Neurological Complications Of Infective Endocarditis Research Articles

Imaging findings of the infective endocarditis with neurological complications

Neurological complications are the most serious extracardiac complications of infective endocarditis. They can be manifested as ischemic stroke, intracranial hemorrhage, mycotic aneurysms, meningitis, cerebritis and abscesses. Avoidance of anticoagulants and antiplatelet agents with early intravenous antibiotic administration is crucial in the management of this condition. MRI of the brain is an important tool for early diagnosis and guiding the treatment decision. The purpose of this article is to review the imaging appearances and the possible mechanisms of the intracranial findings in the patients with neurological complications of infective endocarditis.

Abstract 033: Trends in Cerebral Angiogram Utilization for Patients with Infective Endocarditis: A Nationwide Analysis

Introduction Infectious intracranial aneurysms (IIA) represent one of several cerebrovascular pathologies associated with infective endocarditis (IE). Neuroimaging in patients with IE, especially in those undergoing cardiac procedures, have scarcely been examined in the literature. Digital subtraction angiography (DSA), or cerebral angiogram, remains the gold standard for the detection of IIA, yet the utility of this invasive imaging modality is uncertain. Herein, we aim to better understand current national trends in the use of neuroimaging in this group of patients, and its impact on patient outcomes. Methods Hospitalizations for IE with concurrent procedures for left‐sided cardiac valve surgery (VS) were identified in the National Inpatient Sample (NIS) registry during the period of 2015‐2020 using weighted approximations and validated International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) diagnosis and procedural coding. The primary exposure was DSA and the trend of its use was evaluated during the study period. Multivariable logistic regression analysis was performed to evaluate the adjusted association of angiography with in‐hospital mortality, the primary study endpoint, while accounting for age and illness severity [quantified by All Patient Refined Diagnostic Related Groups (APR‐DRG) illness severity subclass]. Effect size was reported as adjusted odds ratio (aOR) with 95% confidence interval (CI) and a stringent statistical significance threshold of p < 0.001. Results This analysis identified 31,550 hospitalizations for IE treated with VS, of which 1,160 (3.7%) underwent DSA. Utilization of angiography significantly increased during the study period (trend p < 0.001; Kendall’s tau‐b = 0.002), with the rate of the final year of the study nearly doubling that of the first (2020 4.9% vs. 2015 2.5%, p < 0.001). IE VS patients undergoing angiography experienced significantly decreased mortality rates in comparison to those not receiving an angiogram (4.3% vs. 7.5%; p < 0.001). Following multivariable logistic regression analysis, angiography was significantly associated with decreased mortality, independent of age and illness severity (aOR 0.49, 95% CI 0.37, 0.66; p < 0.001). Conclusion The current literature on neurological complications of IE includes limited data on the defined role of neuroimaging in dictating management. The theoretical risk in IE patients undergoing cardiac procedures involving heparinization includes the risk of intracerebral hemorrhage, especially in those with IIA. While less invasive neuroimaging is thought to suffice in detecting bleeds, DSAs remain more sensitive for IIA detection. In our study, not only did the number of IE patients undergoing DSA increase over time, but they had better mortality rates. Future directions should focus on understanding the appropriate timing of imaging in relation to the patient’s disease course to optimize inpatient care.

Abstract 147: Utilization and Application of Transcranial Doppler Emboli Monitoring for Infective Endocarditis

