Abstract
A 59-year-old woman visited a local hospital for fever and was diagnosed as having infective endocarditis (IE) on the basis of blood cultures and transthoracic echocardiography. Based on clinical episodes of subarachnoid hemorrhage after admission, it was judged that she was not a good candidate for urgent open heart surgery, and it was decided to treat her with conservative medical therapy for the acute phase. We explored the optimum timing for surgery by employing gadolinium (Gd) contrast medium-enhanced magnetic resonance imaging (MRI) T2* weighted image (black dots) due to her high risk of perioperative cerebral hemorrhage. After the disappearance of the contrast media enhancement effect around the black dots, open heart surgery was performed successfully on the 103rd hospitalization day. The patient was discharged 22 days after the surgery with no clinical complications. This case suggests that disappearance of the contrast media enhancement effect around the black dots may be a useful marker for optimal timing of surgery to minimize the risk of perioperative cerebral hemorrhage in patients with IE. Learning Objective. The MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE.
Highlights
Infective endocarditis (IE) is a serious disease characterized by refractory heart failure combined with sepsis
We report a case of infective endocarditis (IE) complicated with a brain mycotic aneurysm that was checked regularly by brain magnetic resonance imaging (MRI) with gadolinium (Gd) enhancement to explore optimal timing for open chest surgery
We considered a choice of endovascular embolization for the mycotic aneurysm; there was a concern that mechanical stimulation may result in an iatrogenic rupture of the aneurysm due to weakening of the vascular wall caused by active inflammation
Summary
Infective endocarditis (IE) is a serious disease characterized by refractory heart failure combined with sepsis. Intracranial bleeding is an important potential complication which can be influenced by the timing of open heart surgery [1]. We report a case of IE complicated with a brain mycotic aneurysm that was checked regularly by brain magnetic resonance imaging (MRI) with gadolinium (Gd) enhancement to explore optimal timing for open chest surgery. After disappearance of Gd-enhanced T2∗ weighted image (black dots), the patient underwent successful valve replacement without perioperative symptomatic complications. We discuss the possible usefulness of Gd-enhanced brain MRI to minimize perioperative hemorrhagic complications based on existing knowledge in the literature.
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