Infective endocarditis, stroke

Hart RG, Foster JW, Luther MF, Kanter MC. Stroke in infective endocarditis. Stroke 1990 21 695-700. 

Advances in Neurology 92 197-202 Mas JL, Arquizan C, Lamy C et al. (2001). Patent Foramen Ovale and Atrial Septal Aneurysm Study Group. Recurrent cerebrovascular events associated with patent foramen ovale atrial septal aneurysm or both. New England Journal of Medicine 345 1740-1746 Masuda J, Yutani C, Wald R et al. (1992). Histopathological analysis of the mechanisms of intracranial haemorrhage complicating infective endocarditis. Stroke 23 843-850 Matijevic N, Wu K (2006). Hypercoagulable states and strokes. Current Atherosclerosis Reports 8 324-329... 

Neurology Clinic 22 821-840 van der Meulen JH, Weststrate W, van Gijn J et al. (1992). Is cerebral angiography indicated in infective endocarditis Stroke 23 1662-1667... 

Ischemic stroke has numerous causes. Cerebral infarction may result from large artery atherosclerosis, cardiac embolism, small artery lipohyalinosis, cryptogenic embolism, or, more rarely, from other diverse conditions such as arterial dissection, infective endocarditis, and sickle cell disease. Arterial occlusion is the cause of at least 80% of acute cerebral infarctions. " ... 

Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis Diagnosis, antimicrobial therapy, and management of complications a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association endorsed by the Infectious Diseases Society of America. Circulation 2005 111(23) 394M34. 

About one-fifth of patients with infective endocarditis have an ischemic stroke or TIA as a result of embolism of valvular vegetations. Cerebrovascular symptoms usually occur before the infection has been controlled and may be the presenting feature (Hart et al. 1990 ... 

Fever, cardiac murmur and vegetations are not invariably present in patients with infective endocarditis, and blood cultures are indicated in unexplained stroke particularly if there is raised erythrocyte sedimentation rate, mild anemia, neutrophil leukocytosis or a history of intravenous drug abuse. The cerebrospinal fluid (CSF) can be normal, but > 100 X 10 cells/l polymorphs is said to suggest endocarditis, although similar counts have been described in intracerebral hemorrhage and in hemorrhagic transformation of an infarct, but not in ischemic stroke (Powers 1986). 

Mitral leaflet prolapse is a common incidental finding. It can be complicated by gross mitral regurgitation, infective endocarditis, atrial fibrillation and left atrial thrombus and thus embolism to the brain. However, there is no excess risk of first or recurrent stroke in patients with uncomplicated mitral leaflet prolapse (Orencia et al. 1995a, b). 

Thrombotic thrombocytopenic purpura is a rare acute or subacute disease in adults, rather similar to the hemolytic uremic syndrome in children, in which there is systemic malaise, fever, skin purpura, renal failure, hematuria and proteinuria. Hemorrhagic infarcts caused by platelet microthrombi occur in many organs in the brain they may cause stroke-like episodes (Matijevic and Wu 2006) although more commonly there is global encephalopathy. The blood film shows thrombocytopenia, hemolytic anemia and fragmented red cells. The differential diagnosis includes infective endocarditis, idiopathic thrombocytopenia, heparin-induced thrombocytopenia with thrombosis, systemic lupus erythematosus, non-bacterial thrombotic endocarditis and disseminated intravascular coagulation. 

Kalashnikova LA, Nasonov EL, Stoyanovich LZ et al. (1994). Sneddon s syndrome and the primary antiphospholipid syndrome. Cerebrovascular Diseases 4 76-82 Kanter MC, Hart RG (1991). Neurologic complications of infective endocarditis. Neurology 41 1015-1020 Kaposzta Z, Young E, Bath PMW et al. (1999). Clinical application of asymptomatic embolic signal detection in acute stroke a prospective study. Stroke 30 1814-1818 Katzav A, Chapman J, Shoenfeld Y (2003). 

Subarachnoid hemorrhage due to septic embolic infarction in infective endocarditis. Cerebrovascular Diseases 9 182-184 Krespi Y, Akman-Demir G, Poyraz M et al (2001). Cerebral vasculitis and ischemic stroke in Behcet s disease report of one case and review of the literature. European Journal of Neurology 8 719-722... 

Ruby RJ, Burton JR (1977). Acute reversible hemiparesis and hyponatremia. Lancet i 1212 Sabolek M, Bachus-Banaschak K, Bachus R et al. (2005). Multiple cerebral aneurysms as delayed complication of left cardiac myxoma a case report and review. Acta Neurology Scandinavica 111 345-350 Sacco RL, Kargman DE, Gu Q et al. (1995). Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke 26 14-20 Salgado AV (1991). Central nervous system complications of infective endocarditis. 

Stroke in the context of preceeding malaise for up to some months suggests an inflammatory arterial disorder, particularly giant cell arteritis, infective endocarditis, cardiac myxoma, cancer, thrombotic thrombocytopenic purpura or even sarcoidosis (Ch. 6). 

Previous strokes and/or TIAs in different vascular territories are more likely with a proximal embolic source in the heart, or arch of the aorta, than with a single arterial lesion. Attacks going back months or more make certain causes such as infective endocarditis and arterial dissection unlikely. 

Fever is unusual in the first few hours after stroke onset, and endocarditis or other infections, inflammatory vascular disorders or cardiac myxoma should be considered. Later fever is quite common and usually reflects a complication of the stroke (Ch. 16). 

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