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Álvarez-Zaballos S, Vázquez-Alen P, Muñoz P, de Alarcón A, Gutiérrez Carretero E, Álvarez-Uría A, Fariñas MC, Rodríguez-García R, Goenaga MÁ, Cuervo G, Plata-Ciezar A, Hidalgo-Tenorio C, Aldamiz-Echevarría G, Martínez-Sellés M. Prevalence and prognostic impact of stroke in a national cohort of infective endocarditis. Int J Stroke 2024:17474930241255560. [PMID: 38708722 DOI: 10.1177/17474930241255560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND Stroke is a common complication of infective endocarditis (IE). Our aim was to describe the prevalence and prognostic impact of stroke in a national cohort of IE. METHODS Consecutive inclusion at 46 Spanish hospitals between 2008 and 2021. RESULTS Out of 5667 IE cases, 1125 had acute stroke (19.8%): 818 ischemic strokes (811 cardioembolic strokes (193 with hemorrhagic transformation), 4 transient ischemic attacks, 3 lacunar infarctions), 127 intracranial hemorrhages, and 27 other neurological complications (cerebral abscesses, encephalitis, and meningitis). Compared to patients without stroke, those with stroke had a similar mean age (69 years) but were more frequently female (68.2% vs 63.7%, p = 0.04) and had a higher incidence of intracardiac complications (35% vs 30%, p = 0.01), surgical indication (69.9% vs 65.9%, p = 0.001), in-hospital mortality (40.9% vs 22.0%, p < 0.001), and 1-year mortality (46.2% vs 27.9%, p < 0.001). The following variables were independently associated with stroke: mitral location (odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.34-1.8, p < 0.001), vascular phenomenon (OR = 2.9, 95% CI = 2.4-3.6, p = 0.0001), acute renal failure (OR = 1.2, 95% CI = 1.0-1.4, p = 0.021), septic shock (OR = 1.3, 95% CI = 1.1-1.6, p = 0.007), sepsis (OR = 1.3, 95% CI = 1.1-1.6, p = 0.005), surgery indicated but not performed (OR = 1.4, 95% CI = 1.2-1.7, p < 0.001), community-acquired IE (OR = 1.2, 95% CI = 1-1.4, p = 0.017), and peripheral embolization (OR = 1.6, 95% CI = 1.4-1.9, p < 0.001). Stroke was an independent predictor of in-hospital (OR = 2.1, 95% CI = 1.78-2.51, p < 0.001) and 1-year mortality (hazard ratio = 1.9, 95% CI = 1.6-2.5). CONCLUSION One-fifth of patients with IE have concomitant stroke. Stroke is associated with mortality.
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Affiliation(s)
- Sara Álvarez-Zaballos
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Pilar Vázquez-Alen
- Neurology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Arístides de Alarcón
- Infective Diseases, Microbiology and Parasitology Department, (UCEIMP), Hospital Virgen del Rocío Seville, Seville, Spain
- Grupo de Resistencias bacterianas y antimicrobianos (CIBERINFEC), Madrid, Spain
- Institute of Biomedicine of Seville (IBiS), Seville, Spain
- University of Seville/CSIC, Seville, Spain
| | - Encarnación Gutiérrez Carretero
- Institute of Biomedicine of Seville (IBiS), Seville, Spain
- University of Seville/CSIC, Seville, Spain
- Cardiac Surgery Service CIBERCV, Hospital Virgen del Rocío Seville, Seville, Spain
| | - Ana Álvarez-Uría
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Mª Carmen Fariñas
- Infectious Diseases Department, Hospital Universitario Marqués de Valdecilla IDIVAL, Santander, Spain
- CIBER de Enfermedades Infecciosas-CIBERINFEC (CB21/13/00068), Instituto de Salud Carlos III, Madrid, Spain
- University of Cantabria, Santander, Spain
| | - Raquel Rodríguez-García
- Intensive Medicine Department, Hospital Universitario Central de Asturias, Oviedo, Spain
- University of Oviedo, Oviedo, Spain
| | - Miguel Ángel Goenaga
- Infectious Diseases Department, Hospital Universitario Donosti, ISS Biodonostia, San Sebastián, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antonio Plata-Ciezar
- Infectious Diseases Department, UGC de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Regional Universitario de Málaga, IBIMA, Málaga, Spain
| | - Carmen Hidalgo-Tenorio
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Gonzalo Aldamiz-Echevarría
- Cardiac Surgery Department, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
- Universidad Europea, Madrid, Spain
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Calderón-Parra J, Domínguez F, González-Rico C, Arnaiz de las Revillas F, Goenaga MÁ, Alvarez I, Muñoz P, Alonso D, Rodríguez-García R, Miró JM, De Alarcón A, Antorrena I, Goikoetxea-Agirre J, Moral-Escudero E, Ojeda-Burgos G, Ramos-Martínez A. Epidemiology and Risk Factors of Mycotic Aneurysm in Patients With Infective Endocarditis and the Impact of its Rupture in Outcomes. Analysis of a National Prospective Cohort. Open Forum Infect Dis 2024; 11:ofae121. [PMID: 38500574 PMCID: PMC10946656 DOI: 10.1093/ofid/ofae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 03/12/2024] [Indexed: 03/20/2024] Open
Abstract
Background Several aspects of the occurrence and management of mycotic aneurysm (MA) in patients with infective endocarditis (IE) have not been studied. Objectives To determine the incidence and factors associated with MA presence and rupture and to assess the evolution of those initially unruptured MA. Methods Prospective multicenter cohort including all patients with definite IE between January 2008 and December 2020. Results Of 4548 IE cases, 85 (1.9%) developed MA. Forty-six (54.1%) had intracranial MA and 39 (45.9%) extracranial MA. Rupture of MA occurred in 39 patients (45.9%). Patients with ruptured MA had higher 1-year mortality (hazard ratio, 2.33; 95% confidence interval, 1.49-3.67). Of the 55 patients with initially unruptured MA, 9 (16.4%) presented rupture after a median of 3 days (interquartile range, 1-7) after diagnosis, being more frequent in intracranial MA (32% vs 3.3%, P = .004). Of patients with initially unruptured MA, there was a trend toward better outcomes among those who received early specific intervention, including lower follow-up rupture (7.1% vs 25.0%, P = .170), higher rate of aneurysm resolution in control imaging (66.7% vs 31.3%, P = .087), lower MA-related mortality (7.1% vs 16.7%, P = .232), and lower MA-related sequalae (0% vs 27.8%, P = .045). Conclusions MA occurred in 2% of the patients with IE. Half of the Mas occurred in an intracranial location. Their rupture is frequent and associated with poor prognosis. A significant proportion of initially unruptured aneurysms result from rupture during the first several days, being more common in intracranial aneurysms. Early specific treatment could potentially lead to better outcomes.
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Affiliation(s)
- Jorge Calderón-Parra
- Infectious Diseases Unit, Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Spain
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
| | - Fernando Domínguez
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Department of Cardiology, Puerta de Hierro University Hospital, Majadahonda, Spain
| | - Claudia González-Rico
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla, CIBER Infectious Diseases (CIBERINFEC, CB21/13/00068). Cantabria University, Santander, Spain
| | - Francisco Arnaiz de las Revillas
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla, CIBER Infectious Diseases (CIBERINFEC, CB21/13/00068). Cantabria University, Santander, Spain
| | | | - I Alvarez
- Department of Infectious Diseases, OSI Donostialdea, San Sebastian, Spain
| | - Patricia Muñoz
- Department of Microbiology and Infectious Diseases, University Hospital Gregorio Marañón, CIBER Respiratory Diseases (CIBERES, CB06/06/0058), Complutense University, Madrid, Spain
| | - David Alonso
- Department of Microbiology and Infectious Diseases, University Hospital Gregorio Marañón, CIBER Respiratory Diseases (CIBERES, CB06/06/0058), Complutense University, Madrid, Spain
| | | | - José María Miró
- Department of Infectious Diseases, Clinic Hospital—IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Arístides De Alarcón
- Infectious Diseases, Microbiology, and Parasitology Unit, University Hospital Virgen del Rocio, Seville University, Seville, Spain
| | - Isabel Antorrena
- Cardiology Department, University Hospital La Paz- IDIPAZ, Madrid, Spain
| | | | | | | | - Antonio Ramos-Martínez
- Infectious Diseases Unit, Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Spain
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Faculty of Medicine, Autónoma University of Madrid, Madrid, Spain
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3
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Boukobza M, Ilic-Habensus E, Duval X, Laissy JP. MRI of unruptured infectious intracranial aneurysms in infective endocarditis. A case-control study. J Neuroradiol 2023; 50:539-547. [PMID: 36621458 DOI: 10.1016/j.neurad.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To evaluate the usefulness of T2* and FLAIR sequences in the detection of unruptured infectious intracranial aneurysms (UIIAs) in infective endocarditis (IE) including the relationships between the lesion patterns within subarachnoid spaces and the presence of UIIA. METHODS Retrospective review of 15 consecutive patients with definite IE undergoing MR imaging (FLAIR, T2*, DWI, CE-MRA, 3D-T1, CE-3DT1 sequences), in whom DSA detected infectious intracranial aneurysms (IIA). Aneurysmal features (diameter, location, morphology on DSA) and signal patterns onT2*, FLAIR and conventional MR sequences at the site of the UIIA, follow-up MRI and IE background, were analyzed. A control-group of 15 IE-patients without IIA at DSA served for comparison. RESULTS Among 17 UIIAs studied, T2* sequence displayed a susceptibility vessel sign in 15/17 (88.2%), both distal and proximal, which matched with the IIA visualized on DSA. Three patterns of hyposignal areas were identified: (a) signet-ring or target-sign appearance (n = 7), (b) homogeneous, round-, oval- or pear-shaped area (n = 4), and (c) heterogeneous area (n = 4). A FLAIR hyperintensity of the lumen and of the adjacent cortex was present in 6 (35.3%) and 9 (53%) UIIAs, respectively. On T1 (12 UIIAs) a rounded hyposignal (n = 2), within the UIIA lumen matched with the FLAIR hypersignal. Using both T2* and FLAIR had an incremental value with 100% sensitivity and specificity. CONCLUSION The susceptibility vessel sign is an MR imaging pattern frequently observed at the site of UIIAs in IE-patients. Both T2* and FLAIR may have the potential to depict UIIAs, regardless of their location and shape.
