by logistic regression analysis. RESULTS:The mean age of the 702 patients was 36.7±16.1 years, and the male accounted for 68.1%. Preoperative stroke occurred in 71 patients (10.1%), and dialysis was done in 14 patients (2%) preoperatively. were the pathogenic bacteria in 172 patients, accounting for 59.5% of all positive blood culture results. In the early group, the percentage of IE combined with congenital heart disease was significantly higher than that in the recent group [77 patients (34.4%) in the early group vs 22 patients (4.6%) in the recent group; <0.05]. Postoperative stroke occurred in 15 patients (2.1%), while 59 patients (7%) required new dialysis postoperatively because of renal insufficiency. Twenty-nine patient died in the post-operation, with 4.1% in 30-day mortality. Logistic regression analysis revealed that the high preoperative New York Heart Association (NYHA) grade of cardiac function (OR=3.22, 95% CI 1.50-6.88; <0.01), postoperative stroke (OR=5.75, 95% CI 1.22-27.07; <0.05), postoperative dialysis (OR=15.53, 95% CI 3.50-68.82; <0.01), perivalvular abscess (OR=13.19, 95% CI 3.83-45.42; <0.01) and multivalve involvement (OR=3.57, 95% CI 1.24-10.30; <0.05) were the independent risk factors for early mortality. CONCLUSIONS: is the most common pathogenic bacteria in the patients with IE. Surgery for IE can obtain a satisfactory early outcomes. High preoperative NYHA grade of cardiac function, postoperative stroke, postoperative dialysis, perivalvular abscess and multivalve involvement are the independent risk factors for early mortality.
10.11817/j.issn.1672-7347.2020.190667
Valve surgery for infective endocarditis complicated by stroke: surgical timing and perioperative neurological complications.
Zhang L Q,Cho S-M,Rice C J,Khoury J,Marquardt R J,Buletko A B,Hardman J,Wisco D,Uchino K
European journal of neurology
BACKGROUND AND PURPOSE:Ischaemic and hemorrhagic strokes are dreaded complications of infective endocarditis (IE). The timing of valve surgery for IE patients with stroke remains uncertain. The aim was to study perioperative neurological complications in relation to surgical timing. METHODS:The study cohort consisted of patients diagnosed with acute IE from January 2010 to December 2016. Early surgery was defined as valve surgery within 14 days of IE diagnosis, and late surgery as after 14 days. Neurological complications that occurred within 14 days post-surgery were considered perioperative and classified as new ischaemic stroke or hemorrhagic stroke, expansion of an existing intracranial hemorrhage and new-onset seizures. Perioperative neurological complications were compared by surgical timing and other variables, including pre-surgical imaging. RESULTS:Overall, 183 patients underwent valve surgery: 92 had early surgery at a median of 8 days (interquartile range 6-11); 91 had late surgery at a median of 28 days (interquartile range 19-50). Twenty patients (10.9%) had 24 complications: 11 ischaemic, six intraparenchymal hemorrhages, three subarachnoid hemorrhages (SAHs) and four new-onset seizures. Rates of neurological complications were similar for early and late surgery groups (10.9% vs. 11%). Enterococcal IE was more common amongst patients with perioperative neurological complications (35% vs. 12.3%, P < 0.01). An acute infarct was present on pre-surgical magnetic resonance imaging of 134 patients (74%) and was not associated with perioperative neurological complications. Thirty-five patients (19.3%) had intracranial hemorrhage on pre-surgical imaging. SAH on pre-surgical imaging was associated with developing SAH perioperatively (66.7% vs. 13.5%, P < 0.01). CONCLUSION:Early valve surgery for patients with IE complicated by stroke was not associated with perioperative neurological complications.
10.1111/ene.14438
Cerebrovascular Complication and Valve Surgery in Infective Endocarditis.
