Acute Ischaemic Stroke in Infective Endocarditis: Pathophysiology and Clinical Outcomes in Patients Treated with Reperfusion Therapy

Abstract

Infective endocarditis in the setting of acute stroke poses a clinical challenge given the high mortality and morbidity associated with the condition. The pathophysiological mechanisms including clinical and imaging biomarkers that can provide insights into clinical trajectories of such patients are of immense interest. The current paper aims to provide a comprehensive overview of acute stroke with infective endocarditis and provide insights into various clinical factors mediating outcomes and therapeutic strategies, specifically in the setting of reperfusion therapy. Prognostic and therapeutic pathways to potentially improve functional outcomes in these patients are also discussed.

Catastrophic Mycotic Aneurysm at the Site of Stent Retriever Thrombectomy in Endocarditis

“…While it is recommended that thrombolysis be avoided in patients with infectious endocarditis and acute stroke given the high risk of hemorrhagic transformation, 1 the safety of thrombectomy remains less clear. Many case reports suggest successful outcomes, 2,3 but the risk of hemorrhagic complications remains high, 4 as shown in our patient, in whom the potentially rapid and catastrophic evolution of intracranial mycotic aneurysms is also illustrated. Endothelial injury caused by stent retriever deployment has been described in MRI studies, 5 and we hypothesize that such injury may have favored local bacterial seeding and mycotic aneurysm formation at the site of thrombectomy in our patient.…”

Endovascular Treatment of Large Vessel Occlusion Strokes Caused by Infective Endocarditis: A Systematic Review, Meta-Analysis, and Case Presentation

“…In addition to the direct invasion of micro-organisms to the wall of the affected vessel, the microbial materials within the embolus could further lead to inflammatory and immune responses, the upregulation of their signaling pathways, and subsequent endotheliitis; therefore, the neurologic complications could include a wide range of pathological conditions in the form of meningitis, cerebritis, encephalitis, and abscess formation, etc. [11,26]. Mycotic aneurysms are also another complication that could develop secondary to septic embolization as well as the involvement of the wall of lamina blood vessels, which is accompanied by an increased risk of ICH [27].…”

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

“…Infective endocarditis (IE) is a well-described cause of cardioembolic acute ischemic stroke (AIS) that presents with various potential complications. 1 - 3 AIS manifests in up to 40% of IE patients and is associated with a 30% mortality rate. 1 , 2 , 4 , 5 Furthermore, AIS can evolve into cerebral or subarachnoid hemorrhages.…”

“… 1 The occurrence of AIS in the setting of IE is associated with high morbidity and mortality and thus presents an area of important research. 3 , 6 , 7 …”

“…1 The occurrence of AIS in the setting of IE is associated with high morbidity and mortality and thus presents an area of important research. 3,6,7 AIS treatment guidelines recommend intravenous thrombolysis (IVT) if the presentation is within 4.5 hours of symptom onset. However, in the setting of IE, IVT efficacy is unknown, and it is contraindicated due to the increased risk of intracranial hemorrhage (ICH).…”