Cerebrovascular Complication and Valve Surgery in Infective Endocarditis.

Infective endocarditis (IE) with neurologic complications is common in patients with active IE. The most common and feared neurological complication of left-sided IE is cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage (ICH), or an infectious intracranial aneurysm with or without rupture. In patients with cerebrovascular complications, valve replacement surgery is often delayed for concern of further neurological worsening. However, in circumstances when an indication for valve surgery to treat IE is present, the benefits of early surgical treatment may outweigh the potential neurologic deterioration. Furthermore, valve surgery has been associated with lower in-hospital mortality than medical therapy with intravenous antibiotics alone. Early valve surgery can be performed within 7 days of transient ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains challenging, and current data in the literature are conflicting about the risks and benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often recommended, balancing the risks and benefits of surgery. The range of timing of valve surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary decision between cardiothoracic surgeons, cardiologists, infectious disease experts, and vascular neurologists in an experienced referral center.

Infectious causes of stroke.

PURPOSE OF REVIEW: Stroke continues to be a leading cause of debility in the world. Infections have been associated with stroke, but are not considered as directly causal, and so they are not often included in the traditional stroke workup and management. They are especially important in patients with stroke of undetermined etiology, and in certain patient populations, such as young patients without traditional risk factors, and immunocompromised patients. RECENT FINDINGS: There has been strong evidence for infectious conditions, such as endocarditis, and pathogens, such as varicella zoster in stroke causation, and more supportive evidence is surfacing in recent years of several organisms increasing the stroke risk or being directly causal in stroke. The evidence also seems to be pointing to the role of inflammation in increasing the risk of stroke via accelerated atherosclerosis, vasculitis and vasculopathy. SUMMARY: Infectious causes should be considered in the differential and work up of stroke in certain patient populations and appropriate treatments need to be initiated to minimize adverse stroke-related outcomes.

Nurses Are as Specific and Are Earlier in Calling In-Hospital Stroke Alerts Compared to Physicians.

INTRODUCTION: In-hospital stroke alerts are typically activated by nurses or physicians when a patient's neurological status acutely changes from baseline. It is unclear if knowledge of stroke symptoms translates to accurate activation of the acute stroke team. We hypothesized that nurses who activate the stroke alert system would correctly identify as great a proportion of acute strokes as physicians. We also investigated the time to activation of these in-hospital stroke alerts. METHODS: We retrospectively reviewed consecutive inpatient stroke team calls over a 12-month period at a single, tertiary care center. Calls and exact times were identified from the acute stroke pager log. The type of provider who called the stroke alert, patient characteristics, last known well time, and acute stroke symptoms was prospectively collected and retrospectively verified through electronic medical record review. Patients with definite stroke then were retrospectively identified by World Health Organization Monitoring of Trends and Determinants in Cardiovascular Disease (WHO MONICA) criterion. RESULTS: A total of 93 calls were analyzed. Nurses and physicians/midlevel providers activated the in-hospital stroke alert with a similar percentage of correct stroke diagnosis (62.7% versus 58.8%, P = .82). Nurses activated stroke alerts significantly earlier than physicians/midlevel providers (median 2 hours [IQR .5-6 hours] versus 4.9 hours [IQR 1.3-21.3 hours], P = .0096) from last known well time. CONCLUSIONS: Nurses identify in-hospital ischemic events with a similar percentage as physicians, and they activate the stroke alerts significantly earlier. The median nursing activation time fell within a 3-hour window for potential systemic thrombolytic or early endovascular therapy. An intensive, focused, collaborative education of nursing staff may further improve inpatient stroke outcomes.