Ischaemic Stroke Complicating Infective Endocarditis: Microbleeds Are the Diagnostic Clue

Abstract

Introduction: Ischemic strokes represent a classic complication of infective endocarditis (IE) and are most often related to the fragmentation of valvular vegetation. In most cases, they occur in the Sylvian territory and are related to Staphylococcus aureus. MRI can demonstrate, in addition to the AVCI image, cerebral microbleeds (CMBs) that are very suggestive of the diagnosis. We present the case of a patient who presented an ischemic stroke occurring in the context of infective endocarditis. Observation: A 32-year-old woman with no previous medical history initially presented with acute febrile headache, two weeks later she developed right hemiplegia with aphasia in the context of fever. Her general examination revealed lesions on the soles of her feet, in the form of nodules, infected in places, suggestive of Janeway nodules (characteristic of IE). The brain MRI showed an ischemic stroke in the Sylvian territory, with the presence of multiple microbleeds on the magnetic susceptibility sequences. The biological examination showed a severe inflammatory syndrome; the transthoracic echocardiography (TTE) confirmed the presence of vegetation on the aortic valve; and the blood cultures showed a Staphylococcus aureus. Antibiotic therapy was started, and the patient was transferred to the cardiology department. Discussion: Our observation has a double interest. The first is clinical due to the presence of plantar nodules (Janeway’s nodules) that are characteristic of IE which should orientate the diagnosis before the installation of the stroke, and the second is radiological and linked to the discovery of microbleeds. Their presence is increasingly reported in the literature, but their pathophysiology is not yet very clear. Conclusion: Stroke is the most frequent extracardiac complication during IE. The presence of microbleeds contributes to early diagnosis, especially in asymptomatic forms.