Rice Cory J,Kovi Shivakrishna,Wisco Dolora R
Seminars in neurology
Infective endocarditis (IE) with neurologic complications is common in patients with active IE. The most common and feared neurological complication of left-sided IE is cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage (ICH), or an infectious intracranial aneurysm with or without rupture. In patients with cerebrovascular complications, valve replacement surgery is often delayed for concern of further neurological worsening. However, in circumstances when an indication for valve surgery to treat IE is present, the benefits of early surgical treatment may outweigh the potential neurologic deterioration. Furthermore, valve surgery has been associated with lower in-hospital mortality than medical therapy with intravenous antibiotics alone. Early valve surgery can be performed within 7 days of transient ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains challenging, and current data in the literature are conflicting about the risks and benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often recommended, balancing the risks and benefits of surgery. The range of timing of valve surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary decision between cardiothoracic surgeons, cardiologists, infectious disease experts, and vascular neurologists in an experienced referral center.
10.1055/s-0041-1726327
Stroke in Patients with Infective Endocarditis: A 15-Year Single-Center Cohort Study.
Cao Gui-Fang,Liu Wei,Bi Qi
European neurology
OBJECTIVE:To explore the relationship between infective endocarditis (IE) and stroke. METHODS:The clinical data of patients diagnosed with IE from January 2003 to December 2017 in Beijing Anzhen Hospital Affiliated to Capital Medical University were retrospectively analyzed. RESULTS:A total of 861 patients (mean age: 40.79 ± 16.27 [SD]) with IE was recruited. Vegetations were confirmed in 97.32% of all the patients, among whom 296 were diagnosed with congenital heart disease and another 53 with rheumatic valvular disease. The most common pathogens were Streptococcus, Staphylococcus, and various types of fungi (13.12, 7.31, and 1.16% respectively). Out of the 138 patients diagnosed with stroke, 101 cases were of ischemic stroke, 23 cases were of hemorrhagic stroke, and 12 cases were of concurrent ischemic and hemorrhagic stroke. There were 31 patients who had infarction lesions in more than 2 vascular systems. The mean age of stroke patients was significantly higher than that of patients without stroke (45.76 ± 17.88 vs. 39.83 ± 15.77, p = 0.000). The incidence of mitral valve vegetation (57.24 vs. 43.01%, p = 0.002), atrial fibrillation (4.34 vs. 1.38%, p = 0.018), fungal infection (2.89 vs. 0.83%, p = 0.038) in patients with stroke was significantly higher than those without stroke. Mitral valve vegetation (OR 1.648; 95% CI 1.113-2.442) and age (OR 1.019; 95% CI 1.007-1.032) were independent risk factors for stroke in IE patients. Stroke increased the risk of hospital deaths (OR 7.673 95%CI 3.634-16.202). CONCLUSION:Stroke is a common complication of IE. Mitral valve vegetation and old age may incerease the risk of stroke in patients with IE.
10.1159/000495149
Neurologic Complications of Infective Endocarditis: A Joint Model for a Septic Thromboembolism and Inflammatory Small Vessel Disease.