Introduction The rapid growth of the elderly population, an increase in cardiac disease, and notable use of intracardiac prosthetic devices has led to an increased prevalence of infective endocarditis (IE). Among the sequelae observed with an IE diagnosis, acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), vasculitis, septic emboli, cerebral abscess, and infectious intracranial aneurysms (IIA) continue to complicate overall management of this disease. Current literature on neurological complications of IE includes limited data on the defined role of neuroimaging in dictating inpatient management. Transcranial doppler (TCD) emboli monitoring with high intensity signals (HITS) offers a real time, radiation‐free, relatively low cost, non‐invasive imaging option to potentially risk stratify and identify candidates for earlier intervention to prevent further cerebrovascular (CV) complications. Methods We conducted an observational study of infective endocarditis cases admitted to our institution from April 2022 to May 2023 who had TCD with HITS completed. Baseline clinical characteristics (age, sex, date and timing of TCD with HITS study, date of last positive blood culture, organism of infection, other neuroimaging utilized) were recorded. Observations recorded included the results of the TCD with HITS studies, the overall incidence and timing of neurological complications (AIS, SAH, ICH, IIA, septic emboli, cerebral abscess), timing of valve surgery, and inpatient mortality rates. A positive HITS was defined as detection of cerebral microembolism during ultrasound monitoring of bilateral middle cerebral arteries (MCA) for 30 minutes using a TCD machine (VIASONIX Dolphin IQ). Results Between April 2022 to July 2023, we identified 22 patients with confirmed left‐sided infective endocarditis who underwent TCD with HITS. Mean age was 66 years (SD, 10), and 82% were men. Leading pathogen types were Enterococcus Faecalis (27%) and Staphylococcus Epidermidis (18%). CV complications were noted in 19/22 patients (86%), the most common being AIS (82%) and IPH (18%). Two patients (9%) were found to have a positive HITS study, both of which developed septic emboli that caused ischemic stroke in one case, and hemorrhagic stroke in the other case. Average days from admission to timing of TCD with HITS study was 8.5 days. 14/22 patients underwent valve surgery (64%) during the admission on average 9.2 days after TCD with HITS study in the negative HITS group versus 5 days in the positive HITS group. Of the positive HITS cases, one of them died inpatient. Conclusion The association between neurological complications in patients with IE and cerebral microemboli detected with TCD monitoring has yet to be elucidated. While our observational study was limited by our sample size, both of our IE patients who had positive TCD with HITS studies developed more severe CV complications, and aggressive care was sought out more urgently to further minimize complications. Future directions include pursuing a prospective study incorporating TCD with HITS monitoring for patients with IE in order to risk‐stratify neurological complications and safety of valve surgery.

Combination of cortical-subcortical infarction with lobar microbleeds as a specific MRI pattern in patients with infective endocarditis

Background. Ischemic stroke (IS) and cerebral microbleeds (CMB) are the most common types of neurological complications of infective endocarditis (IE), while their combination is poorly understood.
 Aim. To evaluate the pattern of combination of cortical-subcortical infarction with lobar CMB or subarachnoid hemorrhage (SAH) in patients with left-sided IE.
 Materials and methods. A retrospective case-control study was conducted, including patients with IE who received cardiac surgery at the Federal Center for Cardiovascular Surgery. Inclusion criteria: age of patients 18 years; definite or possible (Duke criteria) IE of the left heart (aortic and/or mitral valves). The control group included patients without IE, with non-lacunar (likely embolic) IS. In both groups, the pattern of combination of cortical-subcortical infarction with lobar CMB or SAH was assessed. Differences between groups of patients were assessed using the 2 test, Fisher's exact test and the MannWhitney test. Additionally, odds ratios for binary features were calculated. To assess the information content of the studied pattern, classical classification quality metrics were calculated: accuracy, sensitivity, and specificity.
 Results. In patients with IS, infarcts corresponded to the main characteristics of cardioembolism: involvement of multiple cerebral arterial territories (84%), multiple infarcts (88%), cortical-subcortical localization (100%), and a high incidence of hemorrhagic transformation (44%). CMB was detected in 64% of cases (in 93.8%, CMB localization was lobar), SAH in 28% of patients (with CMB in 6 out of 7 cases). The pattern of combination of cortical-subcortical infarction with lobar CMB or SAH was observed in 64% in the IE group (in the control group in 12%). Odds ratio for the presence of IE was 13.0 (95% confidence interval 3.0455.9; p0.001). The accuracy of the sign was 76%, specificity 71%, sensitivity 84%.
 Conclusion. The combination of cortical-subcortical infarcts with lobar CMB or SAH may be a sign characteristic of IE-associated stroke.

Mycotic Cerebral Aneurysm: A Rare Complication of Infective Endocarditis

Intracranial mycotic aneurysm or Infected Aneurysm (IA) is rare and accounts for 2-4 % of neurologic complications of infective endocarditis [1]. The terminology «mycotic aneurysm» was used for the first time by William Osler in Gulstonian Lectures of 1885, it refers to a dilatation of an arterial wall caused by any infectious etiology [2]. It is a serious clinical condition that carries a significant morbidity with up to 80% mortality rates when reptured [3]. Therefore, an early and rapid diagnosis is critical for timely treatment to optimize patient outcome.

