Mechanisms of intracranial hemorrhage in infective endocarditis

[Inflammatory causes of stroke-Diagnostics and treatment]

Inflammatory causes of stroke are frequent and often pose diagnostic and therapeutic challenges due to the scarcity of randomized trials and the absence of clear guideline recommendations for many scenarios. Following the publication of the recommendations of the European Stroke Organization on primary angiitis of the central nervous system (PACNS) last year, the German Neurological Society (DGN) has issued very clear guidelines this year on the diagnostics and treatment of PACNS and updated the recommendations for systemic vasculitides; however, stroke often occurs not only as a result of primary vascular inflammation but also as a complication of another organ infection. Approximately 5% of all patients with sepsis, ca. 20% of patients with bacterial meningitis and up to 40% of patients with bacterial endocarditis suffer from a stroke as a complication. This article summarizes the key characteristics of these inflammatory causes of stroke and particularly focuses on the current recommendations for diagnostic and therapeutic management.

Infective Endocarditis Presenting as Intracranial Hemorrhage: A Case Report

We describe a 31-year-old woman who presented with acute right-sided weakness and was found to have a subarachnoid hemorrhage in the left Sylvian fissure and an ipsilateral frontal intraparenchymal hemorrhage. CT angiography revealed an occlusion of the left middle cerebral artery's M1 segment and a saccular aneurysm at its bifurcation. A cerebral angiogram confirmed these findings, and the patient subsequently underwent microsurgical aneurysm resection, which revealed a partially thrombosed pseudoaneurysm. Further stroke workup identified mitral valve vegetation, confirming the diagnosis of infective endocarditis.

Impact of postoperative cerebral complications in acute infective endocarditis: a retrospective single-center study

BACKGROUND

The treatment of patients with infective endocarditis (IE) who have preoperative cerebral complications remains less understood. Therefore, this study aimed to retrospectively evaluate the clinical outcomes of patients with acute IE based on preoperative intracranial findings.

METHODS

Of 32 patients with acute IE treated at our hospital between August 2015 and March 2022, 31 patients of whom preoperative intracranial imaging evaluation was available were included in our analysis and compared with those with and without intracranial findings. We controlled the mean arterial blood pressure and activated clotting time (ACT) to prevent abnormally high perfusion pressures and ACTs during cardiopulmonary bypass (CPB). The preoperative background, and postoperative courses focusing on postoperative brain complications were reviewed.

RESULTS

Among the 31 patients, 20 (65%) had preoperative imaging findings. The group with intracranial findings was significantly older, with more embolisms in other organs, positive intraoperative pathology findings, and longer CPB times. A new cerebral hemorrhage developed postoperatively in one patient without intracranial findings. There were no early deaths; two patients had recurrent infections in each group, and one died because of sepsis in the late phase in the group with intracranial findings.

CONCLUSIONS

Positive intracranial findings indicated significantly active infectious conditions preoperatively but did not affect the postoperative course. Patients without preoperative cerebral complications can develop serious cerebral hemorrhage. Although meticulous examination of preoperative cerebral complications in all patients with IE is essential, a strategy should be adopted to prevent cerebral hemorrhage, even in patients without intracranial findings.

Perioperative Complications in Infective Endocarditis

Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.

A Case of Mitral Valve Infective Endocarditis and Atrial Fibrillation Complicated by Hemorrhagic Stroke: A Challenging Clinical Scenario and Approach to Management

This case report presents a rare and intricate clinical scenario involving a 58-year-old male with a history of hypertension, intravenous drug use (IVDU), and cocaine abuse. The patient presented with profound hypotension and symptoms suggestive of impending shock. Septic workup revealed Staphylococcus aureus in all four blood culture bottles, confirming a diagnosis of infective endocarditis (IE). Transthoracic echocardiography demonstrated a large vegetation measuring 1.9x1.7 cm on the mitral valve. Additionally, the patient exhibited non-ST segment elevated myocardial infarction (NSTEMI) type II in the setting of cocaine use, atrial fibrillation, and therapeutic anticoagulation. Subsequent imaging studies raised concerns regarding hemorrhagic stroke. A multidisciplinary team comprising cardiology, cardiothoracic surgery, infectious disease, and neurology collaborated to develop an optimal management strategy. Considering the high-risk features of the IE and the need to address the hemorrhagic stroke, anticoagulation was temporarily halted, and the patient was transferred for urgent mitral valve replacement surgery. This case highlights the complex interplay between substance abuse, cardiovascular complications, IE, and neurological events, underscoring the challenges encountered in managing such patients.