Cantier Marie,Sabben Candice,Adle-Biassette Homa,Louedec Liliane,Delbosc Sandrine,Desilles Jean-Philippe,Journé Clément,Diallo Devy,Ou Phalla,Klein Isabelle,Chau Françoise,Lefort Agnès,Iung Bernard,Duval Xavier,Olivot Jean-Marc,Ho-Tin-Noe Benoit,Michel Jean-Baptiste,Sonneville Romain,Mazighi Mikael
Critical care medicine
OBJECTIVES:Embolic events from vegetations are commonly accepted as the main mechanism involved in neurologic complications of infective endocarditis. The pathophysiology may imply other phenomena, including vasculitis. We aimed to define the cerebral lesion spectrum in an infective endocarditis rat model. DESIGN:Experimental model of Staphylococcus aureus or Enterococcus faecalis infective endocarditis. Neurologic lesions observed in the infective endocarditis model were compared with three other conditions, namely bacteremia, nonbacterial thrombotic endocarditis, and healthy controls. SETTING:Research laboratory of a university hospital. SUBJECTS:Male Wistar rats. INTERVENTIONS:Brain MRI, neuropathology, immunohistochemistry for astrocyte and microglia, and bacterial studies on brain tissue were used to characterize neurologic lesions. MEASUREMENTS AND MAIN RESULTS:In the infective endocarditis group, MRI revealed at least one cerebral lesion in 12 of 23 rats (52%), including brain infarctions (n = 9/23, 39%) and cerebral microbleeds (n = 8/23, 35%). In the infective endocarditis group, neuropathology revealed brain infarctions (n = 12/23, 52%), microhemorrhages (n = 10/23, 44%), and inflammatory processes (i.e., cell infiltrates including abscesses, vasculitis, meningoencephalitis, and/or ependymitis; n = 11/23, 48%). In the bacteremia group, MRI studies were normal and neuropathology revealed only hemorrhages (n = 2/11, 18%). Neuropathologic patterns observed in the nonbacterial thrombotic endocarditis group were similar to those observed in the infective endocarditis group. Immunochemistry revealed higher microglial activation in the infective endocarditis group (n = 11/23, 48%), when compared with the bacteremia (n = 1/11, 9%; p = 0.03) and nonbacterial thrombotic endocarditis groups (n = 0/7, 0%; p = 0.02). CONCLUSIONS:This original model of infective endocarditis recapitulates the neurologic lesion spectrum observed in humans and suggests synergistic mechanisms involved, including thromboembolism and cerebral vasculitis, promoted by a systemic bacteremia-mediated inflammation.
10.1097/CCM.0000000000003796
Mechanical Thrombectomy for Acute Ischemic Stroke Secondary to Infective Endocarditis.
Ambrosioni Juan,Urra Xabier,Hernández-Meneses Marta,Almela Manel,Falces Carlos,Tellez Adrian,Quintana Eduard,Fuster David,Sandoval Elena,Vidal Barbara,Tolosana Jose M,Moreno Asunción,Chamorro Angel,Miró José M,
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Intravenous thrombolysis is contraindicated in acute ischemic stroke secondary to infective endocarditis. We report our initial experience in 6 cases of proximal vessel occlusion treated with mechanical thrombectomy, which was safe (no bleeding) and effective (significant early neurological improvement) and might be useful in this clinical setting.
10.1093/cid/cix1000
Neurologic complications of infective endocarditis in children.
Cardiology in the young
OBJECTIVES:To define the frequency and characteristics of acute neurologic complications in children hospitalised with infective endocarditis and to identify risk factors for neurologic complications. STUDY DESIGN:Retrospective cohort study of children aged 0-18 years hospitalised at a tertiary children's hospital from 1 January, 2008 to 31 December, 2017 with infective endocarditis. RESULTS:Sixty-eight children met Duke criteria for infective endocarditis (43 definite and 25 possible). Twenty-three (34%) had identified neurologic complications, including intracranial haemorrhage (25%, 17/68) and ischaemic stroke (25%, 17/68). Neurologic symptoms began a median of 4.5 days after infective endocarditis symptom onset (interquartile range 1, 25 days), though five children were asymptomatic and diagnosed on screening neuroimaging only. Overall, only 56% (38/68) underwent neuroimaging during acute hospitalisation, so additional asymptomatic neurologic complications may have been missed. Children with identified neurologic complications compared to those without were older (48 versus 22% ≥ 13 years old, p = 0.031), more often had definite rather than possible infective endocarditis (96 versus 47%, p < 0.001), mobile vegetations >10mm (30 versus 11%, p = 0.048), and vegetations with the potential for systemic embolisation (65 versus 29%, p = 0.004). Six children died (9%), all of whom had neurologic complications. CONCLUSIONS:Neurologic complications of infective endocarditis were common (34%) and associated with mortality. The true frequency of neurologic complications was likely higher because asymptomatic cases may have been missed without screening neuroimaging. Moving forward, we advocate that all children with infective endocarditis have neurologic consultation, examination, and screening neuroimaging. Additional prospective studies are needed to determine whether early identification of neurologic abnormalities may direct management and ultimately reduce neurologic morbidity and overall mortality.