Abstract Number ‐ 218: Mechanical Thrombectomy in a HIV Patient with Staphylococcus Lugdunensis Bacteremia: A Case Report.

Introduction Occlusion of cerebral arteries account for 40–50% of neurological complications of infective endocarditis with the emboli most commonly lodging in the middle cerebral artery. The management of these occlusions with the use of thrombolytic therapies are associated with intracranial hemorrhage whereas outcomes with endovascular thrombectomy, while still under investigation, appear to be more favorable. In this case report, we present a HIV patient with persistent staphylococcus lugdunenesis bacteremia of unknown origin and acute left middle cerebral artery occlusion, who underwent endovascular thrombectomy. Methods Case Report Results A 66‐year‐old male past medical history of HIV on Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir, pancytopenia and treated hepatitis C who presented for malaise, back pain, and urinary symptoms for 1 week. Initial labs remarkable for pancytopenia, CD4 count 44 and positive urinalysis. Ceftriaxone was started for UTI and Trimethoprim/Sulfamethoxazole for PJP prophylaxis. Urine and multiple blood cultures were positive for staphylococcus lugdunensis. Vancomycin was added to antibiotic therapy. On day two of hospitalization, patient developed new onset aphasia, right facial droop, and right hemiparesis. Upon evaluation, NIHSS was 14. CT head was negative. CTA head and neck showed left M1 occlusion. CT perfusion showed an infarct core of 20cc and 144cc of penumbra. Due to concern for possible infective endocarditis, thrombolytics were not administered but he was taken for thrombectomy. Emboli retrieval was successful with mTICI‐2c reperfusion. During thrombectomy, clot noted to have septic emboli appearance. Post thrombectomy, patient had complete resolution of neurological deficits. MRI brain showed multiple punctate foci of restricted diffusion in the left middle cerebral artery distribution consistent with embolic process. TTE was inconclusive. Intraoperative cultures of the clot resulted positive for staphylococcus lugdunensis and pathology examination detailed clot with bacterial colonization. TEE was performed and negative for valvular vegetations, mass, thrombus, or endocarditis but there was an intrapulmonary shunt. Patient later developed a small acute left parietal lobe parenchymal hematoma and basal ganglia infarct. His neurological status remained unchanged. He completed 6 weeks of IV antibiotic therapy upon discharge. Conclusions This case illustrates the importance of timely endovascular thrombectomy in suspected cerebral septic emboli as outcomes are favorable. It supports prompt recognition of septic emboli bacterial species for targeted antibiotic therapy along with further investigation into staphylococcus lugdunensis and its relation with cerebral septic emboli. This case urges additional exploration into the relationship between HIV patients and cerebrovascular disease including cerebral septic emboli.

Neurological complications of infective endocarditis: 10 rules of patient management

Infective endocarditis is a serious diagnostic and therapeutic challenge for doctors of many specialties. In order to form a structured approach to patient management, the article discusses the key points regarding the neurological aspects of the disease, which are formulated in ten rules. They cover the clinical diagnosis of endocarditis in patients with stroke, features of reperfusion therapy, approaches to prescribing antithrombotic and antibiotic therapy, as well as issues of surgical treatment.

Neurological Complications and Clinical Outcomes of Infective Endocarditis

ObjectivesThe aim of this study is to explore the clinical features associated with neurological complications of infective endocarditis (IE) and to assess the impact of neurological complications on clinical outcomes. Materials and methodsThe frequency of relevant clinical features was compared in a case series of IE patients with and without neurological complications admitted to a single health care system from 2015 to 2019. Variables with significant differences (p ≤ 0.05) in baseline characteristics in univariate logistic regression models were entered into multivariable models along with age to determine associations with neurological complications, unfavorable discharge outcomes (modified Rankin score ≥ 3), and in-hospital mortality. Results260 patients with a mean age of 51 (±18) years and 103 (40%) females were included. Neurological complications occurred in 165 (63%) patients, with the most common being septic emboli (66 patients, 25%). In the regression analyses, antiplatelet usage (aOR 1.87, 95% CI [1.05-3.32]) and mitral valve vegetations (aOR 2.66, 95% CI [1.22-5.79]) were independently associated with neurological complications. Territorial infarction (aOR 4.13, 95% CI [1.89-9.06]) and encephalopathy (aOR 3.95, 95% CI [1.19-13.05]) were associated with an increased risk of unfavorable outcome, while cardiac surgery was associated with a lower risk of both unfavorable outcome (aOR 0.40, 95% CI [0.22-0.71]) and in-hospital mortality (aOR 0.18, 95% CI [0.09-0.35]). ConclusionsNeurological complications are common in IE patients and are associated with mitral valve endocarditis and antiplatelet usage. Of the neurological complications, territorial infarcts and encephalopathy are associated with unfavorable discharge outcomes.