Adding Fuel to the Fire: Infective Endocarditis and the Challenge of Cerebrovascular Complications

PURPOSE OF REVIEW

Infective endocarditis is a deadly disease and made more deadly by neurologic complications. We review the cerebrovascular complications of infective endocarditis and focus our discussion on medical and surgical management.

RECENT FINDINGS

While management of stroke in the setting of infective endocarditis differs from standard stroke treatment, mechanical thrombectomy has proven safe and successful. Optimal timing of cardiac surgery in the setting of stroke remains an area of debate, but additional observational studies continue to add more detail to the discussion. Cerebrovascular complications in the setting of infective endocarditis remain a high stakes clinical challenge. Timing of cardiac surgery in IE complicated by stroke exemplifies these dilemmas. While more studies have suggested that earlier cardiac surgery is likely safe for those with small ischemic infarcts, there remains a need for more data defining optimal timing of surgery in all forms of cerebrovascular involvement.

Vascular Complications of Infective Endocarditis: Diagnosis and Management

Introduction: The complications of infective endocarditis (IE) are frequent and severe. Our aim was to study the clinical and paraclinical profiles and prognosis of vascular complications, observed in a cardiology unit in Oujda, Morocco. Among 57 patients hospitalized for IE between 2015 and 2020 at the cardiology unit, 19 patients, or 33.3% of patients, had one or more vascular complications. We present here a retrospective analysis.

Aim: Prevention, early diagnosis, and treatment of vascular complications are primordial to improving prognosis, following the guidelines of the European Society of Cardiology.

Patients and methods: We retrospectively studied 57 patients hospitalized for IE. The diagnostic criteria for IE were modified from the Duke University criteria and we present all vascular complications among this cohort.

Results: Nineteen patients presented with one or more vascular complications, 10 men and nine women, with a mean age of 49 years. IE had grafted on a mechanical prosthetic valve in four cases. Overall, we found 25 vascular lesions: six neurological complications, five cases of peripheral vascular involvement, nine splenic infarcts, and five recurrent septic pulmonary embolisms (SPEs). The vascular complications accrued after three to 14 days of antibiotherapy or on extension reports; blood cultures were positive in 17 (89.4%) cases; streptococcus was isolated in nine cases; Staphylococcus aureus in seven cases; and acinetobacter in one case.

Conclusion: Vascular complications of IE are severe, the most common in our study being splenic infarct. Prevention and early diagnosis are essential to instituting optimal management.

All the patients were followed up with a mean follow-up of three years. Late mortality involved one patient in connection with a hemorrhagic stroke secondary to an accident with vitamin K antagonists after its release in one month. No cases of recurrence of endocarditis were noted in this group.

Data were collected from archived medical records and analyzed by Statistical Package for the Social Sciences.

Cerebrovascular Complication and Valve Surgery in Infective Endocarditis

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.

Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease

Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.

Hemorrhagic stroke

Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.

[Therapeutic and endovascular management of cerebral mycotic aneurysms]

Infective endocardites are associated with both ischemic and hemorrhagic neurological complications and also with cerebral abscesses and the development of "mycotic" aneurysms, which are detected in about 5 % of patients in the acute and sub-acute phase of the infection. Data about their natural history and their hemorrhagic risk are scarce and fragmented. The therapeutic management is represented by the medical treatment of the infection with interventional abstention, the surgical treatment and the endovascular approach by selective embolization of the aneurysm. No evidence is provided concerning the superiority of a specific approach. Mycotic aneurysms remain a diagnostic and therapeutic challenge and their management is necessarily based on a multidiscplinary approach.

Risk of postoperative neurological exacerbation in patients with infective endocarditis and intracranial haemorrhage

OBJECTIVES

Cardiac surgery in patients with infective endocarditis (IE) and preoperative intracranial haemorrhage (pre-ICH) is a highly debatable issue, and guidelines are still not well defined. The goal of this study was to investigate the effect of cardiac surgery and its timing on the clinical outcomes of patients with IE and pre-ICH.