10.1017/S1047951122001159
When the heart rules the head: ischaemic stroke and intracerebral haemorrhage complicating infective endocarditis.
Jiad Estabrak,Gill Sumanjit K,Krutikov Maria,Turner David,Parkinson Michael H,Curtis Carmel,Werring David J
Practical neurology
Sir William Osler meticulously described the clinical manifestations of infective endocarditis in 1885, concluding that: 'few diseases present greater difficulties in the way of diagnosis … which in many cases are practically insurmountable'. Even with modern investigation techniques, diagnosing infective endocarditis can be hugely challenging, yet is critically important in patients presenting with stroke (both cerebral infarction and intracranial haemorrhage), its commonest neurological complication. In ischaemic stroke, intravenous thrombolysis carries an unacceptably high risk of intracranial haemorrhage, while in intracerebral haemorrhage, mycotic aneurysms require urgent treatment to avoid rebleeding, and in all cases, prompt treatment with antibiotics and valve surgery may be life-saving. Here, we describe typical presentations of ischaemic stroke and intracerebral haemorrhage caused by infective endocarditis. We review the diagnostic challenges, the importance of rapid diagnosis, treatment options and controversies.
10.1136/practneurol-2016-001469
Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement.
Del Val David,Abdel-Wahab Mohamed,Mangner Norman,Durand Eric,Ihlemann Nikolaj,Urena Marina,Pellegrini Costanza,Giannini Francesco,Gasior Tomasz,Wojakowski Wojtek,Landt Martin,Auffret Vincent,Sinning Jan Malte,Cheema Asim N,Nombela-Franco Luis,Chamandi Chekrallah,Campelo-Parada Francisco,Munoz-Garcia Erika,Herrmann Howard C,Testa Luca,Won-Keun Kim,Castillo Juan Carlos,Alperi Alberto,Tchetche Didier,Bartorelli Antonio L,Kapadia Samir,Stortecky Stefan,Amat-Santos Ignacio,Wijeysundera Harindra C,Lisko John,Gutiérrez-Ibanes Enrique,Serra Vicenç,Salido Luisa,Alkhodair Abdullah,Livi Ugolino,Chakravarty Tarun,Lerakis Stamatios,Vilalta Victoria,Regueiro Ander,Romaguera Rafael,Kappert Utz,Barbanti Marco,Masson Jean-Bernard,Maes Frédéric,Fiorina Claudia,Miceli Antonio,Kodali Susheel,Ribeiro Henrique B,Mangione Jose Armando,Sandoli de Brito Fabio,Actis Dato Guglielmo Mario,Rosato Francesco,Ferreira Maria-Cristina,Correia de Lima Valter,Colafranceschi Alexandre Siciliano,Abizaid Alexandre,Marino Marcos Antonio,Esteves Vinicius,Andrea Julio,Godinho Roger R,Alfonso Fernando,Eltchaninoff Helene,Søndergaard Lars,Himbert Dominique,Husser Oliver,Latib Azeem,Le Breton Hervé,Servoz Clement,Pascual Isaac,Siddiqui Saif,Olivares Paolo,Hernandez-Antolin Rosana,Webb John G,Sponga Sandro,Makkar Raj,Kini Annapoorna S,Boukhris Marouane,Gervais Philippe,Linke Axel,Crusius Lisa,Holzhey David,Rodés-Cabau Josep
Journal of the American College of Cardiology
BACKGROUND:Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR). OBJECTIVES:The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization. METHODS:Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]). RESULTS:A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47). CONCLUSIONS:Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.
10.1016/j.jacc.2021.03.233
Neurological Complications and Clinical Outcomes of Infective Endocarditis.