Neurologic complications of infective endocarditis in children.

To define the frequency and characteristics of acute neurologic complications in children hospitalised with infective endocarditis and to identify risk factors for neurologic complications. Retrospective cohort study of children aged 0-18years hospitalised at a tertiary children's hospital from 1 January, 2008 to 31 December, 2017 with infective endocarditis. Sixty-eight children met Duke criteria for infective endocarditis (43 definite and 25 possible). Twenty-three (34%) had identified neurologic complications, including intracranial haemorrhage (25%, 17/68) and ischaemic stroke (25%, 17/68). Neurologic symptoms began a median of 4.5days after infective endocarditis symptom onset (interquartile range 1, 25days), though five children were asymptomatic and diagnosed on screening neuroimaging only. Overall, only 56% (38/68) underwent neuroimaging during acute hospitalisation, so additional asymptomatic neurologic complications may have been missed. Children with identified neurologic complications compared to those without were older (48 versus 22% ≥ 13years old, p = 0.031), more often had definite rather than possible infective endocarditis (96 versus 47%, p < 0.001), mobile vegetations >10mm (30 versus 11%, p = 0.048), and vegetations with the potential for systemic embolisation (65 versus 29%, p = 0.004). Six children died (9%), all of whom had neurologic complications. Neurologic complications of infective endocarditis were common (34%) and associated with mortality. The true frequency of neurologic complications was likely higher because asymptomatic cases may have been missed without screening neuroimaging. Moving forward, we advocate that all children with infective endocarditis have neurologic consultation, examination, and screening neuroimaging. Additional prospective studies are needed to determine whether early identification of neurologic abnormalities may direct management and ultimately reduce neurologic morbidity and overall mortality.

CEREBRAL ABSCESS AND MYCOTIC ANEURYSM AS A CONSEQUENCE OF INFECTIVE ENDOCARDITIS: A CASE REPORT

Background: Neurological complications of infective endocarditis are common and can cause significant morbidity and mortality. A broad spectrum of neurological manifestations may be observed. This case is used to show an approach towards the management of neurological complication of bacterial endocarditis based on a review of the published work. Case Presentation: A 26-year-old male patient was admitted to our department with sudden onset of left side weakness associated with aphasia and an intense headache. Clinical assessment showed an infective endocarditis with two mobile vegetations attached to the mitral valve complicated by an intracranial mycotic aneurysm and a brain abscess. The patient was managed only with antibiotic therapy on the decision of a multidisciplinary team, with an excellent clinical outcome. Conclusions: The management of neurologic complications of infective endocarditis remains challenging given the lack of prospective, controlled studies. Therefore, the decision process requires the participating of a multidisciplinary team.

Neurological complications in children with infective endocarditis: Incidence, risk factors, and outcome: A 10-year single-center experience.