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Affiliation(s)
- Monique Boukobza
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Claude-Bernard, Hospital, 46 rue Henri Huchard, Paris 75018, France.
| | - Emila Ilic-Habensus
- Clinical Investigation Center, Assistance Publique-Hôpitaux de Paris, Bichat Claude-Bernard, Hospital, 46 rue Henri Huchard, Paris 75018, France.
| | - Xavier Duval
- Clinical Investigation Center, Assistance Publique-Hôpitaux de Paris, Bichat Claude-Bernard, Hospital, 46 rue Henri Huchard, Paris 75018, France; Department of Infectious Diseases, Assistance Publique-Hôpitaux de Paris, Bichat Claude-Bernard, Hospital, INSERM Clinical Investigation Center 007, and INSERM U738, Paris University, Paris, France.
| | - Jean-Pierre Laissy
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Claude-Bernard, Hospital, 46 rue Henri Huchard, Paris 75018, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, INSERM U1148, Paris University; Bichat Claude-Bernard, Hospital, Paris, France.
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 157] [Impact Index Per Article: 157.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Kim S, Suh CH, Kim TO, Kim KW, Heo H, Shim WH, Kim SJ, Lee SA. Detection rate of brain MR and MR angiography for neuroimaging abnormality in patients with newly diagnosed left-sided infective endocarditis. Sci Rep 2023; 13:17070. [PMID: 37816822 PMCID: PMC10564872 DOI: 10.1038/s41598-023-44253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/05/2023] [Indexed: 10/12/2023] Open
Abstract
We aimed to investigate the detection rate of brain MR and MR angiography for neuroimaging abnormality in newly diagnosed left-sided infective endocarditis patients with/without neurological symptoms. This retrospective study included consecutive patients with definite or possible left-sided infective endocarditis according to the modified Duke criteria who underwent brain MRI and MR angiography between March 2015 and October 2020. The detection rate for neuroimaging abnormality on MRI was defined as the number of patients with positive brain MRI findings divided by the number of patients with left-sided infective endocarditis. Positive imaging findings included acute ischemic lesions, cerebral microbleeds, hemorrhagic lesions, and infectious aneurysms. In addition, aneurysm rupture rate and median period to aneurysm rupture were evaluated on follow-up studies. A total 115 patients (mean age: 55 years ± 19; 65 men) were included. The detection rate for neuroimaging abnormality was 77% (89/115). The detection rate in patients without neurological symptoms was 70% (56/80). Acute ischemic lesions, cerebral microbleeds, and hemorrhagic lesions including superficial siderosis and intracranial hemorrhage were detected on MRI in 56% (64/115), 57% (66/115), and 20% (23/115) of patients, respectively. In particular, infectious aneurysms were detected on MR angiography in 3% of patients (4/115), but MR angiography in 5 patients (4.3%) was insignificant for infectious aneurysm, which were detected using CT angiography (n = 3) and digital subtraction angiography (n = 2) during follow-up. Among the 9 infectious aneurysm patients, aneurysm rupture occurred in 4 (44%), with a median period of aneurysm rupture of 5 days. The detection rate of brain MRI for neuroimaging abnormality in newly diagnosed left-sided infective endocarditis patients was high (77%), even without neurological symptoms (70%).
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Affiliation(s)
- Seongken Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Tae Oh Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hwon Heo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Hyun Shim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Joon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Ah Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Williams TJ, Starr M, El-Dalati S. Intracranial Hemorrhage as a Marker for Mycotic Aneurysm in Patients With Infective Endocarditis. Neurol Clin Pract 2023; 13:e200144. [PMID: 37064584 PMCID: PMC10100440 DOI: 10.1212/cpj.0000000000200144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/09/2023] [Indexed: 03/12/2023]
Abstract
Background and Objective Mycotic aneurysms are a significant complication of IE that can lead to intracranial hemorrhage (ICH) and occasionally require intervention before valve surgery. Digital subtraction angiography (DSA) remains the gold standard for the detection of mycotic aneurysms but is an invasive procedure with contrasted dye exposure. Our objective was to determine predictive factors for the presence of mycotic aneurysms in patients with known infective endocarditis (IE). Methods IRB exemption was obtained from the University of Pittsburgh Medical Center. Patients with left-sided or right-sided endocarditis with patent foramen ovale (PFO) were identified. Records were retrospectively reviewed by an independent investigator. Patients were stratified by demographic information, diagnostic imaging, and clinical outcomes. Standard descriptive statistics were used for characterization. The χ2 analysis and Fisher exact test were used for categorical comparisons. The Student t test was used for group comparisons. Results 36 cases of left-sided or right-sided endocarditis with PFO undergoing evaluation for valve surgery were identified. Twenty-seven patients underwent CNS imaging, and 24 underwent DSA. Six patients were found to have ICH on CNS imaging. Mycotic aneurysms were identified by DSA in 5 patients (13.9%), and of these patients, 4 (80%) presented with ICH and 1 with ischemic stroke. Notably, the patient who presented with ischemic stroke then developed ICH on follow-up CT imaging. The negative predictive value of the absence of ICH on initial CNS imaging for the presence of mycotic aneurysm was 97.4%. Discussion Patients with left-sided and right-sided endocarditis with PFO and ICH on CNS imaging were more likely to have mycotic aneurysms detected through DSA than similar patients without ICH. Routine DSA screening for mycotic aneurysms may not be required in patients with endocarditis undergoing evaluation for valve surgery who present without ICH on CNS imaging.
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Affiliation(s)
- Thomas J Williams
- Department of Neurology (TJW, MS), University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Infectious Diseases, Department of Internal Medicine, (SE-D) University of Kentucky Medical Center, Lexington, KY
| | - Matthew Starr
- Department of Neurology (TJW, MS), University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Infectious Diseases, Department of Internal Medicine, (SE-D) University of Kentucky Medical Center, Lexington, KY
| | - Sami El-Dalati
- Department of Neurology (TJW, MS), University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Infectious Diseases, Department of Internal Medicine, (SE-D) University of Kentucky Medical Center, Lexington, KY
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7
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Affiliation(s)
- Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Anna M Cervantes-Arslanian
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Steven K Feske
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA; Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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8
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Kashkoush A, El-Abtah ME, Achey R, Hussain MS, Toth G, Moore NZ, Bain M. Flow Diversion as Destination Treatment of Intracranial Mycotic Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2023; 24:492-498. [PMID: 36715979 DOI: 10.1227/ons.0000000000000593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/21/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Mycotic aneurysms represent a rare type of intracranial aneurysm. Treatment options usually consist of coiling, clipping, or liquid embolization. Data regarding outcomes after flow diversion of mycotic aneurysms are sparse. OBJECTIVE To present a single-center case series regarding our experience with FD as definitive treatment for ruptured mycotic aneurysms initially treated with coil embolization. METHODS We retrospectively reviewed a prospectively maintained database of all cerebrovascular procedures performed at a single institution between 2017 and 2021 for cases that used FD for the management of intracranial mycotic aneurysms. Prospectively collected data included patient demographics, medical history, rupture status, aneurysm morphology, aneurysm location, and periprocedural complications. The main outcomes included neurological examination and radiographic occlusion rate on cerebral digital subtraction angiography. RESULTS Three patients with 4 ruptured mycotic aneurysms that were initially treated with coil embolization were identified that required retreatment. The aneurysms were located along the middle cerebral artery bifurcation (n = 2), posterior cerebral artery P1/2 junction (n = 1), and basilar artery apex (n = 1), which all demonstrated recurrence after initial coil embolization. Successful retreatment using flow diverting stents was performed in all 3 patients. At the last angiographic follow-up, all aneurysms demonstrated complete occlusion. No patients suffered new periprocedural complications or neurological deficits after FD. CONCLUSION Flow-diverting stents may be an effective treatment option for intracranial mycotic aneurysms that are refractory to previous endovascular coiling. Future studies are warranted to establish the associated long-term safety and clinical efficacy.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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9
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Das AS, McKeown M, Jordan SA, Li K, Regenhardt RW, Feske SK. Risk factors for neurological complications in left-sided infective endocarditis. J Neurol Sci 2022; 442:120386. [PMID: 36030704 DOI: 10.1016/j.jns.2022.120386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/05/2022] [Accepted: 08/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Neurological complications following infective endocarditis (IE) directly contribute to long-term morbidity. We examined the risk factors for different neurological complications of left-sided IE. METHODS Using a database of consecutive adults admitted to a health system with left-sided IE from 2015 to 2019, the frequency of cerebral infarcts, intraparenchymal hemorrhage, cerebral microbleeds (CMB), mycotic aneurysm, and encephalopathy was determined. Variables with significant differences comparing each neurological complication (p < 0.1) were entered into regression models along with age to determine predictors. RESULTS 211 patients with mean age 54 (±18) years, and 69 (33%) females were included. Infarcts were found in 118 (56%) patients, intraparenchymal hemorrhage was found in 17 (8%) patients, CMB were found in 58 (27%) patients, mycotic aneurysms were found in 22 (10%) patients, and encephalopathy occurred in 16 (8%) patients. In multivariable models, vegetation size ≥15 mm was associated with a higher risk of infarcts (aOR 2.26, 95% CI (1.12-4.57)), and the presence of a mycotic aneurysm was a risk factor for intraparenchymal hemorrhage (aOR 18.79, 95% CI (3.97-88.97)). Prosthetic valves (aOR 2.89, 95% CI (1.11-7.54)) and Staphylococcus aureus infection (aOR 3.50, 95% CI (1.08-11.36)) were associated with CMB. No risk factors emerged as predictors of encephalopathy. CONCLUSIONS Large vegetation size is associated with stroke in patients with IE. Mycotic aneurysms are found at a higher frequency in young patients and are the primary cause of intraparenchymal hemorrhage. CMB may be related to prosthetic valves and Staphylococcus aureus infection.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, United States of America.
