1
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Shang K, Xu SB. In reply. Ann Emerg Med 2022; 80:475-476. [PMID: 36265926 DOI: 10.1016/j.annemergmed.2022.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Ke Shang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sha-Bei Xu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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2
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Bao XL, Tang N, Wang YZ. Severe Klebsiella pneumoniae pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism: A case report. World J Clin Cases 2022; 10:11101-11110. [PMID: 36338208 PMCID: PMC9631156 DOI: 10.12998/wjcc.v10.i30.11101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/22/2022] [Accepted: 09/12/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Klebsiella pneumoniae (K. pneumoniae) is a clinically common Gram-negative bacillus that can cause community- and hospital-acquired infections and lead to pneumonia, liver abscesses, bloodstream infections, and other infectious diseases; however, severe pneumonia caused by hypervirulent K. pneumoniae (hvKp) complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism is rarely seen in the clinical setting and has not been reported in the literature.
CASE SUMMARY A 51-year-old man was hospitalized with fever and dyspnea. Persistent mild pain in the middle and upper abdomen began at dawn on the 3rd day following admission and developed into persistent severe pain in the left upper abdomen 8 h later. Based on chest computed tomography (CT), bronchoscopy, bronchoalveolar lavage fluid metagenomic next-generation sequencing, abdominal aortic CT angiography (CTA), and culture of the superior mesenteric artery embolus, adult community-acquired severe hvKp pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism was diagnosed. Notably, he recovered and was discharged from the hospital after receiving effective meropenem anti-infection, endovascular contact thrombolytic, and systemic anticoagulant therapies and undergoing percutaneous thrombus aspiration. Ten days later, the patient returned to the hospital for abdominal CTA examination, which indicated blocked initial common pathway of the celiac trunk and superior mesenteric artery, and local stenosis. Therefore, celiac trunk artery stenting was performed in Chongqing Hospital, and postoperative recovery was good.
CONCLUSION We report a case of hvKp severe pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism and suggest that clinicians should consider the possibility of a Gram-negative bacillus infection and conduct effective pathogen detection in a timely fashion when managing patients with severe community-acquired pneumonia before obtaining bacteriologic and drug sensitivity results. At the same time, when patients have severe pulmonary infection complicated by severe abdominal pain, an acute mesenteric artery embolism should be considered to avoid delays in treatment.
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Affiliation(s)
- Xiao-Li Bao
- Department of Respiratory and Critical Care Medicine, Chongqing University Fuling Hospital, Chongqing 408000, China
| | - Nan Tang
- Department of Respiratory and Critical Care Medicine, Chongqing University Fuling Hospital, Chongqing 408000, China
| | - Yang-Zhong Wang
- Department of Respiratory and Critical Care Medicine, Chongqing University Fuling Hospital, Chongqing 408000, China
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3
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Shang K, Jian LB, Wang H, Xu SB. Intravenous Alteplase in a Patient With Acute Ischemic Stroke Subsequent to Purulent Meningitis: A Case Report and Literature Review. Ann Emerg Med 2022; 79:485-487. [DOI: 10.1016/j.annemergmed.2022.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 01/01/2023]
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4
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Sader E, Abdalkader M, Thom N, Nguyen TN, McDonald S, Greer D, Brown SC, Mohamedali A, Gutierrez J, Shi H, Morris J, Lopez-Rivera V, Sheth SA, Sloane KL, Singhal A, Atchaneeyasakul K, Liebeskind DS, Khandelwal P, Bach I, Raz E, Cervantes-Arslanian AM. Endovascular Treatment of Infective Endocarditis-Related Acute Large Vessel Occlusion Stroke. J Stroke Cerebrovasc Dis 2021; 30:105775. [PMID: 33839380 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/14/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Embolic stroke is a frequent complication of infective endocarditis yet lacks acute treatment as intravenous thrombolysis should be avoided due to high risk of intracerebral hemorrhage. Mechanical thrombectomy for large vessel occlusion may be a promising treatment but there is limited data on safety outcomes in infective endocarditis. MATERIALS AND METHODS In this multi-center retrospective case series, we reviewed data from patients with infective endocarditis-related large vessel occlusion who underwent mechanical thrombectomy in 9 US hospitals. RESULTS We identified 15 patients at 9 hospitals. A minority presented with signs suggesting infection (2 patients (14%) had fever, 7 (47%) were tachycardic, 2 (13%) were hypotensive, and 8 (53%) had leukocytosis). The median National Institute of Health Stroke Score decreased from 19 (range 9-25) at presentation to 7 post-thrombectomy (range 0-22, median best score post-thrombectomy), and the median modified Rankin Scale on or after discharge for survivors was 3 (range 0-6). Approximately 57% of patients had a modified Rankin Scale between 0 and 3 on or after discharge. Hemorrhagic transformation was observed in 7/15 (47%). The mechanical thrombectomy group had 2/9 petechial hemorrhagic transformation (22%), compared to 4/6 parenchymal hematomas (67%) in the tissue plasminogen activator + mechanical thrombectomy group. CONCLUSIONS Our findings suggest that patients with large vessel occlusion due to infective endocarditis may not present with overt signs of infection. Mechanical thrombectomy may be an effective treatment in this patient population for whom intravenous thrombolysis should be avoided.
