Infective endocarditis is associated with worse outcomes in stroke: A Thailand National Database Study

The interplay among a dental procedure, infective endocarditis, and an acute ischemic stroke

BACKGROUND

This case report highlights the rare association among a dental procedure, infective endocarditis, and an acute ischemic stroke.

CASE DESCRIPTION

A 54-year-old woman who experienced an acute ischemic stroke 5 weeks after a tooth extraction is described. The initial symptoms of this patient included mild to moderate word-finding difficulty and right facial droop. Computed tomographic angiography revealed a left M1 segment middle cerebral artery occlusion (thrombolysis in cerebral infarction scale, 0) with reconstitution of the distal middle cerebral branches through arterial collaterals. After initial administration of tissue plasminogen activator, endovascular thrombectomy was successfully performed with thrombolysis in cerebral infarction scale 3 (complete) recanalization. After the procedure, the patient showed improvement in language and neurologic deficits. Imaging showed multifocal, bilateral, cortical, and deep brain hemorrhages. Blood cultures grew Streptococcus mitis, ultimately leading to the diagnosis of endocarditis. Echocardiographic imaging revealed moderate to severe aortic insufficiency, a mitral valve vegetation, and mild mitral valve regurgitation. After evaluation by the cardiothoracic surgery team, the patient was discharged with intravenous antibiotics and short-term outpatient follow-up with the cardiothoracic surgery team.

PRACTICAL IMPLICATIONS

Dental procedures, although generally safe, can introduce oral bacteria into the bloodstream, leading to bacterial seeding of cardiac valves and subsequent infective endocarditis. Recognizing infective endocarditis subsequent to a dental procedure, including a tooth extraction, as a potential cause of an acute ischemic stroke is vital so that prompt treatment can be initiated.

Stroke and endocarditis: Reversing the point of view. A retrospective, cohort study

STUDY OBJECTIVES

The primary objective of our study is to assess the endocarditis prevalence in patients admitted to the emergency department (ED) for a primary diagnosis of acute stroke (AS). Secondary objectives are the identification of early markers of endocarditis in AS patients and the analysis of the short-term outcome of this population.

METHODS

In this observational, retrospective, cohort study we enrolled consecutive adult patients with a primary diagnosis of AS admitted to the Stroke Unit or to the Neurological Intensive Care Unit of our hospital who were then discharged with a diagnosis of endocarditis. These patients were then compared with age and sex-matched controls with a diagnosis of AS and atrial fibrillation.

RESULTS

Endocarditis prevalence in patients admitted to the Stroke Unit or Neurological Intensive Care Unit with a primary diagnosis of AS is 1.0% (95% confidence interval 0.61-1.55). Fever on ED admission, concomitant cancer, low hemoglobin, low lymphocyte levels, a high neutrophils count and erythrocyte sedimentation levels could early differentiate among AS patients, those with endocarditis from those with atrial fibrillation. A moderate-to-severe valvular regurgitation is strongly suggestive of endocarditis. The short term-outcome is markedly worse in endocarditis patients compared to patients with atrial fibrillation, in terms of in-hospital mortality and discharge disability.

CONCLUSIONS

Endocarditis prevalence in patients admitted for a primary diagnosis of AS is low, but this etiology leads to a poor outcome. Some laboratory, clinical-epidemiological and echocardiographic parameters may help the physician to early recognize this condition and, consequently, to promptly start an antibiotic therapy.

Clinical outcomes following reperfusion therapy in acute ischemic stroke patients with infective endocarditis: a systematic review

Background

Acute ischemic stroke (AIS) is a common and fatal complication of infective endocarditis (IE); however, there is a lack of understanding regarding treatment efficacy. This systematic review aimed to evaluate the safety and efficacy of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) in IE patients experiencing AIS.

Objectives

The aim of this study was to perform a systematic review investigating the outcomes of AIS in IE patients receiving IVT and/or EVT as a treatment method and to evaluate the safety and efficacy of these methods of reperfusion therapy.

Design

A systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was conducted.

Data Sources and Methods

The EMBASE, Cochrane, and PubMed databases were searched for literature published between 2005 and 2021 investigating outcomes of reperfusion therapy post-AIS in IE and non-IE patients. Descriptive statistics were used to describe the overall frequency of clinical outcomes, and groupwise comparisons were performed using Fisher’s exact test to assess the significance of groupwise differences.

Results

Three studies were finally included in the systematic review. A total of 13.5% of IE patients compared to 37% of non-IE patients achieved a good functional outcome (modified Rankin Scale score≤ 2) (P < .001). Furthermore, a larger percentage of the IE cohort achieved good functional outcomes after EVT (22.0%) compared to IVT (10.4%) (P = .013). The IE cohort also had a higher 3-month postreperfusion mortality rate (48.8%) compared to the non-IE cohort (24.9%) (P < .001). The rate of intracranial hemorrhage (ICH) postreperfusion was also significantly higher in the IE cohort (23.5%) than in the non-IE cohort (6.5%) (P < .001).

Conclusion

AIS patients with IE, treated with IVT, EVT, or a combination of the two, experience worse clinical and safety outcomes than non-IE patients. EVT yielded better functional outcomes, albeit with higher postreperfusion ICH rates, than IVT.

Stroke Incidence, Rate of Thrombolytic Therapy, Mortality in Thailand from 2009 to 2021

BACKGROUND: Thrombolytic treatment is the main treatment of acute ischemic stroke. Thailand started thrombolytic treatment in 2008 only at university hospitals in Bangkok and gradually increased services in large provincial hospitals until widespread in 2014. However, no studies regard the services in stroke management in Thailand. AIM: This study aims to present data: incidence, rate of thrombolytic treatment, mortality rate of acute stroke in Thailand for 13 years METHODS: A study from the National Health Security Office's database between 2009 and 2021 was reported using percentage statistics, and the number of patients per 100,000 population. RESULTS: The overall incidence of acute stroke patients aged 15 years and over was 172.33- 328.00 per 100,000 population. The incidence of acute ischemic stroke patients aged 15 years and over was 90.37-222.73 per 100,000 population. The incidence of non-traumatic intracerebral hemorrhage patients aged 15 years and over was 55.77-87.63 per 100,000 population. Rate of acute ischemic stroke patients who treated with thrombolytic treatment was 0.18-8.04%. Mortality rate of acute stroke patients was 10.24-14.77%. Mortality rate of acute ischemic stroke patients who treated with thrombolytic treatment was 3.97-10.53%. CONCLUSIONS: Stroke incidence tends to increase over 13 years. Acute ischemic stroke patients receiving thrombolytic treatment tends to increase in number. The mortality rate in patients with acute stroke tends to decline. Especially in patients with acute ischemic stroke, the mortality rate was greatly reduced.