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Related Subjects: | Acute Stroke Assessment (ROSIER&NIHSS) | Atrial Fibrillation | Atrial Myxoma | Causes of Stroke | Ischaemic Stroke | Cancer and Stroke | Cardioembolic stroke | CT Basics for Stroke | Endocarditis and Stroke | Haemorrhagic Stroke | Stroke Thrombolysis | Hyperacute Stroke Care

Any patient with a prosthetic valve or valvular heart disease with a stroke (ischaemic or haemorrhagic) needs to be assumed to have Infective endocarditis until proven otherwise. Stroke Thrombolysis and anticoagulation is associated with increased risk of ICH and poor outcome. Early antibiotics quickly reduce embolic risk.

About

• Stroke Thrombolysis is associated with increased risk of ICH
• Take expert advice but if IE suspected consider risks

Introduction

• Serious potentially fatal infection of cardiac valves and endocardium usually by bacteria.
• Infected destructive vegetations form and erode and destroy the heart valves.
• Vegetations contain fibrin, platelets, microorganisms. These can embolise the cerebral circulation.
• Haemorrhagic transformation from an embolised mycotic vegetation is common and bleeding is seen on CT can mislead the unwary.
• Co-existing anticoagulation can also distract and be blamed. Check the CRP, send cultures and get and arrange an urgent echocardiogram.

Microbiology

Clinical signs or Stigmata of Endocarditis

Vegetations

Roth's spots

Vegetations

Risks

• Approximately 60-80% of those with IE have a Predisposing heart lesion. Mitral valve prolapse only carries appreciable risk where there is associated MR.
• Other risk groups are those IV drug users who get a tricuspid valve endocarditis with Staph aureus.
• Those with Bicuspid aortic valve are also at risk of aortic valve endocarditis.

Risk Stratification of Cardiac Disease

• High risk lesions include prosthetic valves, MR or AR, VSD, PDA.
• Medium risk are those with Aortic stenosis or Hypertrophic cardiomyopathy.
• Low risk are those with Mitral stenosis or ASD.

Markers of severity

• Staph aureus infection
• Prosthetic valve
• Culture negative endocarditis
• Low complement levels

Clinical Findings

• Classically Fever, Malaise, Joint pains, arthropathy.
• Splinter haemorrhages - also seen in manual workers on the dominant hand.
• Patients may have Stroke/TIA like episodes of emboli to brain/eye with infarction or infarction and secondary haemorrhage.
• Peripheral emboli - gangrene / ischaemic bowel or to spinal cord.
• Finger clubbing - not common in less than 5% of SBE. Osler's nodes - painful, tender nodules on the pulps of fingers. Janeway lesions - small < 5 mm flat painless red spots seen on palms and soles.
• Roth's spots - haemorrhage and micro infarction of retinal vessels.
• New or changing murmurs, Splenomegaly

Investigations

• FBC - anaemia, Raised ESR and CRP, U&E
• Urinalysis - microscopic haematuria
• ECG -New AV block even a lengthened PR interval suggests Aortic valve involvement and possibly aortic root abscess.
• CXR - evidence of cardiomegaly, mitral stenosis
• CT: multiple small embolic strokes or large vessel strokes on CT/MRI. Occasionally as small mycotic aneurysms bleed there is a haemorrhage often provoked by any coexisting anticoagulation.
• Transthoracic echo - vegetations and valve disease may be seen. Root abscess.
• Transoesophageal echo - shows much higher quality views of the heart valves. Look for valves structure and vegetations and abscess formation.
• Blood cultures - multiple from multiple sites at different times with fastidious care to avoid contaminants

Modified Duke Criteria for Diagnosis of Infective Endocarditis: Pathological criteria positive OR 2 Major OR 1 Major and 2 minor OR 5 minor criteria

• Pathological criteria
  • Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments, or intracardiac abscess content)
• Major criteria
  • Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridians and the HACEK group OR
  • Persistent bacteraemia from two blood cultures taken more than 12 hours apart or three or more positive blood cultures where the pathogen is less specific, such as Staphylococcus aureus and Staph epidermidis OR
  • Positive serology for Coxiella burnetii, Bartonella species, or Chlamydia psittaci OR
  • Positive molecular assays for specific gene targets
  • Positive echocardiogram showing oscillating structures, abscess formation, new valvular regurgitation, or dehiscence of prosthetic valves
• Minor criteria
  • Predisposing heart disease or IV drug users
  • Fever > 38°C
  • Immunological phenomena such as glomerulonephritis, Osler's nodes, Roth spots, or positive rheumatoid factor
  • Microbiological evidence not fitting major criteria e.g. positive blood culture
  • Elevated C reactive protein or ESR
  • Vascular phenomena such as major emboli, splenomegaly, clubbing, splinter haemorrhages, petechiae, or purpura

Complications

• Valve failure with heart failure
• Septic emboli e.g. stroke
• Glomerulonephritis and progressive renal failure
• Aortic root abscess formation
• Valvular abscess and Pericarditis
• Severe Sepsis
• Multiorgan failure

Differentials

• Marantic endocarditis is a non-bacterial endocarditis with aggregates of platelets to large vegetations on previously undamaged heart valves is dealt with in the cancer and stroke section

Management of Endocarditis

• Acute Stroke with suspected or proven IE and use of thrombolysis: Patients with IES treated with stroke thrombolytics have a high risk of haemorrhage, and favourable functional outcome is extremely uncommon regardless of treatment. Mechanical thrombectomy may be preferred and should be considered on a case by case assessment.
• Medical: It is vitally important to try and obtain cultures of the organism to help guide therapy and so multiple aerobic and anaerobic blood cultures from multiple sites should be taken over 12-24 hrs prior to commencing antibiotics. If antibiotics have already been given this can make organism identification difficult. Ensure sufficient microbiological samples taken before starting blind therapy. This must be balanced with the facts that early antibiotic therapy reduces the risk of embolization dramatically from nearly 4.8 cases per 1,000 patient days in the first week of therapy to less than 1.7 per 1,000 patient days in the second week, with further decreases thereafter. Once the organism is known specific treatment is started usually a prolonged course of antibiotics is needed and determined by local advice and sensitivities. Usually requires 4-6 weeks of IV and then oral therapy. Streptococci - Penicillin G and Gentamicin. Methicillin Sensitive Staph Aureus - take expert guidance. Generally, anticoagulation is avoided if possible as there is a high risk of bleeding into infarcted areas.
• Cardiac Surgical: urgent assessment needed for cardiac failure due to valve damage, extensive MR/AR, large vegetations, septic emboli, abscess formation, fungal infection, antibiotic resistance, failure to respond to medical management. Surgery is evidently high risk with a significant risk of complications. Cardiothoracic centres may be reluctant to take those with pre-existing large strokes with a poor prognosis. Patients may need to be moved to a local cardiothoracic centre perhaps under cardiology to have a further assessment before any surgical intervention.

References

• Endocarditis Review Practical Neurology 2016
• Clinical Characteristics and Thrombolytic Outcomes of Infective Endocarditis-Associated Stroke 2012
• Endovascular treatment of ischemic large-vessel stroke due to infective endocarditis: case series and review of the literature 2020