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Affiliation(s)
- Elie Sader
- Department of Neurology, Boston University Medical Center, 72 East Concord Street, Boston, MA 02118, United States
| | - Mohamad Abdalkader
- Department of Radiology, Boston University Medical Center, United States.
| | - Natalie Thom
- School of Medicine, Boston University Medical Center, United States.
| | - Thanh N Nguyen
- Department of Neurology, Boston University Medical Center, 72 East Concord Street, Boston, MA 02118, United States; Department of Radiology, Boston University Medical Center, United States.
| | - Sandra McDonald
- Department of Neurology, Boston University Medical Center, 72 East Concord Street, Boston, MA 02118, United States.
| | - David Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord Street, Boston, MA 02118, United States.
| | - Stacy C Brown
- Department of Neurology, Yale New Haven Hospital, United States.
| | | | - Jose Gutierrez
- Department of Neurology, Columbia University, United States.
| | - Hang Shi
- Department of Neurology, Columbia University, United States.
| | - Jane Morris
- Department of Neurology, Maine Medical Center, United States
| | - Victor Lopez-Rivera
- Department of Neurology, University of Texas Health Science Center Houston, United States.
| | - Sunil A Sheth
- Department of Neurology, University of Texas Health Science Center Houston, United States.
| | - Kelly L Sloane
- Department of Neurology, Massachusetts General Hospital, United States
| | - Aneesh Singhal
- Department of Neurology, Massachusetts General Hospital, United States.
| | | | - David S Liebeskind
- Department of Neurology, Rutgers, State University of New Jersey Newark, NJ, United States
| | - Priyank Khandelwal
- Department of Neurological Surgery & Neurology, Rutgers, State University of New Jersey Newark, NJ, United States.
| | - Ivo Bach
- Department of Neurology, Rutgers, State University of New Jersey Newark, NJ, United States.
| | - Eytan Raz
- Department of Radiology, NYU Langone Medical Center, United States
| | - Anna M Cervantes-Arslanian
- Department of Neurology, Boston University Medical Center, 72 East Concord Street, Boston, MA 02118, United States; Department of Neurosurgery, Boston University Medical Center, United States.
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5
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Chakraborty T, Rabinstein A, Wijdicks E. Neurologic complications of infective endocarditis. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:125-134. [PMID: 33632430 DOI: 10.1016/b978-0-12-819814-8.00008-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Infective endocarditis (IE) is an infection primarily affecting the endocardium of heart valves that can embolize systemically and to the brain. Neurologic manifestations include strokes, intracerebral hemorrhages, mycotic aneurysms, meningitis, cerebral abscesses, and infections of the spine. Neurologic involvement is associated with worse mortality, though it does not always portend a poor functional prognosis. Neuroimaging is indicated in patients who have neurologic symptoms, including cerebral vessel imaging in patients who have subarachnoid hemorrhage. In the case of acute ischemic stroke (IS), IV thrombolysis is contraindicated but endovascular thrombectomy may be a consideration. Neurologic findings understandably raise concern about valve surgery when indicated due to the risk of hemorrhage with perioperative anticoagulation. However, most neurologic complications do not preclude valve surgery and valve surgery may in fact be indispensable in some cases to prevent further neurologic problems. Management decisions in patients with IE and neurologic complications should therefore be multidisciplinary with a major contribution from the neurologist.