METHODS

We did a single-centre retrospective analysis of data from patients with preoperative brain imaging who had surgery for left-sided IE between January 2007 and May 2018.

RESULTS

Among the 363 patients included in the study, 34 had pre-ICH. Hospital mortality was similar between the patients with and without pre-ICH (29% vs 27%, respectively; P = 0.84). Unadjusted, postoperative neurological deterioration appeared higher in patients with pre-ICH (24% vs 17%; P = 0.35). In multivariable analysis, pre-ICH did not qualify as an independent predictor for either postoperative neurological deterioration [odds ratio 1.10, 95% confidence interval (CI) 0.44-2.73; P = 0.84] or hospital mortality (odds ratio 1.02, 95% CI 0.43-2.40; P = 0.96). Postoperative partial thromboplastin time was significantly elevated in 4 patients with relevant post-ICH compared with those patients without relevant post-ICH (65.5 vs 37.6, respectively; P = 0.004).

CONCLUSIONS

Pre-ICH was not an independent predictor for postoperative neurological deterioration or hospital mortality in patients with IE. Postoperative coagulation management seems to be crucial in patients with IE with ICH. Although this is to date the largest monocentric study addressing surgical decision and timing, the number of patients with pre-ICH was low. Therefore, these conclusions should be regarded with caution; randomized clinical trials are needed.

Differentiating between Mycotic and Dissecting Aneurysms in a Case of Ruptured Distal Superior Cerebral Artery Aneurysm

Objective

We present a case of subarachnoid hemorrhage (SAH) due to ruptured mycotic aneurysm found in the distal superior cerebellar artery (SCA).

Case Presentation

A 64-year-old man was admitted to our hospital with sudden unconsciousness. He had a history of alcoholism but no family history of SAH. Computed tomography (CT) showed apparent SAH; however, CT angiography (CTA) showed no apparent cause of SAH except for two small aneurysms in the same branch of the left distal SCA. We suspected mycotic aneurysm and prescribed antibiotics. It was difficult to diagnose the condition as mycotic aneurysm because there were no vegetations or caries at the time of admission. Because there were two aneurysms in the same branch with partial dilatation and stenosis, we suspected dissecting aneurysm, but continued to administer antibiotics for possible mycotic aneurysm. After the first operation, we diagnosed mycotic aneurysm because a vegetation and valve degeneration was found.

Conclusion

It is difficult to distinguish mycotic aneurysms from dissecting aneurysms because of similar appearance on imaging, especially if no vegetation is found. Nevertheless, it is important to start treatment for mycotic aneurysm. If there is the possibility of mycotic aneurysm, appropriate antibiotics should be administered, and endovascular treatment could be considered for patients with deteriorating conditions.

Non-neoplastic hepatopancreatobiliary lesions simulating malignancy: can we differentiate?

Despite the success of cross-sectional imaging in evaluating hepatopancreatobiliary system malignancies, several non-malignant disease processes may closely mimic malignancy. Differentiating these benign diseases from malignancy may be difficult, or even impossible, even in the hands of experienced imagers. In this manuscript, we present benign mimics involving the hepatopancreatobiliary system and try to increase awareness of these potential pitfalls.

Surgical timing in infective endocarditis complicated by intracranial hemorrhage

Given the growing incidence of infective endocarditis (IE), understanding the risks and benefits of valvular surgery is critical. This decision is particularly complex for the 1 in 10 cases complicated by intracranial hemorrhage (ICH). While guideline recommendations currently favor early surgery in general, delayed intervention of at least 4 weeks is still recommended for patients with ICH. To date, there are no randomized controlled trials that inform management of patients with an indication for surgery but concomitant ICH, and even reported observational data are rare. This paper reviews the current literature on timing of surgery with a specific focus on cases of ICH. It emphasizes a growing body of literature challenging the current paradigm that surgery within 4 weeks is associated with neurologic deterioration and high mortality rates by demonstrating favorable outcomes for patients with pre-operative ICH who undergo early valvular surgery. Based on these data, we propose a practical management algorithm to facilitate decisions on surgical timing in these complicated cases. Since more rigorous evidence may never be available, clinicians should make patient-specific surgical timing decisions that attempt to balance the competing risks of neurologic versus cardiac complications.