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
OBJECTIVES:The aim of this study is to explore the clinical features associated with neurological complications of infective endocarditis (IE) and to assess the impact of neurological complications on clinical outcomes. MATERIALS AND METHODS:The frequency of relevant clinical features was compared in a case series of IE patients with and without neurological complications admitted to a single health care system from 2015 to 2019. Variables with significant differences (p ≤ 0.05) in baseline characteristics in univariate logistic regression models were entered into multivariable models along with age to determine associations with neurological complications, unfavorable discharge outcomes (modified Rankin score ≥ 3), and in-hospital mortality. RESULTS:260 patients with a mean age of 51 (±18) years and 103 (40%) females were included. Neurological complications occurred in 165 (63%) patients, with the most common being septic emboli (66 patients, 25%). In the regression analyses, antiplatelet usage (aOR 1.87, 95% CI [1.05-3.32]) and mitral valve vegetations (aOR 2.66, 95% CI [1.22-5.79]) were independently associated with neurological complications. Territorial infarction (aOR 4.13, 95% CI [1.89-9.06]) and encephalopathy (aOR 3.95, 95% CI [1.19-13.05]) were associated with an increased risk of unfavorable outcome, while cardiac surgery was associated with a lower risk of both unfavorable outcome (aOR 0.40, 95% CI [0.22-0.71]) and in-hospital mortality (aOR 0.18, 95% CI [0.09-0.35]). CONCLUSIONS:Neurological complications are common in IE patients and are associated with mitral valve endocarditis and antiplatelet usage. Of the neurological complications, territorial infarcts and encephalopathy are associated with unfavorable discharge outcomes.
10.1016/j.jstrokecerebrovasdis.2022.106626
High level of D-dimer predicts ischemic stroke in patients with infective endocarditis.
Xu Nan,Fu Yakun,Wang Shuanglin,Li Shenghui,Cai Dong
Journal of clinical laboratory analysis
BACKGROUND:Ischemic stroke is one of the most prominent and serious neurological complications of infective endocarditis (IE). Our study was designed to evaluate the predictive value of higher level of plasma D-dimer on admission for the development of ischemic stroke in patients with IE. METHODS:In this prospective study, a total of 173 consecutive patients with IE were recruited from January 2016 to December 2018. Plasma D-dimer and other clinical indexes of IE patients were measured after admission. The number of patients who developed ischemic stroke during 6-month follow-up was recorded, as well as the occurrence time of ischemic stroke. RESULTS:Ischemic stroke was observed in 38 (22%) patients during 6-month follow-up since definite diagnosis of IE. Patients with ischemic stroke had significantly higher levels of plasma D-dimer than those of patients without stroke (4982 vs 2205 μg/L, P < .001). In addition, Staphylococcus aureus infection (HR: 1.96, 95% CI: 1.51-2.42), mitral valve vegetation (HR: 1.52, 95% CI: 1.32-1.75), and higher levels of on-admission plasma D-dimer (HR: 1.35, 95% CI: 1.27-1.43) were significantly associated with ischemic stroke. Moreover, D-dimer levels ≥3393 μg/L served as a strong predictor for ischemic stroke in patients with IE, and the sensitivity and specificity were 78% and 83%, respectively. CONCLUSION:Our study suggested that higher level of D-dimer on admission was an independent predictor for ischemic stroke in patients with IE. These patients may require special attention, in particular within the first trimester after IE diagnosis.
10.1002/jcla.23206
Predictors, patterns and outcomes following Infective endocarditis and stroke.