| | - Morgan McKeown
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, United States of America.
| | - Stephanie A Jordan
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, United States of America.
| | - Karen Li
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, United States of America.
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, United States of America.
| | - Steven K Feske
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, United States of America.
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10
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Philip J, Bond MC. Emergency Considerations of Infective Endocarditis. Emerg Med Clin North Am 2022; 40:793-808. [DOI: 10.1016/j.emc.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Das AS, Jordan SA, McKeown M, Li K, Dmytriw AA, Regenhardt RW, Feske SK. Screening neuroimaging in neurologically asymptomatic patients with infective endocarditis. J Neuroimaging 2022; 32:1001-1008. [PMID: 35726501 DOI: 10.1111/jon.13020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Neurological complications from infective endocarditis (IE) are common and often present with minimal clinical symptoms. In this study, we examine whether screening neuroimaging in asymptomatic patients results in increased detection of neurological complications and leads to improved patient outcomes. METHODS Using a database of consecutive adults with IE admitted to a single health system from 2015 to 2019, we selected patients who presented without any neurological symptoms and determined whether these patients underwent screening neuroimaging. The presence of septic emboli, territorial infarcts, intracranial hemorrhage, and mycotic aneurysms was recorded. Variables with significant differences in univariable analyses (p < .1) between those with and without screening neuroimaging were entered into regression models with age and sex to determine predictors of neurological complications and favorable discharge outcomes (modified Rankin score ≤2). RESULTS A total of 214 patients were included in the study, of which 154 (72%) received screening neuroimaging. Septic emboli were more common in patients who underwent screening imaging (31% vs. 15%, p = 0.02). In the first multivariate analysis, screening neuroimaging was associated with septic emboli (adjusted odds ratio [aOR] = 2.44, 95% confidence interval [CI]: [1.03-5.75], p = 0.04). In the second multivariate analysis, territorial infarcts (aOR = 0.28, 95% CI: [0.11-0.73], p = .01), but not septic emboli (aOR = 0.71, 95% CI: [0.36-1.43], p = 0.34), were associated with a favorable discharge outcome. CONCLUSIONS Screening neuroimaging leads to the detection of more septic emboli in IE, but only territorial infarcts (in contrast to septic emboli) correlate with an unfavorable discharge outcome.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie A Jordan
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Morgan McKeown
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Li
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven K Feske
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Impact of Brain MRI on the Diagnosis of Infective Endocarditis and Treatment Decisions: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2022; 218:958-968. [PMID: 35043667 DOI: 10.2214/ajr.21.26896] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Despite increasing use of brain MRI to evaluate patients with suspected infective endocarditis, the clinical impact of brain MRI in this setting has not yet been systematically reviewed. OBJECTIVE. The purpose of this study was to evaluate the frequency of brain MRI findings in patients with suspected or confirmed infective endocarditis and to determine the impact of such findings on clinical decisions. EVIDENCE ACQUISITION. A systematic search of the PubMed, Embase, and Cochrane databases was performed from January 1, 1990, to December 31, 2020, to identify original research investigations of brain MRI in patients with suspected or confirmed infective endocarditis. Study quality was assessed with QUADAS-2. Study endpoints included the frequency of brain MRI findings and the frequency of diagnostic modifications, modification of therapeutic plan, and modification of valve surgery plan resulting from MRI findings. Frequencies were pooled by means of the inverse variance method. Subgroup analysis was performed. EVIDENCE SYNTHESIS. A total of 21 studies with 2133 patients were included. Overall study quality was considered moderate. In terms of brain MRI findings, the pooled frequency of acute ischemic lesions was 61.9% (95% CI, 50.7-71.9%); of cerebral microbleeds, 52.9% (95% CI, 41.6-63.9%); hemorrhagic lesions, 24.7% (95% CI, 15.1-37.9%); abscess or meningitis, 9.5% (95% CI, 5.6-15.6%); and intracranial mycotic aneurysm, 6.2% (95% CI, 4.0-9.4%). Subgroup analysis after exclusion of three studies in which neurologic findings were the indication for all brain MRI examinations yielded similar frequencies of these findings. Six studies included results on the impact of brain MRI findings on clinical decisions. The frequencies of diagnostic modifications in two studies were 5.4% and 32.1%. The pooled frequency of therapeutic plan modification in six studies was 12.8% (95% CI, 6.5-23.7%) and of surgical plan modification in five studies was 14.2% (95% CI, 8.2-23.4%). CONCLUSION. In patients with suspected or confirmed infective endocarditis, brain MRI examinations commonly show relevant abnormalities that affect diagnostic and therapeutic clinical decisions. CLINICAL IMPACT. The findings support a potential role for screening brain MRI in the evaluation of patients with suspected or confirmed infective endocarditis, regardless of the presence or absence of neurologic symptoms.
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Small CN, Laurent D, Lucke-Wold B, Goutnik MA, Yue S, Chalouhi N, Koch M, Beaver TM, Martin TD, Hoh B, Arnaoutakis GJ, Polifka AJ. Timing surgery and hemorrhagic complications in endocarditis with concomitant cerebral complications. Clin Neurol Neurosurg 2022; 214:107171. [PMID: 35180644 DOI: 10.1016/j.clineuro.2022.107171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/06/2022] [Accepted: 02/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND To date, limited studies have been conducted regarding the safe timing of valvular repair for infectious endocarditis (IE) in patients with radiographic findings consistent with embolic stroke or infectious intracranial aneurysm (IIA). METHODS A single-center, retrospective review of valvular surgeries for IE was performed (2011-2019). Outcomes for patients who underwent cranial image screening and those who did not were subsequently compared. RESULTS 276 patients underwent valvular repair for IE; 186 (67.4%) were male. The mean age was 51.0 (17.4) years. Mean time from imaging to surgery was 7.5 days. 124 (44.9%) underwent baseline cranial imaging. Of these, 22 (17.7%) had findings concerning for ischemic stroke from embolic origin. 65 patients underwent baseline diagnostic cerebral angiography. 10 (15%) of these patients harbored an IIA. Four out of these 10 (40%) underwent intervention for an IIA. Two of the four who underwent intervention (50.0%) had ruptured IIAs. The remaining six (60%) patients with IIAs received treatment with antibiotics alone. None of the patients with IIAs suffered from symptomatic hemorrhage after valvular surgery. No significant difference in symptomatic hemorrhage after valvular surgery between those with ischemic embolic stroke compared to those without (ischemic stroke-4.5% vs. no ischemic stroke-1.0%; p = 0.32). CONCLUSIONS Patients with radiographic evidence of ischemic stroke from septic emboli can safely undergo valvular surgery for IE without increased risk of symptomatic hemorrhage. We advocate for baseline CTA screening to evaluate for IIA in patients who present with a primary diagnosis of IE and propose a management algorithm.
