Endovascular treatment of ischemic large-vessel stroke due to infective endocarditis: case series and review of the literature

Abstract

Background Mechanical thrombectomy is the standard of care, in selected patients, for acute ischemic stroke with large vessel occlusion but its use in patients with stroke secondary to infective endocarditis is controversial. We report three cases of acute ischemic stroke treated by mechanical thrombectomy and we propose an extensive review of the literature to evaluate the clinical safety and efficacy of thrombectomy in patients with stroke secondary to infective endocarditis. Methods A comprehensive literature search was performed following a pre-specified protocol of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials were considered that included endocarditis-related acute ischemic stroke patients who underwent mechanical thrombectomy. Results The database search yielded 431 relevant records published until January 2020. Nineteen articles fulfilled the eligibility criteria that described thirty patients. After the thrombectomy, 13.3% of the patients experienced intracranial haemorrhage. After the procedure, the median National Institutes of Health Stroke Scale score dropped from 15 (IQR 7) to 2.5 (IQR 5.75). At 90 days, mortality was 23.3% while 46.7% of the patients were functionally independent (mRS ≤ 2). Discussion Based on our review, the use of mechanical thrombectomy in patients with large vessel occlusion due to endocarditisassociated stroke might improve patient outcome but it should be considered on a case by case base as the safety has not been well established yet. Further research on risk stratification is needed to drive clinician during the decision-making process.

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

“…Functional independence with an mRS score of less than 2 was achieved in 46.7% of patients. 87 Of the notable randomized trials that established the usefulness of MT for large vessel occlusion, the results of this analysis were worse than some, but not all, falling somewhere in the middle: EXTEND-IA SWIFT PRIME showed 71% and 60% good outcome, respectively, and MR CLEAN showed 33%. 1 3 4 A less rigorous review by Bolognese and coworkers found a similar number of favorable outcomes, defined here as mRS score ≤3 in 69% of patients.…”

“…His conclusions represent the currently highest quality data point. 87 He reports results of 30 patients reported in 19 published case series out of 431 screened records. Overall, MT was as effective as in patients presenting with ELVOs due to non-endocarditis etiologies.…”

A Cryptogenic Stroke Associated With Infective Endocarditis and Antiphospholipid Antibody Syndrome: Case Report and Literature Review

“…Furthermore, if fever is not present during the initial evaluation, a rapid and accurate diagnosis of IE complicated by stroke is difficult during the rapid intravenous thrombolysis (IVT) treatment process in the emergency department. IVT and endovascular therapy (EVT) are the standard of care in selected patients for acute ischemic stroke, but their use in patients with stroke secondary to IE is controversial ( 13 , 14 ). IVT is contraindicated because of the increased risk of intracranial hemorrhage and worse outcomes ( 15 , 16 ).…”

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

“…This does not apply in the setting of IE due to the substantial risk of haemorrhage, although IE diagnosis is difficult to achieve in this time period and thus sometimes leads to IVT being administered [7]. However, EVT treatment is associated with approximately 50% of patients achieving a good functional outcome (modified Rankin Scale (mRS) score 0-2) at three months [49]. A systematic review found the risk of intracranial haemorrhage (ICH) was 4.14 times higher in AIS patients with IE receiving IVT compared to EVT alone [7].…”