ArticleNeurological research and practice2026
Three-territory sign in infective endocarditis and concomitant stroke: a retrospective analysis on characteristics and associated factors.
Article in Neurological research and practice, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundInfective 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.
methodsData 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.
resultsWe 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).
conclusionsThree-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.
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