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Affiliation(s)
- Coulter N Small
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA.
| | - Dimitri Laurent
- Lillian S. Wells Department of Neurosurgery, University of Florida, 1505 SW Archer Road, Gainesville, FL 32608, USA
| | - Brandon Lucke-Wold
- Lillian S. Wells Department of Neurosurgery, University of Florida, 1505 SW Archer Road, Gainesville, FL 32608, USA
| | - Michael A Goutnik
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA
| | - Sijia Yue
- Department of Biostatistics, University of Florida, 2004 Mowry Road, Gainesville, FL 32603, USA
| | - Nohra Chalouhi
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, 1505 SW Archer Road, Gainesville, FL 32608, USA
| | - Matthew Koch
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, 1505 SW Archer Road, Gainesville, FL 32608, USA
| | - Thomas M Beaver
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Department of Surgery, Division of Cardiothoracic Surgery, 1600 SW Archer Road, Gainesville, FL 32608, USA
| | - Tomas D Martin
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Department of Surgery, Division of Cardiothoracic Surgery, 1600 SW Archer Road, Gainesville, FL 32608, USA
| | - Brian Hoh
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, 1505 SW Archer Road, Gainesville, FL 32608, USA
| | - George J Arnaoutakis
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Department of Surgery, Division of Cardiothoracic Surgery, 1600 SW Archer Road, Gainesville, FL 32608, USA
| | - Adam J Polifka
- College of Medicine, University of Florida, Office of Admissions, PO Box 100215, Gainesville, FL 32610, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, 1505 SW Archer Road, Gainesville, FL 32608, USA
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Funatsu T, Ishikawa T, Yamaguchi K, Eguchi S, Matsuoka G, Moriya K, Nakano H, Morita S, Shiwa T, Hori T, Kawamata T. Intracranial Mycotic Aneurysm after Left Ventricular Assist Device Implantation Treated with Trans-arterial Embolization via the Brachial Artery: A Case Report. NMC Case Rep J 2022; 8:433-438. [PMID: 35079500 PMCID: PMC8769479 DOI: 10.2176/nmccrj.cr.2020-0259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 01/04/2021] [Indexed: 11/20/2022] Open
Abstract
Implantation of left ventricular assist device (LVAD) is widely performed in patients with end-stage chronic heart failure. Infection and stroke are major complications after LVAD implantation. However, the incidence of intracranial mycotic aneurysm after LVAD implantation is rare, and with no standard of care. In this study, we describe a case of an intracranial mycotic aneurysm after LVAD implantation that was successfully treated with trans-arterial embolization (TAE) with N-butyl 2-cyanoacrylate (NBCA) via the brachial artery. A 49-year-old man with a history of implantation of LVAD for ischemic cardiomyopathy was admitted to our institution. He had infectious endocarditis and was administered systemic antibiotics. At 3 weeks after admission, intracranial mycotic aneurysm of the left posterior parietal artery was detected during a diagnostic examination for asymptomatic intracranial hemorrhage. Anticoagulant therapy was administered to prevent thromboembolic complications of LVAD implantation. Under local anesthesia, TAE with NBCA was performed via the brachial artery because of the tortuous anatomy of the origin of the innominate artery and implant of the aortic arch. The aneurysm was completely obliterated. The patient was discharged without neurological deficits. TAE using NBCA could be an effective modality for the treatment of intracranial mycotic aneurysm after LVAD implantation.
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Affiliation(s)
- Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Seiichiro Eguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Go Matsuoka
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Keisuke Moriya
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroshi Nakano
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shuhei Morita
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomoko Shiwa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahiro Hori
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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15
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Usefulness of contrast-enhanced 3D MR angiography and contrast-enhanced 3D T1 sequence for detecting intracranial infectious aneurysms in infectious endocarditis. Eur J Radiol 2021; 144:110008. [PMID: 34742109 DOI: 10.1016/j.ejrad.2021.110008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the diagnostic value of contrast-enhanced MRA (CE MRA) and CE 3D-T1 for identifying intracranial infectious aneurysms (IIAs) in infective endocarditis (IE) with digital substraction angiography (DSA) as reference. METHODS Twenty-one IE patients (14 males; mean age: 53 years) with 30 IIAs, diameter ranging 1.5-15 mm (<3mm, n = 14, 46.7%; 3-5 mm, n = 12,40%), underwent CE MRA and CE 3D-T1 at 1.5 T. Two readers evaluated images for aneurysm detection, characterization, quality of visualization. DSA was obtained at a median of 3 days (range 1-15) after MRI. RESULTS The sensitivity, specificity, positive and negative predictive values and accuracy of IIA detection were respectively: 80%, 100%, 100%, 82.3%, 90% for CE MRA and 86.7%, 100%, 100%, 88.2%, 93.3% for CE 3D T1 compared to DSA. No significant difference was observed between CE MRA and CE 3D-T1 for accuracy and quality of visualization. All IIAs of ≥3 mm in diameter (16/30; 53.%) were identified by both sequences, which were also able to detect IIAs ≤ 3 mm (n = 14/30, 46.7%). False negatives were observed with both sequences for 4 IIAs of <2 mm, 3 being compressed by hemorrhagic lesions. Two other IIAs of <2 mm were overlooked by CE MRA. CE 3D-T1 overestimated IIAs luminal diameter by 8% relatively to DSA (P = NS). Intra and inter-observer agreement were good and similar with both methods. CONCLUSION Both CE MRA and CE 3D-T1 have good accuracy compared to DSA detection and characterization of IIAs. CE 3D-T1 also evaluates anatomical relationships of IIAs, which could help DSA location and endovascular treatment.
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16
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Mitsui K, Oda R, Lee T, Watanabe K, Nakamura T, Miyazaki R, Terui M, Okata S, Nagase M, Nitta G, Nagamine S, Kaneko M, Hara N, Ogishima T, Takeguchi T, Nagata Y, Yoshizaki T, Nozato T, Ashikaga T. Multiple mycotic aneurysms with infective endocarditis: A case report. J Infect Chemother 2021; 27:1513-1516. [PMID: 34049794 DOI: 10.1016/j.jiac.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 11/24/2022]
Abstract
Mycotic aneurysms are sometimes seen in patients with infective endocarditis. We report a case of infective endocarditis with multiple mycotic aneurysms. Although antibiotics were effective, mycotic aneurysms appeared in the cerebral, hepatic, and gastroepiploic arteries. A 55-year-old man presented with mitral valve endocarditis due to Streptococcus oralis. Surgical treatment was deferred because of cerebral hemorrhage. After antibiotic initiation, his fever and C-reactive protein levels declined, and blood culture was negative. However, he experienced repeated cerebral hemorrhage and the number of cerebral mycotic aneurysms increased. Additionally, his spleen ruptured and the number of mycotic aneurysms in the hepatic and gastroepiploic arteries increased. After embolization for mycotic aneurysm and mitral valve replacement, no mycotic aneurysms appeared. Regardless of whether laboratory data improve or not, multiple mycotic aneurysms sometimes appear, and cardiac surgery for infection control should be considered in the early phase.
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Affiliation(s)
- Kentaro Mitsui
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan.
| | - Rentaro Oda
- Division of Infectious Diseases, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu City, Chiba, 279-0001, Japan
| | - Tetsumin Lee
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Keita Watanabe
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Tomofumi Nakamura
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Ryoichi Miyazaki
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Mao Terui
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Shinichiro Okata
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Masashi Nagase
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Giichi Nitta
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Sho Nagamine
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Masakazu Kaneko
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Nobuhiro Hara
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Takahiro Ogishima
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Takaya Takeguchi
- Department of Radiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Yasutoshi Nagata
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Tomoya Yoshizaki
- Department of Cardiovascular Surgery, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Toshihiro Nozato
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
| | - Takashi Ashikaga
- Department of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino City, Tokyo, 180-8610, Japan
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Khan F, Sharma N, Ud Din M, Shirke S, Abbas S. Convexal Subarachnoid Hemorrhage Caused by Infective Endocarditis in a Patient with Advanced Human Immunodeficiency Virus (HIV): The Culprits and Bystanders. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931376. [PMID: 33986239 PMCID: PMC8130978 DOI: 10.12659/ajcr.931376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Convexal subarachnoid hemorrhage (cSAH), a rare form of non-aneurysmal subarachnoid hemorrhage, is confined to cerebral convexities without extension into basal cisterns or ventricles. Typical presentation includes thunderclap/progressive headache or transient focal neurological symptoms; rare manifestations include seizures, intractable vomiting, or altered mental status. Here, we report the first case of convexal subarachnoid hemorrhage and multifocal ischemic lesions caused by infective endocarditis (IE) in a treatment-naïve advanced HIV patient. CASE REPORT A 52-year-old HAART-naïve, HIV-positive, African American man presented with altered mental status, shortness of breath, nonproductive cough, and generalized weakness. His past medical history was significant for congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease (noncompliant with hemodialysis). Head computed tomography (CT) showed an isolated sulcal hemorrhage in the mid-left frontal lobe. Fluid-attenuated inversion recovery/gradient recalled echo sequences confirmed a hemorrhage in the left-mid-frontal sulcus, and diffusion-weighted imaging revealed multifocal bilateral ischemic lesions. Transesophageal echocardiography exhibited mitral valve vegetations. Multifocal ischemic lesions and cSAH caused by infectious endocarditis were confirmed. Initiation of intravenous vancomycin and piperacillin-tazobactam allowed the patient to have resolution of his altered mental status. A head CT 5 days later revealed the resolution of cSAH. CONCLUSIONS Infective endocarditis should be considered as an underlying etiology of cSAH, especially when present with multifocal ischemic lesions. Risk factors contributing to the development of cSAH in the IE patient population should be explored in future studies. HIV has not been previously reported in this subgroup and its prevalence should be considered. The prognosis for cSAH in relation to IE is generally favorable.