Early vs Late Surgery for Patients With Endocarditis and Neurological Injury: A Systematic Review and Meta-analysis

BACKGROUND

Surgical timing in infective endocarditis (IE) with preoperative neurological events remains controversial. The relevant society guidelines are each on the basis of a small number of observational studies. This meta-analysis was designed to search the available literature broadly and assess the weight of available evidence as comprehensively as possible.

METHODS

We searched MEDLINE and EMBASE to April 2018 for studies that compared mortality or neurological exacerbation in early vs late surgery for IE complicated by neurological events. Random effects meta-analysis was performed.

RESULTS

Twenty-seven observational studies (25 unadjusted, n = 879; 2 adjusted, n = 451) met inclusion criteria. Using early and late thresholds defined in each study (7 or 14 days), early surgery in ischemic or hemorrhagic stroke was associated with elevated perioperative mortality vs late surgery (pooled relative risk [RR], 1.74; 95% confidence interval, 1.34-2.25; P < 0.0001; I² = 0%) and greater neurological exacerbation (RR, 2.09; 95% confidence interval, 1.32-3.32; P = 0.002; I² = 33%). In subgroup analysis, for ischemic stroke, early surgery before 7 vs before 14 days exhibited similar perioperative mortality and neurological exacerbation. For hemorrhagic stroke, performing surgery before 21 vs before 28 days showed trends toward perioperative mortality (RR, 1.77 vs 0.63, interaction P = 0.14) and neurological (RR, 2.02 vs RR, 0.44; interaction P = 0.11) exacerbation. There was no difference in long-term mortality but reporting was sparse. Early surgery was often performed for clinical deterioration, negatively biasing outcomes.

CONCLUSIONS

Available observational data support delaying surgery by 7-14 days if possible in IE complicated by ischemic stroke and > 21 days in hemorrhagic stroke to decrease perioperative mortality and neurological exacerbation rates. Randomized trials are needed for definitive guidance.

Intracranial haemorrhage in infective endocarditis

BACKGROUND

Although intracranial cerebral haemorrhage (ICH) complicating infective endocarditis (IE) is a critical clinical issue, its characteristics, impact, and prognosis remain poorly known.

AIMS

To assess the incidence, mechanisms, risk factors and prognosis of ICH complicating left-sided IE.

METHODS

In this single-centre study, 963 patients with possible or definite left-sided IE were included from January 2000 to December 2015.

RESULTS

Sixty-eight (7%) patients had an ICH (mean age 57±13 years; 75% male). ICH was classified into three groups according to mechanism: ruptured mycotic aneurysm (n=22; 32%); haemorrhage after ischaemic stroke (n=27; 40%); and undetermined aetiology (n=19; 28%). Five variables were independently associated with ICH: platelet count<150×10⁹/L (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.01-5.4; P=0.049); severe valve regurgitation (OR 3.2, 95% CI 1.3-7.6; P=0.008); ischaemic stroke (OR 4.2, 95% CI 1.9-9.4; P<0.001); other symptomatic systemic embolism (OR 14.1, 95% CI 5.1-38.9; P<0.001); and presence of mycotic aneurysm (OR 100.2, 95% CI 29.2-343.7; P<0.001). Overall, 237 (24.6%) patients died within 2.3 (0.7-10.4) months of follow-up. ICH was not associated with increased mortality (P not significant). However, the 1-year mortality rate differed according to ICH mechanism: 14%, 15% and 45% in patients with ruptured mycotic aneurysm, haemorrhage after ischaemic stroke and undetermined aetiology, respectively (P=0.03). In patients with an ICH, mortality was higher in non-operated versus operated patients when cardiac surgery was indicated (P=0.005). No operated patient had neurological deterioration.

CONCLUSIONS

ICH is a common complication of left-sided IE. The impact on prognosis is dependent on mechanism (haemorrhage of undetermined aetiology). We observed a higher mortality rate in patients who had conservative treatment when cardiac surgery was indicated compared with in those who underwent cardiac surgery.

