Clinical Pathways
Clinical Pathways
Infective Endocarditis-Associated Stroke
Infective Endocarditis-Associated Stroke

Infective Endocarditis-Associated Stroke

Tags
Emerg. Med. Practice
Published
March 1, 2023
Author(s)
Lauren Gillespie, MD; Natalie Kreitzer, MD

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Action

Patient presents with clinical findings concerning for ischemic stroke

  • Rapidly assess airway, breathing, circulation
  • Address immediate life threats and perform initial resuscitation
  • Obtain IV access
  • Obtain history, including last-known-well time
  • Obtain blood glucose and correct if abnormal
  • Consult with stroke team
  • Order CT head without contrast

(Class I)

Decision

Evidence of intracranial hemorrhage?

Background

ICH is also common in the setting of infective endocarditis, occurring in nearly 27% of patients.26^{26} Certain types of bacteria, such as Staphylococcus, beta hemolytic Streptococcus, and viridans group streptococci, carry high risk for microbleeds and larger ICHs.29^{29} Unlike ischemic strokes, however, there are several etiologies and risk factors for ICH with infective endocarditis. In general, ICH secondary to infective endocarditis develops due to hemorrhagic conversion of an ischemic hemorrhage, vascular friability secondary to infective endocarditis, or a ruptured infected aneurysm. Additionally, ICH with infective endocarditis occurs more frequently in patients with a history of IV drug use.30^{30}

The risk for hemorrhage is higher among patients who are anticoagulated, particularly those with a supratherapeutic international normalized ratio (INR).10,26,31^{10,26,31} Because patients with a prosthetic valve commonly require long-term anticoagulation for stroke prevention, determining whether to continue anticoagulation if these patients develop endocarditis can be challenging, and the literature is mixed as to whether mortality from ICH is increased or decreased with anticoagulation.32,33^{32,33} Although Streptococcus and Staphylococcus species have platelet aggregation capability, studies have not demonstrated improved outcomes with use of antiplatelet agents with respect to neurologic complications and outcomes.34,35^{34,35}

Small hemorrhages are extremely common in infective endocarditis; cortical microbleeds are noted on the MRIs of 58% of asymptomatic patients with infective endocarditis, compared to only 5% of the general population.28,36^{28,36} Not surprisingly, these microbleeds are associated with development of larger ICHs.37 IEAS carries an approximately 10% risk for hemorrhagic conversion, although this may be higher with S aureus, up to 57%.38^{38}

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References
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Intracranial hemorrhage
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