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Affiliation(s)
- Tia Chakraborty
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | | | - Eelco Wijdicks
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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6
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Settarzade E, Peker A, Topcuoglu MA, Arsava EM, Demircin M, Arat A. Clinical challenges associated with the endovascular treatment of acute stroke in a patient with infective endocarditis. J Cerebrovasc Endovasc Neurosurg 2020; 22:176-181. [PMID: 32971576 PMCID: PMC7522393 DOI: 10.7461/jcen.2020.22.3.176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 04/30/2020] [Indexed: 11/23/2022] Open
Abstract
Although stroke is common in infective endocarditis (IE), only 26 cases of thrombectomy have been reported to date for IE-related acute stroke. We report a 40-year-old man who presented with left middle cerebral artery occlusion of unknown cause. Multiple attempts of mechanical aspiration thrombectomy and stentrievers failed to recanalize the artery. Effective revascularization was eventually achieved by placing a self-expanding intracranial stent. Post-procedurally the patient was diagnosed with IE with mitral valve insufficiency, mandating emergent valvular replacement while the patient was still on tirofiban infusion. On follow-up, the patient had a modified Rankin’s score of 0, had no recurrent stroke, and the intracranial stent remained patent yet stenosed. Based on the use of a self-expanding intracranial stent in the setting of IE, we discuss the consequences of the fibrotic and inflammatory content of the embolus and the associated high risk of intracranial hemorrhage which complicates clinical decision making.
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Affiliation(s)
- Emil Settarzade
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Peker
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - M Akif Topcuoglu
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - E Murat Arsava
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Metin Demircin
- Department of Cardiovascular Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Anıl Arat
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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7
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Acute Ischemic Stroke Treatment in Infective Endocarditis: Systematic Review. J Stroke Cerebrovasc Dis 2020; 29:104598. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104598] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 01/16/2023] Open
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8
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O'Connor KP, Perez GS, Ray B, Peterson JEG, Bohnstedt BN. Histopathological examination of an embolus in infective endocarditis: Case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Wang Y, Zhao W, Lu J, Li G, Peng B, Wang H. Recurrent Acute Ischemic Stroke after Infective Endocarditis Caused by Streptococcus Constellatus : First Case Report and Analysis of the Case Series. J Stroke Cerebrovasc Dis 2018; 27:e180-e189. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/07/2018] [Accepted: 03/28/2018] [Indexed: 12/31/2022] Open
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10
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Bolognese M, von Hessling A, Müller M. Successful thrombectomy in endocarditis-related stroke: Case report and review of the literature. Interv Neuroradiol 2018; 24:529-532. [PMID: 29768962 DOI: 10.1177/1591019918774761] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Neurological complications of infective endocarditis are frequent, especially ischaemic strokes. As intravenous thrombolysis in infective endocarditis-related ischaemic stroke has a controversial benefit/risk ratio, alternative treatment regimens have to be considered. We present the case of a young patient with septic embolism of the middle cerebral artery who was successfully treated with mechanical thrombectomy, and give a short review of the existing literature.
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Affiliation(s)
- Manuel Bolognese
- 1 Department of Neurology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | | | - Martin Müller
- 1 Department of Neurology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
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11
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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12
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Brownlee WJ, Anderson NE, Barber PA. Intravenous thrombolysis is unsafe in stroke due to infective endocarditis. Intern Med J 2014; 44:195-7. [DOI: 10.1111/imj.12343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/28/2013] [Indexed: 11/29/2022]
Affiliation(s)
- W. J. Brownlee
- Department of Neurology; Auckland City Hospital; Auckland New Zealand
| | - N. E. Anderson
- Department of Neurology; Auckland City Hospital; Auckland New Zealand
| | - P. A. Barber
- Department of Neurology; Auckland City Hospital; Auckland New Zealand
- Centre for Brain Research; Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
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13
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Abstract
Infective endocarditis is a serious disease of the endocardium of the heart and cardiac valves, caused by a variety of infectious agents, ranging from streptococci to rickettsia. The proportion of cases associated with rheumatic valvulopathy and dental surgery has decreased in recent years, while endocarditis associated with intravenous drug abuse, prosthetic valves, degenerative valve disease, implanted cardiac devices, and iatrogenic or nosocomial infections has emerged. Endocarditis causes constitutional, cardiac and multiorgan symptoms and signs. The central nervous system can be affected in the form of meningitis, cerebritis, encephalopathy, seizures, brain abscess, ischemic embolic stroke, mycotic aneurysm, and subarachnoid or intracerebral hemorrhage. Stroke in endocarditis is an ominous prognostic sign. Treatment of endocarditis includes prolonged appropriate antimicrobial therapy and in selected cases, cardiac surgery. In ischemic stroke associated with infective endocarditis there is no indication to start antithrombotic drugs. In previously anticoagulated patients with an ischemic stroke, oral anticoagulants should be replaced by unfractionated heparin, while in intracranial hemorrhage, all anticoagulation should be interrupted. The majority of unruptured mycotic aneurysms can be treated by antibiotics, but for ruptured aneurysms, endovascular or neurosurgical therapy is indicated.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal.