Magnetic Resonance Imaging Susceptibility-Weighted Imaging Lesion and Contrast Enhancement May Represent Infectious Intracranial Aneurysm in Infective Endocarditis

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

Rare manifestations of infective endocarditis: the long known, never to be forgotten diagnosis

Infective endocarditis (IE) is a life-threatening condition often manifesting as a multisystem disease; its heterogeneous features present a diagnostic challenge. We report two cases of IE masquerading as rare extracardiac complications: a splenectomised patient with a periarticular ankle abscess and acute encephalopathy; and a young man with a cutaneous vasculitis following a spontaneous intracerebral haemorrhage. In both cases, the diagnosis was suspected following detection of afebrile bacteraemia and confirmed with echocardiography. Risk factors included a pneumococcal bacteraemia in the asplenic patient and a previously undiagnosed bicuspid aortic valve in the second patient. Both patients recovered well with appropriate antibiotic therapy followed by valve surgery. IE is an important diagnosis to consider in patients with systemic symptoms or organ specific, otherwise unexplained relevant pathology especially in the presence of a cardiac murmur or risk factors for IE including structural heart disease, prosthetic valves or intravascular devices, and in immunosuppressed patients.

Preoperative Cerebrovascular Evaluation in Patients With Infective Endocarditis

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.

Associations and outcomes of septic pulmonary embolism

Background:

Septic pulmonary embolism is a serious but uncommon syndrome posing diagnostic challenges because of its broad range of clinical presentation and etiologies.

Objective:

To understand the clinical and radiographic associations of septic pulmonary embolism in patients presenting to an acute care safety net hospital.

Methods:

We conducted a retrospective analysis of imaging and electronic health records of all patients diagnosed with septic pulmonary embolism in our hospital between January 2000 and January 2013.

Results:

41 episodes of septic pulmonary embolism were identified in 40 patients aged 17 to 71 years (median 46); 29 (72%) were men. Presenting symptoms included: febrile illness (85%); pulmonary complaints (66%) including pleuritic chest pain (22%), cough (19%) and dyspnea (15%); and those related to the peripheral foci of infection (24%) and shock (19%). Sources of infection included: skin and soft tissue (44%); infective endocarditis (27%); and infected peripheral deep venous thrombosis (17%). 35/41 (85%) were bacteremic with staphylococcus aureus. All patients had peripheral nodular lesions on chest CT scan. Treatment included intravenous antibiotics in all patients. Twenty six (63%) patients required pleural drainage and/or drainage of peripheral abscesses. Seven (17%) patients received systemic anticoagulants. Eight (20%) patients died due to various complications.

Conclusion:

The epidemiology of septic pulmonary embolism has broadened over the past decade with an increase in identified extrapulmonary, non-cardiac sources. In the context of an extrapulmonary infection, clinical features of persistent fever, bacteremia and pulmonary complaints should raise suspicion for this syndrome, and typical findings on the chest CT scans confirm the diagnosis. Antibiotics, local drainage procedures and increasingly, anticoagulation are keys to successful outcomes.

Usefulness of anticoagulant therapy in the prevention of embolic complications in patients with acute infective endocarditis

Background. The use of anticoagulant therapy (ACT) in patients with acute infective endocarditis (IE) remains a controversial issue. Our study attempts to estimate the impact of ACT on the occurrence of embolic complications and the usefulness of ACT in the prevention of embolism in IE patients. Methods. The present authors analyzed 150 patients with left-sided IE. Embolisms including cerebrovascular events (CVE) and the use of ACT were checked at the time of admission and during hospitalization. Results. 57 patients (38.0%) experienced an embolic event. There was no significant difference in the incidence of CVE and in-hospital mortality between patients with and without warfarin use at admission, although warfarin-naïve patients were significantly more likely to have large (>1 cm) and mobile vegetation. In addition, there was no significant difference in the incidence of postadmission embolism and in-hospital death between patients with and without in-hospital ACT. On multivariate logistic regression analysis, ACT at admission was not significantly associated with a lower risk of embolism in patients with IE. Conclusions. The role of ACT in the prevention of embolism was limited in IE patients undergoing antibiotic therapy, although it seems to reduce the embolic potential of septic vegetation before treatment.

