No intracranial hemorrhage

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Prior history of endocarditis, valve replacement, IV drug use, immunosuppression, valvulopathy, Janeway lesions, splinter hemorrhages, fever, shock

Endocarditis requires a high index of suspicion for diagnosis. Stroke secondary to endocarditis should always be considered when caring for patients with suspected stroke, given the differences in management and the potential for causing significant patient harm if endocarditis is missed. The history should include the same questions that are important in acute ischemic stroke, which are aimed at ascertaining candidacy for therapies. Patients with IEAS are not candidates for thrombolytic therapy, so questions related to this are less important than questions specific to endocarditis, such as identifying endocarditis-specific risk factors and identifying antibiotic regimens to target the causative organisms.$^{18}$ The history should also include the usual elements, such as a complete medical history, surgical history, and allergies. (See Table 1.)

The neurologic examination of acute stroke patients should focus not only on localizing the affected vasculature, but should also include the NIHSS. Although the NIHSS is limited by its inability to communicate the degree of impairment in the full range of cerebral functions, it is essential for rapid communication between consulting stroke neurologists and other clinicians, and it is widely accepted and frequently used. Higher numbers, with a maximum of 42 points, indicate increased stroke severity across a series of functional neurologic domains. The full NIHSS is available at: https://www.stroke.nih.gov/resources/scale.htm Given the potential concomitant associated constellations, additional organ involvement, and the often-occult nature of endocarditis, spending a short period of time evaluating for the classic clinical examination manifestations of endocarditis is useful in further clarifying the underlying diagnosis. (See Figure 1.)