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Silent Strike: Stroke in Context of Endocarditis - Brain Imaging as a Catalyst for Diagnosis
Iulia-Cosmina Stoican1, Dorin Dragoș2,3, Atena Papagheorghe4
1Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania.
Insights
Brain imaging can help diagnose bacterial endocarditis by identifying stroke patterns like multiple lesions or territories affected. Early imaging aids clinicians in suspecting this serious condition, especially when other diagnostic criteria are unclear.
Area of Science:
- Neurology
- Infectious Diseases
- Radiology
Background:
- Infective endocarditis is a challenging diagnosis due to varied presentations and potential for lethal complications.
- Ischemic strokes, often caused by septic or thrombotic emboli from endocarditis, present a diagnostic dilemma.
- The Modified Duke Criteria are standard for diagnosing infective endocarditis.
Purpose of the Study:
- To assess the utility of brain imaging as a diagnostic tool for bacterial endocarditis.
- To identify specific brain imaging findings associated with endocarditis-related strokes.
Main Methods:
- A nested case-control study involving 84 patients with ischemic stroke.
- Cases (n=42) had endocarditis-related strokes; controls (n=42) had strokes from other causes.
- Comparison of brain imaging features between case and control groups.
Main Results:
- Endocarditis-related strokes showed significant differences on brain imaging, including multiple territories, multiple lesions, watershed lesions, and greater ischemia extent.
- Multiple lesions were the most sensitive finding (Sn=0.786, Sp=0.857).
- Involvement of multiple arterial territories demonstrated the highest specificity (Sp=0.929) and positive likelihood ratio (LR+=10.394).
- Larger ischemic lesion extent (pc-ASPECTS score) increased endocarditis likelihood (AUROC=0.7361).
Conclusions:
- Early brain imaging can be crucial for suspecting bacterial endocarditis.
- Specific imaging patterns may serve as valuable diagnostic clues.
- Further research is needed to clarify the role of early brain imaging when Modified Duke Criteria are inconclusive.
Introduction:
Endocarditis is a pathology which is rarely encountered in clinical practice that presents itself in various manners, thus posing a great challenge for the clinician in the process of formulating a timely diagnosis, especially given its potentially lethal evolution. The diagnosis of infective endocarditis is based on Modified Duke Criteria. A wide array of complications may accompany endocarditis, including septic or thrombotic emboli to various territories - those occluding branches of cerebral arteries result in ischemic strokes, which may be demonstrated by brain imaging and the symptoms which may range from mild mental status alteration to deep coma.
Objective:
Assessment of brain imaging as a diagnostic tool for bacterial endocarditis.
Materials And Methods:
This is a nested case-control study, in which 84 patients with ischemic stroke were enrolled, half of them having endocarditis related stroke (cases), and the other half stroke due to cardioembolism from other sources or to large-artery atherosclerosis (controls).
Results:
Brain imaging revealed statistically significant differences between the two cohorts, endocarditis related stroke being more strongly associated with multiple territories involvement, multiple lesions coexistence, watershed lesions, and a greater extent of ischemia all these may serve as valuable diagnostic clues. Among these findings, the presence of multiple lesions has been the most sensitive tool (Sn = 0.786, Sp = 0.857, LR+ = 5.497, LR- = 0.25), while the involvement of multiple arterial territories had the highest specificity and positive likelihood ratio for endocarditis-related stroke (Sn = 0.738, Sp = 0.929, LR+ = 10.394, LR- = 0.282). A larger ischemic lesion as quantified by pc-ASPECTS score (more than by the ASPECTS score) also increases the likelihood of endocarditis as the cause of ischemic stroke, with an AUROC of 0.7361 (95% CI 0.629-0.843).
Conclusions:
Early brain imaging could play a crucial role in endocarditis, helping the clinician to suspect this diagnosis. Further studies are needed to understand the role of early brain imaging when Modified Duke Criteria fail to establish the diagnosis.
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