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Affiliation(s)
- Faisal Khan
- Department of Neurology, Sam Houston State University College of Osteopathic Medicine, Huntsville, TX, USA
| | - Neha Sharma
- Houston Medical Clerkship, Sugar Land, TX, USA
| | - Moin Ud Din
- Houston Medical Clerkship, Sugar Land, TX, USA
| | - Saloni Shirke
- Caribbean Medical University School of Medicine, Willemstad, Curacao, Netherlands Antilles
| | - Saima Abbas
- Department of Infectious Disease, Rockledge Regional Medical Center, Rockledge, FL, USA
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18
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Rice CJ, Kovi S, Wisco DR. Cerebrovascular Complication and Valve Surgery in Infective Endocarditis. Semin Neurol 2021; 41:437-446. [PMID: 33851397 DOI: 10.1055/s-0041-1726327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infective endocarditis (IE) with neurologic complications is common in patients with active IE. The most common and feared neurological complication of left-sided IE is cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage (ICH), or an infectious intracranial aneurysm with or without rupture. In patients with cerebrovascular complications, valve replacement surgery is often delayed for concern of further neurological worsening. However, in circumstances when an indication for valve surgery to treat IE is present, the benefits of early surgical treatment may outweigh the potential neurologic deterioration. Furthermore, valve surgery has been associated with lower in-hospital mortality than medical therapy with intravenous antibiotics alone. Early valve surgery can be performed within 7 days of transient ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains challenging, and current data in the literature are conflicting about the risks and benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often recommended, balancing the risks and benefits of surgery. The range of timing of valve surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary decision between cardiothoracic surgeons, cardiologists, infectious disease experts, and vascular neurologists in an experienced referral center.
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Affiliation(s)
- Cory J Rice
- Erlanger Medical Center, University of Tennessee-Chattanooga College of Medicine, Chattanooga, Tennessee
| | - Shivakrishna Kovi
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dolora R Wisco
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Sudhir BJ, Honavalli Murali S, Gohil J, Poyuran R, Sethuraman M, Harihara Venkat E. Cyanosis and Clipping: Noninfectious Aneurysm in a Patient with 22q11.2 Deletion Syndrome. Pediatr Neurosurg 2021; 56:45-49. [PMID: 33550290 DOI: 10.1159/000512581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022]
Abstract
Noninfectious cerebral aneurysms are rare in patients with congenital cyanotic heart disease. We present a patient with DiGeorge/velocardiofacial syndrome with a complex congenital cyanotic heart disease with a ruptured anterior communicating artery aneurysm. The 10-year-old child was managed by surgical clipping of the aneurysm. Surgical challenges included prominent veins in the Sylvian fissure, difficulty in differentiating arterial and venous bleed, and anesthetic risks. The patient recovered without any neurological deficits. This is the first report of a patient with 22q11.2 deletion syndrome, with a noninfectious cerebral aneurysm.
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Affiliation(s)
- Bhanu Jayanand Sudhir
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India,
| | - Sanjay Honavalli Murali
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Jaypalsinh Gohil
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Rajalakshmi Poyuran
- Department of Neuro-Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Manikantan Sethuraman
- Department of Neuro-Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Easwer Harihara Venkat
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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20
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Benedetto U, Spadaccio C, Gentile F, Moon MR, Nappi F. A narrative review of early surgery versus conventional treatment for infective endocarditis: do we have an answer? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1626. [PMID: 33437825 PMCID: PMC7791236 DOI: 10.21037/atm-20-3880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The most appropriate strategy and timing for surgery in infective endocarditis (IE) remains an argument of debate. Despite some authors promote the adoption of an early surgical approach (within 48 hours) to limit mortality and complications, no robust randomized trials are available on this argument and the evidence on this subject remain at the "expert opinion" level. Additionally, the different messages promulgated by the American and European guidelines contributed to fuel confusion regarding the relative priority of the surgical over medical therapy in IE. The European Society of Cardiology (ESC) guidelines individuates three level of urgency: emergency surgery, to be performed within 24 hours; urgent surgery, recommended within a few days; elective surgery to be performed after 1-2 weeks of antibiotic therapy. Urgent surgery is recommended for most cases of IE. In the American Heart Association (AHA)'s guidelines define early surgery as "during the initial hospitalization and before completion of a full course of antibiotics." Some of the available evidences showed that are no proven benefits in delaying surgery if a definite diagnosis of IE has been established. However, this argument is controversial across the literature and several factors including the center specific experience can play a role in decision-making. In this review the latest evidences on IE clinical and surgical characteristics along with the current studies on the adoption of an early surgical approach are analyzed to clarify whether enough evidence is available to inform an update of the guidelines.
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Affiliation(s)
- Umberto Benedetto
- Department of Cardiothoracic Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Cristiano Spadaccio
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | | | - Marc R Moon
- Department of Cardiac Thoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
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Diagnostic Utility of CT and MRI for Mycotic Aneurysms: A Meta-Analysis. AJR Am J Roentgenol 2020; 215:1257-1266. [DOI: 10.2214/ajr.19.22722] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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22
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Brown P, Fulks D. An unusual ischaemic presentation of thrombosed intracranial mycotic aneurysm with subsequent subarachnoid haemorrhage. BMJ Case Rep 2020; 13:e237044. [PMID: 33040039 PMCID: PMC7552799 DOI: 10.1136/bcr-2020-237044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 11/03/2022] Open
Abstract
We present an unusual case of acute ischaemic stroke secondary to thrombosed mycotic aneurysm with subsequent early aneurysmal rupture and subarachnoid haemorrhage, successfully treated with endovascular coil embolisation of the thrombosed segment. Imaging correlates are presented demonstrating successful endovascular management despite vessel occlusion precluding angiographic visualisation of the aneurysmal segment. Imaging and clinical follow-up is provided demonstrating durable occlusion and excellent clinical outcome with full functional recovery.
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Affiliation(s)
- Patrick Brown
- Radiology and Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Daniel Fulks
- Radiology, The University of Tennessee Medical Center, Knoxville, Tennessee, USA
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23
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Boukobza M, Ilic-Habensus E, Duval X, Laissy JP. Acute convexity subarachnoid hemorrhage (cSAH) in infectious endocarditis (IE): imaging features and follow-up. J Neurol 2020; 267:2971-2982. [PMID: 32494850 DOI: 10.1007/s00415-020-09953-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022]
Abstract
AIM To assess: (1) the prevalence of convexity subarachnoid hemorrhage (cSAH) in infective endocarditis (IE); (2) its relationship with IE features; (3) the associated lesions; (4) whether cSAH is a predictor of future hemorrhage; (5) whether cSAH could cause cortical superficial siderosis (cSS). METHODS We retrospectively evaluated the MRI data in 240 IE-patients: At baseline, the location of cSAH and associated lesions; at follow-up, the occurrence of new lesions and of cSS. Patients with and without cSAH were compared. RESULTS There were 21 cSAH-IE patients without (Group 1a) and 10 with intracranial infectious aneurysms (IIAs) (Group 1b). cSAH was revealed by headache (16.1%), confusion (9.7%), acute meningeal syndrome (3.2%) and was incidental in 71%. In most cases, the cSAH was: in the frontal (61.3%) and the parietal lobe (16.1%), unifocal, and mainly localized within a single sulcus (80.7%), appearing as a thick intrasulcal dark line on T2* in 70% of IIA patients. Valvular vegetations (87.1%, p < 0.0001), vegetations length ≥ 15 mm (58.1%, p < 0.0001) and mitral valve involvement (61.3%; p = 0.05) were significantly associated. There was no significant difference between the two groups in terms of pathogen distribution, valve characteristics and clinical expression. Associated lesions were: CMBs (77.4%), DWILs (51.6%), brain hemorrhages (16.1%) brain micro-abscesses (3.2%) meningitis (3.2%), visceral emboli (45.2%). At follow-up: no SAH recurrence or neurological event. cSS disappeared in 7/12 cases. CONCLUSION cSAH in IE is mostly an incidental finding but may be the telltale sign of an IIA. cSAH is not a marker of poor prognosis in non-IIA patients.
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Affiliation(s)
- Monique Boukobza
- Department of Radiology, Bichat Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Emila Ilic-Habensus
- Center of Clinical Investigations, Bichat Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Xavier Duval
- Center of Clinical Investigations, Inserm 1425, Bichat Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris-Diderot University, Inserm U1137, Paris, France
| | - Jean-Pierre Laissy
- Department of Radiology, Bichat Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris-Diderot University, Inserm U1148, Paris, France
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24
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Fisher B, Seese L, Mathier MA, Sultan I, Kilic A. Ruptured cerebral mycotic aneurysm in a left ventricular assist device patient with bacteremia. Int J Artif Organs 2020; 44:65-67. [PMID: 32475219 DOI: 10.1177/0391398820925493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 50-year-old male with a history of nonischemic dilated cardiomyopathy presented in cardiogenic shock and ultimately underwent durable left ventricular assist device implantation. He recovered well initially but developed persistent bacteremia. His indwelling pacemaker leads were extracted due to evidence of vegetation. Shortly thereafter, around 3 months post-left ventricular assist device, he succumbed to a massive intracranial hemorrhage due to ruptured cerebral mycotic aneurysm. This case highlights the potential importance of brain imaging in left ventricular assist device patients with persistent bacteremia to avoid this likely catastrophic complication.