| | - Ana Catarina Fonseca
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
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14
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Novy E, Sonneville R, Mazighi M, Klein IF, Mariotte E, Mourvillier B, Bouadma L, Wolff M. Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management. Med Mal Infect 2013; 43:443-50. [PMID: 24215865 DOI: 10.1016/j.medmal.2013.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 09/05/2013] [Accepted: 09/27/2013] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- E Novy
- Service de réanimation médicale et des maladies infectieuses, université Paris-Diderot, Sorbonne Paris-Cité, hôpital Bichat-Claude-Bernard, Assistance Publique-hôpitaux de Paris, 46, rue Henri-Huchard, 75877 Paris cedex 18, France
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15
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Asaithambi G, Adil MM, Qureshi AI. Thrombolysis for Ischemic Stroke Associated With Infective Endocarditis. Stroke 2013; 44:2917-9. [DOI: 10.1161/strokeaha.113.001602] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral ischemic events are highly prevalent and associated with high rates of death and disability in patients with infective endocarditis (IE). However, the role of thrombolysis in these patients remains unclear. We sought to determine the rates and outcomes of acute ischemic stroke patients with IE treated with intravenous thrombolysis (IVT).
Methods—
We determined the rates of post-thrombolytic intracerebral hemorrhage and favorable outcome among acute ischemic stroke patients with IE treated with IVT. Patients were identified using Nationwide Inpatient Sample data from 2002 to 2010. We compared the rates of various outcomes with ischemic stroke patients without IE treated with IVT.
Results—
There were 222 patients (mean age 59±18 years; 46% women) who were treated with IVT for acute ischemic stroke associated with IE and 134 048 patients (mean age 69±15 years; 49% women) who were treated for stroke without IE. The rate of post-thrombolytic intracerebral hemorrhage was significantly higher in patients with IE compared with those without IE (20% versus 6.5%;
P
=0.006). There was a significantly lower rate of favorable outcome in the IE group (10% versus 37%;
P
=0.01).
Conclusions—
High rates of post-thrombolytic intracerebral hemorrhage and low rates of favorable outcome mandate caution in using IVT in acute ischemic stroke patients with IE.
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Affiliation(s)
- Ganesh Asaithambi
- From the Zeenat Qureshi Stroke Research Center (G.A., M.M.A., A.I.Q.), University of Minnesota, Minneapolis, MN
| | - Malik M. Adil
- From the Zeenat Qureshi Stroke Research Center (G.A., M.M.A., A.I.Q.), University of Minnesota, Minneapolis, MN
| | - Adnan I. Qureshi
- From the Zeenat Qureshi Stroke Research Center (G.A., M.M.A., A.I.Q.), University of Minnesota, Minneapolis, MN
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16
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Walker KA, Sampson JB, Skalabrin EJ, Majersik JJ. Clinical characteristics and thrombolytic outcomes of infective endocarditis-associated stroke. Neurohospitalist 2013; 2:87-91. [PMID: 23983869 DOI: 10.1177/1941874412446199] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Our aim was to describe the clinical features of infective endocarditis (IE) in the acute stroke setting and outcomes following thrombolytic therapy. METHODS This is a single-center, retrospective, descriptive case series of IE-related stroke (IES). Infective endocarditis diagnosis was based on the modified Duke criteria. RESULTS From 2001 to 2007, 18 patients with acute stroke had definite or possible IE. Presenting stroke subtypes were: 11 ischemic stroke; 2 intracerebral hemorrhage; and 5 with a combination of ischemia and subarachnoid hemorrhage. On presentation, 6 had objective fever and 5 had subjective fever, 8 had heart murmur, and 3 had classic IE stigmata. The most common laboratory abnormalities were leukocytosis (n = 11) and anemia (n = 10). Sixteen patients had valvular vegetations on echocardiogram; 6 of 8 patients had vegetations visualized on transesophageal echocardiogram that were not detected by transthoracic echocardiogram. Two of the 3 patients with valve replacements had vegetations only on their native valves. Of 11 patients with pure ischemic stroke, 4 received thrombolytics and had hemorrhagic conversion. Overall mortality of IES was 56% (10 of 18). Mortality in pure ischemic IES patients was 29% (2 of 7, median National Institute of Health Stroke Scale [NIHSS] 13) in those not receiving thrombolytics and 75% (3 of 4, median NIHSS 14) in those receiving thrombolytics. CONCLUSIONS Though diagnosis of IE in the acute stroke setting is difficult, features of the history, examination, and laboratory data may raise concern for IE. In this case series, thrombolytics in patients with IE-associated stroke were associated with very poor outcomes.
