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Background <p>Infective endocarditis (IE) is a rare yet challenging cause of acute stroke. A stroke imaging pattern with ischemic lesions in all three major cerebral vascular supply territories (three-territory sign), is considered typical for IE. However, data on its frequency and significance are scarce.</p> Methods <p>Data on IE patients with concomitant acute stroke admitted to three tertiary care hospitals in Berlin, Germany, between 2017 and 2023 were retrospectively analyzed. Presence of the three-territory sign was evaluated on cerebral magnetic resonance imaging (cMRI). Presence and distribution of accompanying hemorrhagic stroke, cerebral microbleeds (CMB) and chronic infarcts were evaluated, too. Bivariate and multivariable logistic regression analyses were performed to identify variables associated with three-territory sign.</p> Results <p>We identified 135 patients with IE and acute stroke on cMRI (median age 67 years [56–76], 31.9% female). Three-territory sign was present in 86/135 patients (63.7%). Three-territory sign was independently associated with detection of Staphylococcus aureus [adjusted odds ratio (aOR) = 3.98 (95% CI 1.35–11.75)] and additional extracerebral arterial embolism [aOR = 4.78 (95% CI 1.77–12.91)] but not with presence or distribution of hemorrhagic stroke, CMB or chronic infarcts. In-hospital mortality was higher in IE patients with three-territory sign compared to those without (31.4% vs. 12.2%; <i>p</i> = 0.01).</p> Conclusions <p>Three-territory sign is common but not obligatory in IE patients with acute ischemic stroke. cMRI will rather depict this stroke pattern in the more severely diseased IE patients as three-territory sign makes detection of a particularly virulent pathogen (Staphylococcus aureus) more likely and indicates higher severity of disease.</p> Trial registration <p>Not applicable.</p>

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Three-territory sign in infective endocarditis and concomitant stroke: a retrospective analysis on characteristics and associated factors

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年4月20日

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  • Hannah Schuermann,
  • Regina von Rennenberg,
  • Christoph Riegler,
  • Simon Hellwig,
  • Helena Stengl,
  • Simon Litmeier,
  • Jan F. Scheitz,
  • Wolfram Doehner,
  • Heinrich Audebert,
  • Tim Bastian Braemswig,
  • Christian H. Nolte

摘要

Background

Infective endocarditis (IE) is a rare yet challenging cause of acute stroke. A stroke imaging pattern with ischemic lesions in all three major cerebral vascular supply territories (three-territory sign), is considered typical for IE. However, data on its frequency and significance are scarce.

Methods

Data on IE patients with concomitant acute stroke admitted to three tertiary care hospitals in Berlin, Germany, between 2017 and 2023 were retrospectively analyzed. Presence of the three-territory sign was evaluated on cerebral magnetic resonance imaging (cMRI). Presence and distribution of accompanying hemorrhagic stroke, cerebral microbleeds (CMB) and chronic infarcts were evaluated, too. Bivariate and multivariable logistic regression analyses were performed to identify variables associated with three-territory sign.

Results

We identified 135 patients with IE and acute stroke on cMRI (median age 67 years [56–76], 31.9% female). Three-territory sign was present in 86/135 patients (63.7%). Three-territory sign was independently associated with detection of Staphylococcus aureus [adjusted odds ratio (aOR) = 3.98 (95% CI 1.35–11.75)] and additional extracerebral arterial embolism [aOR = 4.78 (95% CI 1.77–12.91)] but not with presence or distribution of hemorrhagic stroke, CMB or chronic infarcts. In-hospital mortality was higher in IE patients with three-territory sign compared to those without (31.4% vs. 12.2%; p = 0.01).

Conclusions

Three-territory sign is common but not obligatory in IE patients with acute ischemic stroke. cMRI will rather depict this stroke pattern in the more severely diseased IE patients as three-territory sign makes detection of a particularly virulent pathogen (Staphylococcus aureus) more likely and indicates higher severity of disease.

Trial registration

Not applicable.