Background and ObjectiveDespite improvement in medical management, infective endocarditis (IE) remains a serious disease that may affect children with and without preexisting cardiac conditions with significant morbidity and mortality. Neurological complications of IE represent the worst with guarded prognosis. The aim of this study is to describe the incidence, etiology, characteristics, risk factors, and outcome of children with neurological complications associated with IE.Material and methodsA retrospective cohort study was conducted from 2009 to 2019 where all pediatric patients who fulfilled the modified Duke criteria for IE were included. We divided the cases into 2 groups: IE with neurological complications and IE without neurological complications control group. We compared the two groups statistically and analyzed the results.ResultsWe identified 31 (17 male, 14 female) patients with IE. Neurological complications occurred in 7/31 (23%) patients, mainly in the form of a stroke. Gram-positive microbes were the main causative agents for IE (52%) followed by gram-negative (14%), then fungal organisms (3%). Univariate analysis identified the following risk factors for neurological complications: lower body weight, higher C- reactive protein (CRP) level, and left-sided valvular lesions with P values of (0.0003, 0.0001, and 0.04), respectively.Although mortality was higher in the neurological complications group, it was 43% in comparison to 21% in the control group and it did not reach statistical significance (P = .49). Large vegetation size (more than 10 mm) was seen in 57% of patients with neurological complications as compared to 16% in the control group (P = .052).ConclusionNeurological complications occurred in almost a quarter of children with IE. Possible risk factors include lower body weight, left-sided valvular lesion, and higher levels of inflammatory markers (CRP). Stroke was the most common neurological complication encountered with possible increased risk of mortality.

Chapter 11 - Neurologic complications of infective endocarditis

Infective endocarditis (IE) is an infection primarily affecting the endocardium of heart valves that can embolize systemically and to the brain. Neurologic manifestations include strokes, intracerebral hemorrhages, mycotic aneurysms, meningitis, cerebral abscesses, and infections of the spine. Neurologic involvement is associated with worse mortality, though it does not always portend a poor functional prognosis. Neuroimaging is indicated in patients who have neurologic symptoms, including cerebral vessel imaging in patients who have subarachnoid hemorrhage. In the case of acute ischemic stroke (IS), IV thrombolysis is contraindicated but endovascular thrombectomy may be a consideration. Neurologic findings understandably raise concern about valve surgery when indicated due to the risk of hemorrhage with perioperative anticoagulation. However, most neurologic complications do not preclude valve surgery and valve surgery may in fact be indispensable in some cases to prevent further neurologic problems. Management decisions in patients with IE and neurologic complications should therefore be multidisciplinary with a major contribution from the neurologist.

Neurologic complications of infective endocarditis: A four's year experience of Casablanca university hospital

Clinical manifestations of infective endocarditis(IE) include systemic, cardiac, and extracardiac multiorgan symptoms and signs. Hence, neurological complications have been linked to poor outcome and remains the most frequent extracardiac signs of IE with 25% of patients experience at least one neurological event. To assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development and their influence on the clinical outcome. Retrospective study included patients with possible or definite infective endocarditis according to the European society of cardiology modified Duke Criteria, admitted between 2016 and 2019 in the Cardiology department of Casablanca university. Seventy-one patients were male and 47 were female with a mean (SD) age = 40.3 (15.2) years. 85 episodes were designed as definite IE. Neurologic complications were identified in 24,5% patients with 22 events associated with definite IE. Nineteen complications were thought to be caused by major cerebral embolism including ischemic brain infarction and transient ischemic stroke. On the other hand, cerebral hemorrhage was found in 6 patients and no significant association between anticoagulation therapy and cerebral hemorrhage was found in our study. Neurologic complications were significantly associated with Staphylococcus aureus infection ( P = 0.017) and with IE affecting both the aortic and the mitral valves ( P = 0.03). Death during the acute phase of IE occurred in 8 episodes (30%) with neurologic complications and in 9 episodes (10%) without neurologic complications. Mortality was highly associated with neurologic complications with a P = 0.017. Our results reinforce that neurologic complications has negative impact on the outcome of patients with IE. Furthermore, appropriate antimicrobial therapy should be instituted rapidly to prevent neurologic events and reduce mortality rate.

Management of Large Vessel Occlusion Stroke Related to Infective Endocarditis: Is Mechanical Thrombectomy a Safe Option?

