Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Unsuspected Infective Endocarditis

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.