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Affiliation(s)
- Bryant Fisher
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael A Mathier
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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25
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Caton MT, Wiggins WF, Nunez D. The “connecting vessel” sign: an imaging biomarker to differentiate ruptured infected (mycotic) intracranial aneurysm mimicking the CTA spot sign. Emerg Radiol 2020; 27:259-268. [DOI: 10.1007/s10140-020-01749-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
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26
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Wang X, Chen G, Li M, Liang J, Guo H, Song G, Bao Y. Rapid formation and rupture of an infectious basilar artery aneurysm from meningitis following suprasellar region meningioma removal: a case report. BMC Neurol 2020; 20:94. [PMID: 32171270 PMCID: PMC7071631 DOI: 10.1186/s12883-020-01673-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/03/2020] [Indexed: 12/05/2022] Open
Abstract
Background Infectious basilar artery (BA) aneurysm has been occasionally reported to be generated from meningitis following transcranial operation. However, infectious BA aneurysm formed by intracranial infection after endoscopic endonasal operation has never been reported. Case presentation A 53-year-old man who was diagnosed with suprasellar region meningioma received tumor removal via endoscopic endonasal approach. After operation he developed cerebrospinal fluid (CSF) leak and intracranial infection. The patient ultimately recovered from infection after anti-infective therapy, but a large fusiform BA aneurysm was still formed and ruptured in a short time. Interventional and surgical measures were impossible due to the complicated shape and location of aneurysm and state of his endangerment, therefore, conservative anti-infective therapy was adopted as the only feasible method. Unfortunately, the aneurysm did not disappear and the patient finally died from repeating subarachnoid hemorrhage (SAH). Conclusion Though extremely rare, it was emphasized that infectious aneurysm can be formed at any stage after transnasal surgery, even when the meningitis is cured. Because of the treatment difficulty and poor prognosis, it was recommended that thorough examination should be timely performed for suspicious patient to make correct diagnosis and avoid fatal SAH.
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Affiliation(s)
- Xu Wang
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Ge Chen
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Mingchu Li
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Jiantao Liang
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Hongchuan Guo
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Gang Song
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Yuhai Bao
- Department of Skull Base Surgery Center, Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.
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27
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Abstract
The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke-Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke-Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.
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28
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Barry O, Wang Y, Wahl G. Determination of baseline alveolar mucosa perfusion parameters using laser Doppler flowmetry and tissue spectrophotometry in healthy adults. Acta Odontol Scand 2020; 78:31-37. [PMID: 31349769 DOI: 10.1080/00016357.2019.1645353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: To determine the baseline perfusion parameters of the alveolar mucosa using laser Doppler flowmetry and tissue spectrophotometry (LDF-TS) in healthy adults.Material and methods: Forty-two healthy adult subjects of either sex were tested. The perfusion of the alveolar mucosa was evaluated using a laser Doppler flowmetry and tissue spectrophotometry using O2C 'oxygen to see' device. The measurements encompassed the maxillary and mandibular mucosa at 20 different points.Results: The O2C device is a reliable method for noninvasive measurement of different perfusion parameters of the oral mucosa. The hemoglobin saturation values (So2 in %), as well as relative amount of hemoglobin in arbitrary units (AU) of the maxillary mucosa demonstrated lower values of that in the mandible. The flow value (AU) exhibited a significant difference in the posterior molar region only, while the velocity value (AU) showed a significant difference across all points except for the anterior region.Conclusion: the present study provides a set of brand-new perfusion parameters of the microcirculation of the alveolar mucosa using LDF-TS. The study suggests a variation of the perfusion parameters between the maxilla and the mandible. Differences in the anatomy of the blood supply, the thickness of the mucosa and the cortical bone, may be attributed to this variation. Further studies using different probes and a combination of ultrasonic measurements and SDF imaging will aid in giving a better overview of the perfusion in the oral mucosa.
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Affiliation(s)
- Obada Barry
- Department of Oral Surgery, Bonn University Dental Clinic, Bonn, Germany
| | - Ying Wang
- Department of Oral Surgery, Bonn University Dental Clinic, Bonn, Germany
| | - Gerhard Wahl
- Department of Oral Surgery, Bonn University Dental Clinic, Bonn, Germany
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29
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Ando K, Hasegawa H, Kikuchi B, Saito S, On J, Shibuya K, Fujii Y. Treatment Strategies for Infectious Intracranial Aneurysms: Report of Three Cases and Review of the Literature. Neurol Med Chir (Tokyo) 2019; 59:344-350. [PMID: 31270285 PMCID: PMC6753255 DOI: 10.2176/nmc.oa.2019-0051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We retrospectively reviewed the cases of three patients with infectious intracranial aneurysms (IIAs), and discuss the indications for surgical and endovascular treatments. We treated two men and one woman with a total of six aneurysms. The mean age was 43.3 years, ranging from 36 to 51 years. One patient presented initially with an intraparenchymal hemorrhage, one with mass effect, and the other one had four aneurysms (one causing subarachnoid hemorrhages and the other causing delayed intraparenchymal hemorrhages). The average size of all aneurysms was 12.2 mm (range, 2–50 mm). They were preferentially located in the distal posterior cerebral artery, and then, in the middle cerebral artery. All cases were caused by infective endocarditis. We selected endovascular treatments for five aneurysms and treated all but one within 24 h from detection. One aneurysm was treated by combined therapy with endovascular intervention and surgery. After treatment, none of the IIAs presented angiographical recurrence or re-bleeding. If feasible, endovascular treatment is probably the first choice, but a combined surgical and endovascular approach should be considered if surgery or endovascular treatment alone are not feasible. The method of treatment should be individualized. For cases with high risk of aneurysm rupture, treatment should be performed as soon as possible.
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Affiliation(s)
- Kazuhiro Ando
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Hitoshi Hasegawa
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Bumpei Kikuchi
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Shoji Saito
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Jotaro On
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Kohei Shibuya
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Yukihiko Fujii
- Department of Neurosurgery, Brain Research Institute, Niigata University
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30
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Acute Development and Rupture of a Basilar Tip Mycotic Aneurysm. World Neurosurg 2019; 124:373-377. [PMID: 30660878 DOI: 10.1016/j.wneu.2018.12.211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 12/26/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Infectious intracranial aneurysms are rare but encountered when associated with rupture or detected on screening of high-risk patients. The time course of the development of these aneurysms is unknown. Ultimately, the data published on mycotic aneurysms are in the form of case series, retrospective studies, with one recent systematic review, all of which have difficulty defining specifics regarding aneurysmal formation in these patients. We present a case that may help define the time frame of mycotic aneurysm growth. CASE DESCRIPTION A patient with endocarditis, first identified to have a distal middle cerebral artery aneurysm treated with Onyx embolization, and an otherwise-unremarkable cerebral angiogram experienced significant subarachnoid hemorrhage 5 days later. Within that short time frame on appropriate antibiotic therapy, she developed and ruptured a basilar tip aneurysm, which was subsequently treated with coil embolization. CONCLSUSIONS The time course of infectious intracranial aneurysm development is not known and difficult to define. This case illustrates an example of the development of a new infectious intracranial aneurysm and subsequent rupture over the course of 5 days, showing that these types of aneurysms and subsequent neurologic sequelae can happen acutely.
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31
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Sotero FD, Rosário M, Fonseca AC, Ferro JM. Neurological Complications of Infective Endocarditis. Curr Neurol Neurosci Rep 2019; 19:23. [PMID: 30927133 DOI: 10.1007/s11910-019-0935-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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.
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Affiliation(s)
- Filipa Dourado Sotero
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Madalena Rosário
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.,Faculdade de Medicina, Hospital de Santa Maria, Universidade de Lisboa, Neurology 6th floor, Avenida Professor Egas Moniz s/n, 1649-035, Lisbon, Portugal
| | - José M Ferro
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal. .,Faculdade de Medicina, Hospital de Santa Maria, Universidade de Lisboa, Neurology 6th floor, Avenida Professor Egas Moniz s/n, 1649-035, Lisbon, Portugal.
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32
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Boissonneau S, Graillon T, Meyer M, Brunel H, Fuentes S, Dufour H. Intracranial Giant Mycotic Aneurysm without Endocarditis and Vasculitis: Report of Rare Entity and Review of Literature. World Neurosurg 2018; 119:353-357. [PMID: 30144607 DOI: 10.1016/j.wneu.2018.08.086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/12/2018] [Accepted: 08/13/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Infectious aneurysm is a rare complication in intracranial aneurysm. Moreover, giant aneurysm is a rare entity in intracranial aneurysm. In the great majority of infectious intracranial aneurysms, vasculitis and/or endocarditis is associated. CASE DESCRIPTION Here, we report the case of an 83-year-old man who developed a giant infectious intracranial aneurysm on the anterior communicating artery. This patient had never shown any intracranial bleeding. A surgery was performed, and purulent liquid and aneurysm wall were removed during procedure. The bacteriologic analyses reported Campylobacter fetus. CONCLUSIONS This bacterium seems to be more and more frequent in North America and Europe, according to the current literature. Moreover, cases of mycotic extracranial aneurysm were reported. Here we report the first case of intracranial giant infectious aneurysm in an adult patient, without any endocarditis or vasculitis. This new entity could be the cause of a bacterial graft on an asymptomatic giant preexisting intracranial aneurysm or a consequence of campylobacteriosis.