IntroductionAcute ischemic stroke is the most common neurological complication of infective endocarditis. Intravenous thrombolysis is contraindicated in these patients due to a higher risk of hemorrhagic complications. Whether mechanical thrombectomy has some benefit in these patients remains unanswered although some favorable results can be found in literature. MethodsWe report twelve cases of acute ischemic stroke due to septic emboli treated with mechanical thrombectomy in two comprehensive stroke centers. ResultsMedian age was 63 years (IQR 58.8-77.5 years). Diagnosis of infective endocarditis was previous to the diagnosis of stroke in three of the patients. There were five cases of prosthetic-valve endocarditis and eight cases of native-valve endocarditis. Two patients were treated with intravenous thrombolysis with an extensive subarachnoid hemorrhage in 24 h follow-up CT in one of them. Another patient suffered an arterial perforation during the endovascular procedure without successful recanalization. 6 of the patients (50%) developed some type of hemorrhagic complications with three cases of symptomatic intracerebral hemorrhage. Early neurological recovery was achieved in 3 (25%) patients. Functional independence at 3 months in patients with successful revascularization was reached in 50% of the cases. ConclusionsIn patients with large vessel acute ischemic stroke related to infective endocarditis, mechanical thrombectomy might be considered with some potential benefit reported. There may be a high risk of hemorrhagic complications, as known for intravenous thrombolysis in this condition, suggesting that this procedure should be carefully evaluated in these patients.

Неврологические осложнения инфекционного эндокардит

Неврологические осложнения инфекционного эндокардит

High level of D-dimer predicts ischemic stroke in patients with infective endocarditis.

BackgroundIschemic stroke is one of the most prominent and serious neurological complications of infective endocarditis (IE). Our study was designed to evaluate the predictive value of higher level of plasma D‐dimer on admission for the development of ischemic stroke in patients with IE.MethodsIn this prospective study, a total of 173 consecutive patients with IE were recruited from January 2016 to December 2018. Plasma D‐dimer and other clinical indexes of IE patients were measured after admission. The number of patients who developed ischemic stroke during 6‐month follow‐up was recorded, as well as the occurrence time of ischemic stroke.ResultsIschemic stroke was observed in 38 (22%) patients during 6‐month follow‐up since definite diagnosis of IE. Patients with ischemic stroke had significantly higher levels of plasma D‐dimer than those of patients without stroke (4982 vs 2205 μg/L, P < .001). In addition, Staphylococcus aureus infection (HR: 1.96, 95% CI: 1.51‐2.42), mitral valve vegetation (HR: 1.52, 95% CI: 1.32‐1.75), and higher levels of on‐admission plasma D‐dimer (HR: 1.35, 95% CI: 1.27‐1.43) were significantly associated with ischemic stroke. Moreover, D‐dimer levels ≥3393 μg/L served as a strong predictor for ischemic stroke in patients with IE, and the sensitivity and specificity were 78% and 83%, respectively.ConclusionOur study suggested that higher level of D‐dimer on admission was an independent predictor for ischemic stroke in patients with IE. These patients may require special attention, in particular within the first trimester after IE diagnosis.

Neurologic Complications of Infective Endocarditis: A Joint Model for a Septic Thromboembolism and Inflammatory Small Vessel Disease.

Embolic events from vegetations are commonly accepted as the main mechanism involved in neurologic complications of infective endocarditis. The pathophysiology may imply other phenomena, including vasculitis. We aimed to define the cerebral lesion spectrum in an infective endocarditis rat model. Experimental model of Staphylococcus aureus or Enterococcus faecalis infective endocarditis. Neurologic lesions observed in the infective endocarditis model were compared with three other conditions, namely bacteremia, nonbacterial thrombotic endocarditis, and healthy controls. Research laboratory of a university hospital. Male Wistar rats. Brain MRI, neuropathology, immunohistochemistry for astrocyte and microglia, and bacterial studies on brain tissue were used to characterize neurologic lesions. In the infective endocarditis group, MRI revealed at least one cerebral lesion in 12 of 23 rats (52%), including brain infarctions (n = 9/23, 39%) and cerebral microbleeds (n = 8/23, 35%). In the infective endocarditis group, neuropathology revealed brain infarctions (n = 12/23, 52%), microhemorrhages (n = 10/23, 44%), and inflammatory processes (i.e., cell infiltrates including abscesses, vasculitis, meningoencephalitis, and/or ependymitis; n = 11/23, 48%). In the bacteremia group, MRI studies were normal and neuropathology revealed only hemorrhages (n = 2/11, 18%). Neuropathologic patterns observed in the nonbacterial thrombotic endocarditis group were similar to those observed in the infective endocarditis group. Immunochemistry revealed higher microglial activation in the infective endocarditis group (n = 11/23, 48%), when compared with the bacteremia (n = 1/11, 9%; p = 0.03) and nonbacterial thrombotic endocarditis groups (n = 0/7, 0%; p = 0.02). This original model of infective endocarditis recapitulates the neurologic lesion spectrum observed in humans and suggests synergistic mechanisms involved, including thromboembolism and cerebral vasculitis, promoted by a systemic bacteremia-mediated inflammation.

