Abstract WP262: Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Infective Endocarditis

Introduction: Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke. However during the hyperacute stroke evaluation, the exclusion of IE may be difficult. Methods: We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 with acute ischemic stroke who received IVtPA and identified patients who were diagnosed with infective endocarditis. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2. Results: Among 1022 acute ischemic stroke patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority, 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). All patients met criteria for IVtPA and there were no protocol violations. The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed MCA occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy with Thrombolysis in cerebral infarction scale 2A recanalization. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage on Hospital Day #2 due to mycotic cerebral aneurysm. The blood culture results included MRSE (1), Streptococci viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcome, and the mean 3 months mRS was 4.8 (range, 3 to 6). Conclusions: In a large series of acute ischemic stroke patients who received IVtPA, undiagnosed IE is rare (0.5%). Fever was not commonly present during initial evaluation. Despite affecting younger patients with initial mild deficits, patients with IE had poor functional outcomes.