Acute Stroke Therapy In Infective Endocarditis - Case Series And Systematic Review

Objective: To report our clinical experience managing acute ischemic stroke secondary to infective endocarditis. Background: Acute ischemic stroke (AIS) is common in patients with infective endocarditis (IE). Use of IV thrombolytic therapy (IV-tPA) has been reported and appears to carry greater risk of hemorrhage, while reports of endovascular therapy are rare. Design/Methods: A retrospective review was done of 116 consecutive patients with IE who were seen by stroke neurology in a tertiary care center from January 2015 to July 2016. One case using IV-tPA and one case using endovascular thrombectomy. We searched PubMed from inception to August 2016 and systematic review was performed to evaluate acute stroke therapy in IE. Results: In case 1, an 82 year old female with prosthetic aortic valve endocarditis and atrial fibrillation presented with slurred speech and right hemiplegia. IV-tPA was given within 2.5 hours, and NIHSS improved from 11 to 1 over 24 hours. CT Brain done 24 hours post-tPA revealed a small L thalamic hemorrhage. In case 2, a 49 year old IV drug-using male with prior IE and current prosthetic aortic valve endocarditis developed right middle cerebral artery (MCA) occlusion with an NIHSS 17. Endovascular thrombectomy was performed with successful TICI 3 recanalization. CT Brain done 24 hours post-thrombectomy showed evolving right MCA infarct with hemorrhagic conversion. Systematic review revealed 7 reports of IV thrombolysis, 5 reports of mechanical thrombectomy, and 3 reports with intra-arterial thrombolysis plus endovascular thrombectomy. Including our cases, IV thrombolysis, alone, had a hemorrhagic complication rate of 82%. Endovascular thrombectomy alone, with at least TICI IIb recanalization, had a hemorrhagic complication rate of 17%. Intra-arterial thrombolysis and endovascular thrombectomy together had a hemorrhagic complication rate of 0%. Conclusions: Endovascular thrombectomy alone appears to be safer than IV-tPA alone in the management of AIS in patients with IE. Disclosure: Dr. Marquardt has nothing to disclose. Dr. Cho has nothing to disclose. Dr. Zhang has nothing to disclose. Dr. Uchino has nothing to disclose. Dr. Wisco has nothing to disclose.