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Affiliation(s)
| | - Thomas Graillon
- APHM, CHU Timone, Department of Neurosurgery, Marseille, France; Aix Marseille University, APHM, CNRS, CRN2M, Marseille, France
| | - Mikael Meyer
- APHM, CHU Timone, Department of Neurosurgery, Marseille, France
| | - Herve Brunel
- Neuroradiology Service, CHU Timone, Marseille, France
| | | | - Henry Dufour
- APHM, CHU Timone, Department of Neurosurgery, Marseille, France; Aix Marseille University, APHM, CNRS, CRN2M, Marseille, France
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33
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Cho SM, Marquardt RJ, Rice CJ, Buletko AB, Zhang LQ, Khoury J, Thatikunta P, Hardman J, Wisco D, Uchino K. Cerebral microbleeds predict infectious intracranial aneurysm in infective endocarditis. Eur J Neurol 2018; 25:970-975. [PMID: 29603515 DOI: 10.1111/ene.13641] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Magnetic resonance imaging (MRI) features such as cerebral microbleeds and sulcal susceptibility-weighted imaging (SWI) or gradient-echo T2* lesions in infective endocarditis (IE) have been associated with the presence of infectious intracranial aneurysm (IIA). Our aim was to validate these MRI predictors for IIA in order to better assist in assessing the appropriate indications for digital subtraction angiography (DSA). METHODS The derivation cohort comprised IE patients with neurological evaluation, MRI and DSA at a single tertiary referral center from January 2015 to July 2016. Validation was performed in a cohort of IE patients who underwent MRI and DSA at the same center from 2010 to 2014. RESULTS Of 62 patients in the derivation cohort, 10 (16%) had IIAs. Of 129 in the validation cohort, 19 (15%) IIAs were identified. The MRI predictors for IIA consist of (i) contrast enhancement with microbleeds, (ii) cerebral microbleeds >5 mm or sulcal SWI lesions and (iii) any MRI hemorrhages. The sensitivity for the presence of IIA in each group of the derivation cohort was 90%, 80% and 100%, respectively. The sensitivity in the validation cohort was 47%, 68% and 94% respectively. The specificity in the derivation cohort was 87%, 85% and 18%. In the validation cohort, the specificity was similar at 87%, 75% and 27%. CONCLUSIONS The absence of MRI hemorrhages may not necessitate the need for DSA.
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Affiliation(s)
- S-M Cho
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.,Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R J Marquardt
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - C J Rice
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A B Buletko
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - L Q Zhang
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Khoury
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - P Thatikunta
- Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - J Hardman
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - D Wisco
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - K Uchino
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
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34
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Ko H, Kim G, Lee HD, Choi KH, Sung SC. Ruptured intracranial aneurysm in an adolescent with infective endocarditis. Pediatr Int 2018; 60:376-377. [PMID: 29573363 DOI: 10.1111/ped.13513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/05/2017] [Accepted: 12/20/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Hoon Ko
- Department of Pediatric Cardiology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam, Korea
| | - Geena Kim
- Department of Pediatric Cardiology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam, Korea
| | - Hyoung Doo Lee
- Department of Pediatric Cardiology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam, Korea
| | - Kwang Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam, Korea
| | - Si Chan Sung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam, Korea
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35
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Alawieh A, Chaudry MI, Turner RD, Turk AS, Spiotta AM. Infectious intracranial aneurysms: a systematic review of epidemiology, management, and outcomes. J Neurointerv Surg 2018; 10:708-716. [DOI: 10.1136/neurintsurg-2017-013603] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 12/27/2022]
Abstract
Infectious intracranial aneurysms (IIAs) are a rare cerebrovascular complication of systemic infections induced by microbial infiltration and degradation of the arterial vessel wall. Studies on the epidemiology and management of IIAs are limited to case reports and retrospective single-center studies, and report a large variability in epidemiological features, management, and outcomes due to the limited sample size. We conducted a systematic review of all published papers on IIAs in the English literature using MEDLINE and SCOPUS database from January 1950 to June 2017. A total of 288 publications describing 1191 patients with IIA (1398 aneurysms) were included and reviewed for epidemiological features, disease features, treatment and outcome. All patients were merged into a single cohort and summary data are presented. The majority of reported IIAs are distally located, relatively small (<5 mm), involve the anterior circulation, are associated with a relatively high rate of rupture, and demonstrate a propensity to multiplicity of aneurysms. Sensitive diagnosis of IIAs requires digital subtraction angiography and not CT angiography or MR angiography. Treatment of ruptured, symptomatic, or enlarging IIAs has evolved over the last 50 years. Endovascular therapy is associated with a high success rate and low morbidity compared with microsurgical and medical management. A treatment algorithm for the management of patients with IIA in various contexts is proposed and the need for prospective multicenter studies is emphasized.
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36
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Initial Treatment Strategy for Intracranial Mycotic Aneurysms: 2 Case Reports and Literature Review. World Neurosurg 2017; 106:1051.e9-1051.e16. [DOI: 10.1016/j.wneu.2017.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/19/2022]
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37
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Cantier M, Mazighi M, Klein I, Desilles JP, Wolff M, Timsit JF, Sonneville R. Neurologic Complications of Infective Endocarditis: Recent Findings. Curr Infect Dis Rep 2017; 19:41. [PMID: 28929294 DOI: 10.1007/s11908-017-0593-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to provide recent insights in management of neurologic complications of left-sided infective endocarditis (IE). RECENT FINDINGS Cerebral lesions observed in IE patients are thought to involve synergistic pathophysiological mechanisms including thromboembolism, sepsis, meningitis, and small-vessel cerebral vasculitis. Brain MRI represents a major tool for the detection of asymptomatic events occurring in the majority of patients. The latter can impact therapeutic decisions and prognosis, especially when cardiac surgery is indicated. In patients presenting with neurologic complications, surgery could be safely performed earlier than previously thought. Symptomatic cerebral ischemic or hemorrhagic events occur in 20-55% of IE patients, whereas asymptomatic events are detected in 60-80% of patients undergoing systematic brain MRI. Management of such patients requires an experienced multidisciplinary team. Recent studies suggest that early cardiac surgery, when indicated, can be performed safely in patients with cerebral ischemic events. Other important issues include the appropriate use of anti-infective and anti-thrombotic agents, and endovascular treatment for mycotic aneurysms. Altered mental status at IE onset, which is associated with brain injury, is a major determinant of short-term outcome.
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Affiliation(s)
- Marie Cantier
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France. .,INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
| | - Mikael Mazighi
- INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Department of Neurology, Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Isabelle Klein
- Imaging Department, Clinique Alleray Labrouste, Paris, France
| | - J P Desilles
- INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Michel Wolff
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - J F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Romain Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France. .,INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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Cho SM, Rice C, Marquardt RJ, Zhang LQ, Khoury J, Thatikunta P, Buletko AB, Hardman J, Uchino K, Wisco D. Magnetic Resonance Imaging Susceptibility-Weighted Imaging Lesion and Contrast Enhancement May Represent Infectious Intracranial Aneurysm in Infective Endocarditis. Cerebrovasc Dis 2017; 44:210-216. [DOI: 10.1159/000479706] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/21/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Infectious intracranial aneurysm (IIA) can complicate infective endocarditis (IE). We aimed to describe the magnetic resonance imaging (MRI) characteristics of IIA. Methods: We reviewed IIAs among 116 consecutive patients with active IE by conducting a neurological evaluation at a single tertiary referral center from January 2015 to July 2016. MRIs and digital cerebral angiograms (DSA) were reviewed to identify MRI characteristics of IIAs. MRI susceptibility weighted imaging (SWI) was performed to collect data on cerebral microbleeds (CMBs) and sulcal SWI lesions. Results: Out of 116 persons, 74 (63.8%) underwent DSA. IIAs were identified in 13 (17.6% of DSA, 11.2% of entire cohort) and 10 patients with aneurysms underwent MRI with SWI sequence. Nine (90%) out of 10 persons with IIAs had CMB >5 mm or sulcal lesions in SWI (9 in sulci, 6 in parenchyma, and 5 in both). Five out of 8 persons who underwent MRI brain with contrast had enhancement within the SWI lesions. In a multivariate logistic regression analysis, both sulcal SWI lesions (p < 0.001, OR 69, 95% CI 7.8-610) and contrast enhancement (p = 0.007, OR 16.5, 95% CI 2.3-121) were found to be significant predictors of the presence of IIAs. Conclusions: In the individuals with IE who underwent DSA and MRI, we found that neuroimaging characteristics, such as sulcal SWI lesion with or without contrast enhancement, are associated with the presence of IIA
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Yuan SM, Wang GF. Cerebral mycotic aneurysm as a consequence of infective endocarditis: A literature review. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW This review analyzes recent studies evaluating the diagnostic and therapeutic impacts of systematic extracardiac imaging techniques in patients with suspected or proven infective endocarditis. RECENT FINDINGS Extracardiac imaging techniques are more and more frequently used to establish infective endocarditis (IE) diagnosis in doubtful situations. They also help in evaluating the risk-benefit balance of therapeutic strategies and particularly valvular surgery which is performed in approximately 50% of patients. Latest research underlines the high frequency of asymptomatic lesions found, and a different advantage-disadvantage profile for each of these techniques. Extracardiac imaging techniques are helpful in doubtful situations and may be considered in other situations. Their interest for improving patients' prognosis remains to be established.
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Pettersson GB, Coselli JS, Pettersson GB, Coselli JS, Hussain ST, Griffin B, Blackstone EH, Gordon SM, LeMaire SA, Woc-Colburn LE. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary. J Thorac Cardiovasc Surg 2017; 153:1241-1258.e29. [PMID: 28365016 DOI: 10.1016/j.jtcvs.2016.09.093] [Citation(s) in RCA: 254] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 09/12/2016] [Accepted: 09/16/2016] [Indexed: 12/23/2022]
Affiliation(s)
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex
| | | | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex
| | - Syed T Hussain
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Gordon
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex
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Cheng-Ching E, John S, Bain M, Toth G, Masaryk T, Hui F, Hussain MS. Endovascular Embolization of Intracranial Infectious Aneurysms in Patients Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate. INTERVENTIONAL NEUROLOGY 2017; 6:82-89. [PMID: 28611838 DOI: 10.1159/000455806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. METHODS Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. RESULTS Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. CONCLUSIONS Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.