Acta bio-medica : Atenei Parmensis
Patients with infective endocarditis can have multiple neurological manifestations. Cerebrovascular events (CVE) in patients with IE can be hemorrhagic or embolic. Multiple factors are known to predispose to CVE and increased mortality in patients with IE. In this study, we aimed to describe various outcomes among patients with IE and CVE. We retrospectively analyzed 160 patients with definite IE. Among these, patients with radiological evidence of CVE were included. Clinical, radiological, echocardiographic details were obtained. Outcome studied were the requirement of intensive care unit care, the requirement of mechanical ventilation, prolonged course of antibiotics, prolonged duration of hospital stay, the requirement of surgical intervention, and mortality. In this study, 16 [10%] of patients with IE were identified to have a CVE. The mean age of the patients was 55, and 87.5% of them were male. 25% of patients had prior IE. IE involving left-sided valves were predominant, with the involvement of mitral valve reported in 62.5% of patients. More than half of the patient's had details of magnetic resonance imaging (MRI) of the brain. CVE were mostly ischemic, anterior circulation predominant, multiple, and bilateral. In patients with IE and CVE morbidity including the requirement of ICU care, prolonged antibiotics course, and the requirement of surgical intervention contributed to increased duration of hospital stay. In conclusion, CVE in patients with IE tends to present as multiple infarcts predominantly located over anterior circulation. IE patients with CVE tend to have higher morbidity and mortality.
10.23750/abm.v93i2.10185
Pediatric Infective Endocarditis and Stroke: A 13-Year Single-Center Review.
Cao Gui-Fang,Bi Qi
Pediatric neurology
OBJECTIVE:We explored the relationship between pediatric infective endocarditis and stroke. PATIENTS AND METHODS:All children encountered with infective endocarditis from January 2002 to December 2015 were included as our sample, and their medical records were comprehensively reviewed. RESULTS:Sixty children with infective endocarditis were identified, including 30 boys and 30 girls aged eight months to 18 years (mean ± SD: 10.3 ± 5.6), and om 43 (71.6%) of these individuals had congenital heart disease. Left-sided endocarditis occurred in 25 patients (41.7%), and vegetations were found in 58 individuals (96.6%). The most often encountered microorganisms were Streptococcus viridans and Staphylococcus aureus, which were identified in five and four patients, respectively. Postendocarditis stroke occurred in nine patients, including five with cerebral infarction, two with intracerebral hemorrhage, and one with subarachnoid hemorrhage. The remaining child experienced cerebral infarction, intracerebral hemorrhage and subarachnoid hemorrhage simultaneously. The incidence of stroke in children with left-sided endocarditis was significantly higher than that of which in those who had right-sided endocarditis (32% versus 2.8%, P < 0.01). The most common manifestation of stroke was hemiparesis (55.5%). Two girls died of stroke, and the mortality rate in the patients who had stroke was significantly higher than that in those without stroke (22.2 % versus 3.9 %, P < 0.05). CONCLUSIONS:Our data indicate that stroke is common among children with infective endocarditis, especially in those with left-sided endocarditis, and major stroke may increase their risk of death. Congenital heart disease is the main underlying disease in children with infective endocarditis in China.
10.1016/j.pediatrneurol.2018.07.001
Neurological Complications of Infective Endocarditis.
Sotero Filipa Dourado,Rosário Madalena,Fonseca Ana Catarina,Ferro José M
Current neurology and neuroscience reports
PURPOSE OF REVIEW:The purpose of this narrative review and update is to summarize the current knowledge and provide recent advances on the neurologic complications of infective endocarditis. RECENT FINDINGS:Neurological complications occur in about one-fourth of patients with infective endocarditis. Brain MRI represents a major tool for the identification of asymptomatic lesions, which occur in most of the patients with infective endocarditis. The usefulness of systematic brain imaging and the preferred treatment of patients with infective endocarditis and silent brain lesions remains uncertain. The basis of treatment of infective endocarditis is early antimicrobial therapy. In stroke due to infective endocarditis, anticoagulation and thrombolysis should be avoided. Endovascular treatment can be useful for both acute septic emboli and mycotic aneurysms, but evidence is still limited. In patients with neurological complications, cardiac surgery can be safely performed early, if indicated. The optimal management of a patients with neurological complications of infective endocarditis needs an individualized case discussion and the participation of a multidisciplinary team including neurologists, cardiologists, cardiothoracic surgeons, neuroradiologists, neurosurgeons, and infectious disease specialists.