Neurological Complications of Endocarditis: A Multidisciplinary Review with Focus on Surgical Decision Making.

Infective endocarditis (IE) is a systemic disease with many potential neurologic manifestations including ischemic and hemorrhagic strokes, cerebral microbleeding, infectious intracranial aneurysms, meningitis, brain abscesses, and encephalopathy. The majority of left-sided (heart) IE patients have brain lesions that may alter management decisions, warranting the systematic use of magnetic resonance imaging. Many patients require surgical treatment of valvular disease, and central nervous system lesions weigh into decision making. Data regarding the timing of surgery are conflicting, but earlier surgery appears to be safe in most ischemic strokes, while ideally surgery should be delayed for 3 to 4 weeks in patients with hemorrhagic strokes. IE requires a multidisciplinary team to collaboratively care for the patient. In this article, we review the current understanding and management of the neurological complications of IE and their impact on the performance and timing of cardiac surgery.

Neurological Complications of Infective Endocarditis.

The purpose of this narrative review and update is to summarize the current knowledge and provide recent advances on the neurologic complications of infective endocarditis. Neurological complications occur in about one-fourth of patients with infective endocarditis. Brain MRI represents a major tool for the identification of asymptomatic lesions, which occur in most of the patients with infective endocarditis. The usefulness of systematic brain imaging and the preferred treatment of patients with infective endocarditis and silent brain lesions remains uncertain. The basis of treatment of infective endocarditis is early antimicrobial therapy. In stroke due to infective endocarditis, anticoagulation and thrombolysis should be avoided. Endovascular treatment can be useful for both acute septic emboli and mycotic aneurysms, but evidence is still limited. In patients with neurological complications, cardiac surgery can be safely performed early, if indicated. The optimal management of a patients with neurological complications of infective endocarditis needs an individualized case discussion and the participation of a multidisciplinary team including neurologists, cardiologists, cardiothoracic surgeons, neuroradiologists, neurosurgeons, and infectious disease specialists.

Cardiac surgery in infective endocarditis with neurological complications: Identifying prognosis risk factors in mortality and handicap at 6 months

Neurological complications of infective endocarditis (IE) concerns 20–40% of cases when symptomatic and 70% when asymptomatic. It is a well-identified gravity factor. Surgical indications in IE are larges and usual in emergency situations. However, neurological event, symptomatic or not, counts in surgical discussion. Sub-groups of patients with real risk of neurological deterioration during extracorporeal circulation are difficult to identify. The purpose of this study was to identify the risk factors of death and handicap in patients operated for infective endocarditis with neurological complications. Retrospective monocentric study realized in CHU of Toulouse from October 2014 to March 2017. We included 78 patients treated by cardiac surgery in a context of infective endocarditis complicated by neurological event (ischemic or hemorrhagic stroke, meningitis or mycotic aneurysm). The primary endpoint was mortality and Rankins score greater than or equal to 2, at six month. Primary endpoint occurred in 21 patients (26%). Risk factors were anteriority of mechanical valve replacement ( P = 0,004), pejorative SOFA score ( P < 0,0001), diabetes ( P = 0,005), high Euroscore ( P = 0,0004), infection by methicillin-sensitive Staphylococcus aureus ( P = 0,033), oral streptococcus ( P = 0,037) initial hemodynamic instability ( P = 0,005), aminoside treatment ( P = 0,001), duration of reanimation ( P = 0,004), vasopressive drugs use and mechanical ventilation pre and post-surgery. However, we did not find significative results to several variables as hemorrhagic stroke ( P = 0,69), surgery delay ( P = 0,324), neurological symptoms ( P = 0,120), Glasgow score ( P = 0,146) and oral anticoagulation ( P = 0,211) ( Fig. 1 ). Main risk factors of death or handicap at six month, after a cardiac surgery in context of IE with neurological complication were hemodynamic presentation, micro organism and diabetes.