The diagnostic and therapeutic challenges of infective endocarditis presenting as acute stroke

Description

An 81-year-old man presented with sudden-onset slurred speech and right-sided weakness commencing 2 hours previously. Initial National Institute of Health Stroke Scale score was 13. Non-contrast CT brain scan excluded haemorrhage, and he received intravenous thrombolysis. Medical history included tissue aortic valve replacement. On arrival, his temperature was 38°C. Two hours after thrombolysis he had two seizures, and his Glasgow Coma Scale score dropped from 15/15 to 6/15 (breakdown: eyes 1, voice 1, motor 4). Repeat CT demonstrated a left middle cerebral artery territory infarct, and he was transferred to the intensive care unit (figure 1). Transthoracic and transoesophageal echo identified an aortic root abscess and 10x6 mm aortic valve vegetation (figure 2). He was transferred to a cardiothoracic centre and underwent successful aortic root replacement. Blood cultures were negative, but aortic valve biopsy grew staphylococcus epidermidis. He remains aphasic with a right haemiplegia.

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