Pediatric Endocarditis and Stroke: A Single-Center Retrospective Review of Seven Cases

Abstract

The approach to the acute management of stroke in children with infective endocarditis is limited by the paucity of published data on their clinical course and outcome. We conducted a retrospective study at an urban tertiary care academic center to characterize the clinical course of seven pediatric patients with endocarditis and subsequent cerebral infarct. Among 115 patients with endocarditis, a stroke occurred in seven. Four patients had congenital heart disease. In 6 patients, the stroke was in the distribution of the middle cerebral artery and there was no preference for left or right hemisphere. The most common presenting symptom was focal weakness. Three patients had mycotic aneurysms, all of which were successfully repaired. Two patients were placed on aspirin therapy with no adverse effects. All patients survived but neurological recovery was variable. The two youngest patients (3 and 14 weeks of age) had the longest periods of hospitalization and had the most severe neurologic impairment. These findings suggest that children may have better outcome than adults after stroke secondary to bacterial endocarditis. Routine surveillance for mycotic aneurysms in patients with new neurological deficits and the use of aspirin should be considered in the medical management.

Infective Endocarditis in Childhood: 2015 Update

“…Neurological sequelae include stroke, brain abscess, hemorrhage, seizures, diffuse vasculitis, or meningitis, and these events may occur in up to 30% of cases. 144 The incidence of stroke has been reported to be 6% in pediatric populations 145 and 11% in those of all ages with CHD. 146 Mycotic aneurysms may occur in any systemic artery or the pulmonary arteries but are particularly dangerous in the cerebral circulation; surgical therapy may be used because of the risk of rupture.…”

Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated?

“…In a recent review of 115 children with IE, seven (6%) had a stroke. 15 Unlike our patient, they all presented with stroke after the diagnosis of IE and after cardiac surgery. Neurological outcome at 4 to 6 months after the stroke was reported in five of the seven patients.…”

“…Poor neurological outcome was associated with very young age, absence of congenital heart disease, and mitral valve involvement. 15 Two of the five patients had no deficit and did not have any of the risk factors. Our patient was a young adolescent but had the other two risk factors for poor outcome.…”

Haemorrhagic stroke as the first presentation of undiagnosed infective endocarditis in an 8 year old boy

“…The decision regarding when to treat a mycotic aneurysm depends upon the size and location of the aneurysm, the clinical presentation, and observed changes in the patient and the aneurysm over time 5 . Given that stroke occurred in only 6% of all children with endocarditis, routine surveillance screening with CT or MRI in all children with endocarditis cannot be advocated 8 .…”