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Affiliation(s)
- Kevin A Walker
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
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17
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Ong E, Mechtouff L, Bernard E, Cho TH, Diallo LL, Nighoghossian N, Derex L. Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature. J Neurol 2013; 260:1339-42. [PMID: 23292203 DOI: 10.1007/s00415-012-6802-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/10/2012] [Accepted: 12/11/2012] [Indexed: 11/29/2022]
Abstract
Infective endocarditis represents a classical contra-indication to thrombolysis for acute ischemic stroke due to a potential increased risk of intracranial hemorrhage. However, some case reports have suggested safety and potential efficacy of intravenous or intra-arterial thrombolysis in stroke related to infective endocarditis. We present a case of ischemic stroke related to infective endocarditis who was treated with intravenous tissue plasminogen activator within the first 3 h of symptoms onset and subsequently developed symptomatic multifocal intracerebral hemorrhages, and summarize currently available data on this issue.
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Affiliation(s)
- Elodie Ong
- Stroke Unit, Neurology Department, Neurological Hospital, Lyon, 59, boulevard Pinel, 69677 Bron Cedex, France
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18
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Albrecht P, Stettner M, Husseini L, Macht S, Jander S, Mackenzie C, Oesterlee U, Slotty P, Methner A, Hartung HP, Aktas O. An emboligenic pulmonary abscess leading to ischemic stroke and secondary brain abscess. BMC Neurol 2012; 12:133. [PMID: 23121862 PMCID: PMC3517440 DOI: 10.1186/1471-2377-12-133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 10/30/2012] [Indexed: 12/04/2022] Open
Abstract
Background Ischemic stroke by septic embolism occurs primarily in the context of infective endocarditis or in patients with a right-to-left shunt and formation of a secondary cerebral abscess is a rare event. Erosion of pulmonary veins by a pulmonary abscess can lead to transcardiac septic embolism but to our knowledge no case of septic embolic ischemic stroke from a pulmonary abscess with secondary transformation into a brain abscess has been reported to date. Case presentation We report the case of a patient with a pulmonary abscess causing a septic embolic cerebral infarction which then transformed into a cerebral abscess. After antibiotic therapy and drainage of the abscess the patient could be rehabilitated and presented an impressive improvement of symptoms. Conclusion Septic embolism should be considered as cause of ischemic stroke in patients with pulmonary abscess and can be followed by formation of a secondary cerebral abscess. Early antibiotic treatment and repeated cranial CT-scans for detection of a secondary abscess should be performed.
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Affiliation(s)
- Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
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19
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First Reported Use of Retrievable Stent Technology for Removal of a Large Septic Embolus in the Middle Cerebral Artery. World Neurosurg 2012; 77:591.e1-5. [DOI: 10.1016/j.wneu.2011.05.059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 04/11/2011] [Accepted: 05/27/2011] [Indexed: 11/22/2022]
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Dababneh H, Hedna VS, Ford J, Taimeh Z, Peters K, Mocco J, Waters MF. Endovascular intervention for acute stroke due to infective endocarditis. Neurosurg Focus 2012; 32:E1. [DOI: 10.3171/2011.11.focus11263] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The overall incidence of neurological complications due to infective endocarditis is as high as 40%, with embolic infarcts more common than hemorrhagic strokes. The standard of care for typical strokes does not apply to infective endocarditis because there is a substantial risk of hemorrhage with thrombolysis. In the last decade there have been multiple case reports of intravenous and intraarterial thrombolysis with successful outcomes for acute strokes with related infective endocarditis, but successful endovascular interventions for acute strokes associated with infective endocarditis are rarely reported. To the authors' knowledge, this report is the first case in the literature to use a mechanical retrieval device in successful vegetation retrieval in an infective endocarditis acute stroke. Although an interventional approach for treatment of acute stroke related to infective endocarditis is a promising option, it is controversial and a cautious clinical decision should be made on a case-by-case basis. The authors conclude that this approach can be tested in a case series with matched controls, because this condition is rare and a randomized clinical trial is not a realistic option.