10.1007/s11910-019-0935-x
The Effect of Preexisting Anticoagulation on Cerebrovascular Events in Left-Sided Infective Endocarditis.
Davis Kyle A,Huang Glen,Petty S Allan,Tan Walter A,Malaver Diego,Peacock James E
The American journal of medicine
BACKGROUND:Stroke is a frequent complication of infective endocarditis, especially infection involving left-sided valves. Management of anticoagulation in left-sided infective endocarditis is controversial as it is unclear whether anticoagulation impacts stroke and bleeding risk in patients with this condition. The objective of this study was to evaluate the effect of anticoagulation on stroke occurrence and bleeding complications in patients with left-sided infective endocarditis. METHODS:Patients admitted to a tertiary academic hospital with left-sided infective endocarditis between December 2011 and April 2018 were identified. Patients were stratified based on receipt of therapeutic anticoagulation prior to admission. The primary outcome measure was the rate of radiographically confirmed stroke at 10 weeks. RESULTS:Two-hundred and fifty-eight consecutive patients with left-sided infective endocarditis were identified. Patients receiving anticoagulation (n = 50) were older (median age 63 vs 52; P = .02), were more likely to have a history of atrial fibrillation (22% vs 8.2%; P < .01), more often had prosthetic valves (38% vs 13.9%; P < .01), and had a lower incidence of mitral valve involvement (40% vs 62%; P < .01), compared with patients not receiving anticoagulation. There was no significant difference in the rate of stroke, cerebrovascular hemorrhage, or mortality at 10 weeks between the two cohorts. CONCLUSIONS:Preexisting anticoagulation did not appear to have an effect on stroke, cerebrovascular hemorrhage, or mortality in patients with left-sided infective endocarditis at 10 weeks. Continuation of anticoagulation in patients with a definitive preexisting indication should be considered in patients with left-sided infective endocarditis in the absence of other contraindications.
10.1016/j.amjmed.2019.07.059
Clinical risk factors for acute ischaemic and haemorrhagic stroke in patients with infective endocarditis.
Valenzuela Ives,Hunter Madeleine D,Sundheim Kathryn,Klein Bradley,Dunn Lauren,Sorabella Robert,Han Sang M,Willey Joshua,George Isaac,Gutierrez Jose
Internal medicine journal
BACKGROUND:Stroke as a complication of infective endocarditis portends a poor prognosis, yet risk factors for stroke subtypes have not been well defined. AIM:To identify risk factors associated with ischaemic and haemorrhagic strokes. METHODS:A retrospective patient chart review was performed at a single US academic centre to identify risk factors and imaging for patients who were 18 years or older with infectious endocarditis (IE) and stroke diagnoses. Differences in patient characteristics by stroke status were assessed using univariate analysis, χ or student's t-test as well as logistic regression models for multivariable analyses and correlation matrices to identify possible collinearity between variables and to obtain odds ratios (OR) and their 95% confidence intervals. RESULTS:A final sample of 1157 participants was used for this analysis. The total number of non-surgical strokes was 178, with a prevalence of 15.4% (78% ischaemic, 10% parenchymal haemorrhages, 8% subarachnoid haemorrhages and 4% mixed ischaemic/haemorrhagic). Multivariate risk factors for ischaemic stroke included prior stroke (OR 2.0, 1.3-3.1), Staphylococcus infection (OR 2.0, 1.3-3.0), mitral vegetations (OR 2.2, 1.4-3.3) and valvular abscess (OR 2.7, 1.7-4.3). Risk factors for haemorrhagic stroke included fungal infection (OR 6.4, 1.2-34.0), male gender (OR 3.5, 1.4-8.3) and rheumatic heart disease (OR 3.3, 1.1-10.4). CONCLUSION:Among patients with IE, there exist characteristics that relate differentially to ischaemic and haemorrhagic stroke risk.
10.1111/imj.13958