Objective

Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke (AIS). However, during the hyperacute stroke evaluation, the exclusion of IE may be difficult. We sought to report the prevalence of undiagnosed IE in AIS patients who received IVtPA.

Methods

We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 who received IVtPA for suspected AIS and identified patients diagnosed with IE. 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 AIS 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). The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed middle cerebral artery (MCA) occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage due to mycotic cerebral aneurysm rupture. Blood culture results included MRSE (1), Streptococcus viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcomes, and the mean 3 month mRS was 4.8 (range, 3 to 6). The 90 day mortality was 60%.

Conclusion

In a series of AIS patients who received IVtPA by academic vascular neurologists, the risk of undiagnosed IE was low (0.5%). Fever was not commonly present during initial evaluation in IE presenting with AIS. Despite affecting younger patients with initial mild deficits, AIS patients with IE who received IVtPA had poor functional outcomes.

中文翻译：

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急性缺血性卒中合并可疑心内膜炎患者的静脉溶栓治疗

目的

感染性心内膜炎（IE）被认为是急性缺血性卒中（AIS）中静脉内组织纤溶酶原激活剂治疗（IVtPA）的绝对禁忌症。但是，在超急性中风评估期间，排除IE可能很困难。我们试图报告在接受IVtPA的AIS患者中未诊断出IE的患病率。

方法

我们回顾了2014年1月1日至2019年3月31日在我们的综合性卒中中心住院的连续患者，他们因疑似AIS接受了IVtPA的治疗，并确定了诊断为IE的患者。数据从人口统计学，病史，临床表现，上次已知的正常（LKN）时间，美国国立卫生研究院中风量表（NIHSS），神经影像学，培养结果和90天改良兰金量表（mRS）中提取。良好的功能预后定义为mRS≤2。

结果

在接受IVtPA的1022例AIS患者中，有5例（0.5％）最终被确诊为IE。在5例IE患者中，平均年龄为53.4岁（范围为25-74），其中3名（60％）为女性。大多数4（80％）是白人。IE的医学风险因素占3（60％），包括静脉内吸毒（1）和透析（2）。最初的NIHSS为4.6（范围为1至8）。最初出现发烧的只有一名患者（102.7 F）。从LKN到IVtPA的平均时间为3.0小时（范围从1.9到4.4）。血管成像显示，大脑中动脉（MCA）阻塞4例（80％），无阻塞1例（20％）。一名患者接受了血管内血栓切除术。2例（40％）发生了出血并发症，其中1例由于真菌性脑动脉瘤破裂而发生了蛛网膜下腔出血。血液培养结果包括MRSE（1），绿色链球菌（2）和阴性（2）。所有患者的TEE均显示二尖瓣上有植物。没有患者的功能预后良好，平均3个月mRS为4.8（范围3至6）。90天死亡率为60％。

结论

在一系列由学术血管神经科医生接受IVtPA的AIS患者中，未被诊断的IE风险很低（0.5％）。在伴随AIS的IE中进行初始评估时，发烧并不常见。尽管影响了最初有轻度缺陷的年轻患者，但接受IVtPA的IE的AIS IE患者的功能预后较差。