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Affiliation(s)
| | | | | | - Ziad Taimeh
- 4Department of Medicine, University of Louisville Health Care Center, Louisville, Kentucky
| | - Keith Peters
- 3Radiology, University of Florida/Shands Hospital, Gainesville, Florida; and
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Complicaciones neurológicas de la endocarditis infecciosa: controversias. REVISTA COLOMBIANA DE CARDIOLOGÍA 2011. [DOI: 10.1016/s0120-5633(11)70189-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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22
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Ionita CC, Siddiqui AH, Levy EI, Hopkins LN, Snyder KV, Gibbons KJ. Acute ischemic stroke and infections. J Stroke Cerebrovasc Dis 2010; 20:1-9. [PMID: 20538486 DOI: 10.1016/j.jstrokecerebrovasdis.2009.09.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 08/24/2009] [Accepted: 09/10/2009] [Indexed: 11/26/2022] Open
Abstract
We present an overview of multiple infections in relation to acute ischemic stroke and the therapeutic options available. Conditions that are a direct cause of stroke (infectious endocarditis, meningoencephalitides, and human immunodeficiency virus infection), the pathophysiologic mechanism responsible for stroke, and treatment dilemmas are presented. Independently or in conjunction with conventional risk factors, chronic and acute infections can trigger an acute ischemic stroke through an accelerated process of atherosclerosis and immunohematologic alterations. Acute ischemic stroke has a negative impact on the antibacterial immune response, leading to stroke-induced immunodepression and infections, the most common poststroke medical complications. Poststroke infections are independent predictors of poor outcome. Antibiotic trials for poststroke infection prevention are reviewed. Although antibiotic prophylaxis is not the standard of care in acute stroke, current guidelines support prompt treatment of stroke-related infections.
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Affiliation(s)
- Catalina C Ionita
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York.
| | - Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Radiology and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - L Nelson Hopkins
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Radiology and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Kevin J Gibbons
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
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23
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Bhuva P, Kuo SH, Claude Hemphill J, Lopez GA. Intracranial hemorrhage following thrombolytic use for stroke caused by infective endocarditis. Neurocrit Care 2009; 12:79-82. [PMID: 19688612 DOI: 10.1007/s12028-009-9253-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 07/21/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is one of the most common neurological manifestations of infective endocarditis. The use of intravenous tissue plasminogen activator (t-PA) in the management of acute ischemic stroke is the accepted standard of practice. Current guidelines for intravenous (IV) t-PA therapy in acute ischemic stroke do not exclude patients with infective endocarditis. We present three patients who received IV t-PA for acute ischemic stroke in the setting of infective endocarditis and developed multifocal intracranial hemorrhage as a complication. CONCLUSION Infective endocarditis related strokes are associated with a higher risk of hemorrhagic complications and our experience suggests that IV t-PA use may potentiate that risk.
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Affiliation(s)
- Parita Bhuva
- Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030, USA
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Tan M, Armstrong D, Birken C, Bitnun A, Caldarone CA, Cox P, Kahr W, Macgregor D, Askalan R. Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated? Dev Med Child Neurol 2009; 51:151-4. [PMID: 19191846 DOI: 10.1111/j.1469-8749.2008.03188.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Thrombolysis is considered to be contraindicated in acute ischemic stroke secondary to infective endocarditis (IE). We report a 12-year-old female who presented with acute dense right hemiparesis and aphasia. Cranial magnetic resonance imaging and angiography showed multiple diffusion-restricted lesions in the left hemisphere and absence of flow in the left internal carotid artery. She was treated with intra-arterial tissue plasminogen activator within 6 hours of her presentation. Subsequently she was diagnosed with pneumococcal endocarditis and underwent debridement of vegetations and patch repair of the mitral valve. The patient did not have hemorrhagic complications following thrombolytic therapy or surgery. Pathological analysis of the mitral valve vegetations revealed mostly fibrin thrombus. Follow-up imaging showed complete recanalization of the left internal carotid artery, and the patient had a remarkable neurological recovery. This is the first case report of successful intra-arterial thrombolytic therapy in childhood IE-related stroke. We believe that thrombolytic therapy contributed to a favorable outcome in our patient and may be safe in selected patients with childhood IE-related acute ischemic stroke.
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Affiliation(s)
- Marilyn Tan
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
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