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Affiliation(s)
- Esteban Cheng-Ching
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Seby John
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Bain
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Masaryk
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ferdinand Hui
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Treatment Strategy Based on Experience of Treating Intracranial Infectious Aneurysms. World Neurosurg 2017; 97:351-359. [DOI: 10.1016/j.wneu.2016.09.119] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 09/25/2016] [Accepted: 09/29/2016] [Indexed: 12/26/2022]
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Hamisch CA, Mpotsaris A, Timmer M, Reiner M, Stavrinou P, Brinker G, Goldbrunner R, Krischek B. Interdisciplinary Treatment of Intracranial Infectious Aneurysms. Cerebrovasc Dis 2016; 42:493-505. [PMID: 27598469 DOI: 10.1159/000448406] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/11/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Intracranial infectious aneurysms (IIAs) are a rare clinical entity without a definitive treatment guideline. In this study, we evaluate the treatment options of these lesions based on our own clinical experience and review the current knowledge of therapy as portrayed in the literature. METHODS We conducted a single-center retrospective analysis of all patients with an IIA and performed a systematic review of the literature using the MEDLINE database. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-October 2015) using the following keywords (in combination): 'infectious', 'mycotic', 'cerebral aneurysm', 'intracranial aneurysm'. 1,721 potentially relevant abstracts were identified and 63 studies were selected for full review. The studies were analysed regarding ruptured versus unruptured aneurysms, aneurysm localization and treatment, as well as clinical and radiological outcome. RESULTS Our institutional series consisted of 6 patients (median age 57 [32-76]) treated between 2011 and 2015. All patients presented with ruptured IIAs located on the middle cerebral artery (MCA, 5 patients) and anterior cerebral artery (ACA, 1 patient). Five patients were treated by clipping and resecting the aneurysm, 1 patient underwent coiling. All patients received antibiotic therapy and 1 patient died. We further identified 814 patients (median age 35.5 [0-81]) in 63 studies. Locations of the aneurysms were mentioned in 55 studies. The most frequent locations of the aneurysms were: MCA (63.5%), posterior cerebral artery (14%), ACA (9.0%) and others (13.5%). Treatment for IIAs was described in 62 studies: antibiotic treatment (56.1%), a combination of antibiotics and surgery (20.9%) or antibiotics and endovascular treatment (23.0%). Outcome was mentioned in 82.4% of the patients with a mortality rate of 16.8%. An evaluation of treatment outcome was limited due to the heterogeneity of patients in the published case series. CONCLUSION Antibiotic therapy of patients with IIA is mandatory. However, due to the complexity of the disease and its accompanying comorbidities, a general treatment algorithm could not be defined. Analogous to non-mycotic aneurysms, further treatment decisions require an interdisciplinary approach involving neurosurgeons, interventionists and infectious disease specialists.
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Affiliation(s)
- Christina A Hamisch
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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Walkoff L, Brinjikji W, Rouchaud A, Caroff J, Kallmes DF. Comparing magnetic resonance angiography (MRA) and computed tomography angiography (CTA) with conventional angiography in the detection of distal territory cerebral mycotic and oncotic aneurysms. Interv Neuroradiol 2016; 22:524-8. [PMID: 27298009 DOI: 10.1177/1591019916653247] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 04/09/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Mycotic and oncotic aneurysms may result in devastating neurologic sequelae if undetected. The objectives of this study were to examine interobserver variability and accuracy of cross-sectional imaging for the detection of distal territory mycotic and oncotic aneurysms. METHODS We searched our institutional database for all radiology reports from 2005 to 2015 with an indication or diagnosis of mycotic or oncotic aneurysm. Patients who underwent DSA and either CTA or MRA within 12 weeks of each other were identified. The cross-sectional images from each study were blinded and reviewed by two radiologists. If positive for aneurysm, location and number of aneurysms were reported. Sensitivity, specificity, positive predictive value, negative predictive value, and interobserver variability were determined for MRA and MRA/CTA. RESULTS Twenty-five patients were included in this study. Ten (40%) harbored distal aneurysms. Cross-sectional imaging had a sensitivity of 45.5%, specificity of 90.0%, and kappa value of 0.29 (0.00-0.69) for the detection of cerebral mycotic and oncotic aneurysms. CONCLUSIONS Because of the low sensitivity and high interobserver variability of cross-sectional imaging, DSA should remain the gold standard for evaluation of suspected oncotic and mycotic aneurysms. In cases in which cross sectional imaging is negative and there is a high clinical suspicion for mycotic aneurysm, DSA should be strongly considered.
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Affiliation(s)
| | | | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, Hôpital Bicêtre, APHP, Paris Sud Université, France
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Jamil O, Taussky P, Schmidt RH, Park MS. Fulminant Vasculitis Associated with Extracranial Dissections and Occlusion, Ischemic Strokes, and Aneurysm Rupture: Case Report and Review of the Literature. World Neurosurg 2016; 91:674.e7-674.e11. [PMID: 27113401 DOI: 10.1016/j.wneu.2016.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/13/2016] [Accepted: 04/15/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Central nervous system vasculitis has multiple presentations, including stroke, seizures, cranial nerve palsies, and encephalopathy. CASE DESCRIPTION We present the case of an unresponsive 45-year-old woman with vasculitis associated with fulminant intracranial vessel dissection and occlusion with ischemic strokes and subarachnoid hemorrhage secondary to aneurysm rupture. Imaging studies demonstrated both ischemic and hemorrhagic strokes. She had a ruptured right internal carotid artery dorsal variant aneurysm, right vertebral artery dissection with occlusion and posterior inferior cerebellar artery infarct, left vertebral artery dissection, and severe vasculitis involving intracranial and extracranial vessels. She initially was treated for her vasculitis with high-dose steroids followed by clip wrapping of the dorsal variant aneurysm. Unfortunately, her surgery was complicated by intraprocedural rupture, and the patient died during her hospitalization. CONCLUSIONS Fulminant central nervous system vasculitis can occur with critical vascular anomalies that require emergent intervention and should be part of the differential diagnosis of patients presenting with these multiple vascular pathologies.
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Affiliation(s)
- Osama Jamil
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Richard H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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John S, Walsh KM, Hui FK, Sundararajan S, Silverman S, Bain M. Dynamic Angiographic Nature of Cerebral Mycotic Aneurysms in Patients With Infective Endocarditis. Stroke 2016; 47:e8-e10. [DOI: 10.1161/strokeaha.115.011198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 01/24/2023]
Affiliation(s)
- Seby John
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Kevin M. Walsh
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Ferdinand K. Hui
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Sophia Sundararajan
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Scott Silverman
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Mark Bain
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
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Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075-3128. [PMID: 26320109 DOI: 10.1093/eurheartj/ehv319] [Citation(s) in RCA: 3107] [Impact Index Per Article: 345.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
MESH Headings
- Acute Kidney Injury/diagnosis
- Acute Kidney Injury/therapy
- Ambulatory Care
- Aneurysm, Infected/diagnosis
- Aneurysm, Infected/therapy
- Anti-Bacterial Agents/therapeutic use
- Antibiotic Prophylaxis
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Clinical Laboratory Techniques
- Critical Care
- Cross Infection/etiology
- Dentistry, Operative
- Diagnostic Imaging/methods
- Embolism/diagnosis
- Embolism/therapy
- Endocarditis/diagnosis
- Endocarditis/therapy
- Endocarditis, Non-Infective/diagnosis
- Endocarditis, Non-Infective/therapy
- Female
- Fibrinolytic Agents/therapeutic use
- Heart Defects, Congenital
- Heart Failure/diagnosis
- Heart Failure/therapy
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Long-Term Care
- Microbiological Techniques
- Musculoskeletal Diseases/diagnosis
- Musculoskeletal Diseases/microbiology
- Musculoskeletal Diseases/therapy
- Myocarditis/diagnosis
- Myocarditis/therapy
- Neoplasms/complications
- Nervous System Diseases/diagnosis
- Nervous System Diseases/microbiology
- Nervous System Diseases/therapy
- Patient Care Team
- Pericarditis/diagnosis
- Pericarditis/therapy
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prognosis
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/therapy
- Recurrence
- Risk Assessment
- Risk Factors
- Splenic Diseases/diagnosis
- Splenic Diseases/therapy
- Thoracic Surgical Procedures
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Behrouz R. Preoperative Cerebrovascular Evaluation in Patients With Infective Endocarditis. Clin Cardiol 2015; 38:439-42. [PMID: 25872491 DOI: 10.1002/clc.22400] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/01/2015] [Indexed: 11/11/2022] Open
Abstract
Approximately 12% to 40% of infective endocarditis patients experience cerebrovascular complications. One of the major clinical challenges in cerebrovascular medicine is management of infective endocarditis patients with cerebrovascular complications who require valve operations. Cerebrovascular specialists are often summoned to address appropriate preoperative brain imaging, timing of surgery, and estimation of the risk of perioperative cerebral embolization and hemorrhage. This article addresses these issues based on the available evidence.
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Affiliation(s)
- Réza Behrouz
- Division of Cerebrovascular Diseases, Department of Neurology, Ohio State University College of Medicine, Columbus, Ohio
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