Meningitis complicated by mycotic aneurysms

Mycotic aneurysms complicated by vasospasm and strokes represent a rare manifestation of bacterial meningitis. We describe a healthy woman diagnosed with bacterial meningitis and mycotic aneurysms, who received both antibiotic and corticosteroid therapy. This approach fostered a significant radiologic improvement in her mycotic aneurysms as evidenced by serial angiographic examinations. During her course, she developed vasospasm and strokes and required intra-arterial verapamil. More importantly and as a result of these combined therapies, the patient experienced a substantial clinical improvement. This case allows the description of mycotic aneurysms epidemiology, clinical presentation and complications. In addition, our vignette bestows the relevance of serial neurologic examinations and radiologic testing during the acute vasculopathy period. Current conservative and interventional therapeutic options are briefly discussed.

Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis

BACKGROUND

Cerebral angiography remains the gold standard for the detection of mycotic aneurysms, and it has been estimated that ruptured mycotic aneurysms result in 5% of the neurological complications of patients with infective endocarditis (IE).

OBJECTIVE

To determine the diagnostic yield of cerebral angiography in the above patient population and to assess patient factors that might suggest greater or lesser utility.

METHODS

We retrospectively reviewed 168 patients who underwent cerebral angiography with a diagnosis of IE or infected left ventricular assist device at the Cleveland Clinic between January 2003 and March 2010 in accordance with institutional review board guidelines. Chart and imaging review was performed.

RESULTS

15/168 patients (8.9%) had mycotic aneurysms; 93.3% (14/15) of the patients with mycotic aneurysms presented with CNS hemorrhage and 66.7% (10/15) had acute ischemic findings. Of the 15 patients with mycotic aneurysms on angiography, seven underwent CT angiography and six underwent MR angiography, which showed mycotic aneurysms in three (42.9%) and two cases (one of which was questionable; 33.3%), respectively.

CONCLUSIONS

Patients with IE or similar sources of central bacterial emboli are prone to neurovascular complications. Approximately 9% of patients with IE at our institution who undergo cerebral angiography have mycotic aneurysms. Presentation with hemorrhage appears to be more predictive of aneurysm, as approximately 22% of patients with IE and hemorrhage were found to have an aneurysm compared with only 1% when hemorrhage was absent. Thus, patients with IE presenting with intracranial hemorrhage should undergo vascular imaging, preferably with cerebral angiography.

Neurologic complications of valvular heart disease

Valvular heart disease (VHD) is frequently associated with neurologic complications; cerebral embolism is the most common of these since thrombus formation results from the abnormalities in the valvular surfaces or from the anatomic and physiologic changes associated with valve dysfunction, such as atrial or ventricular enlargement, intracardiac thrombi, and cardiac dysrhythmias. Prosthetic heart valves, particularly mechanical valves, are very thrombogenic, which explains the high risk of thromboembolism and the need for anticoagulation for the prevention of embolism. Infective endocarditis is a disease process with protean manifestations that include not only cerebral embolism but also intracranial hemorrhage, mycotic aneurysms, and systemic manifestations such as fever and encephalopathy. Other neurologic complications include nonbacterial thrombotic endocarditis, a process associated with systemic diseases such as cancer and systemic lupus erythematosus. For many of these conditions, anticoagulation is the mainstay of treatment to prevent cerebral embolism, therefore it is the potential complications of anticoagulation that can explain other neurologic complications in patients with VHD. The prevention and management of these complications requires an understanding of their natural history in order to balance the risks posed by valvular disease itself against the risks and benefits associated with treatment.

Clinical characteristics and thrombolytic outcomes of infective endocarditis-associated stroke

OBJECTIVE

Our aim was to describe the clinical features of infective endocarditis (IE) in the acute stroke setting and outcomes following thrombolytic therapy.

METHODS

This is a single-center, retrospective, descriptive case series of IE-related stroke (IES). Infective endocarditis diagnosis was based on the modified Duke criteria.

RESULTS

From 2001 to 2007, 18 patients with acute stroke had definite or possible IE. Presenting stroke subtypes were: 11 ischemic stroke; 2 intracerebral hemorrhage; and 5 with a combination of ischemia and subarachnoid hemorrhage. On presentation, 6 had objective fever and 5 had subjective fever, 8 had heart murmur, and 3 had classic IE stigmata. The most common laboratory abnormalities were leukocytosis (n = 11) and anemia (n = 10). Sixteen patients had valvular vegetations on echocardiogram; 6 of 8 patients had vegetations visualized on transesophageal echocardiogram that were not detected by transthoracic echocardiogram. Two of the 3 patients with valve replacements had vegetations only on their native valves. Of 11 patients with pure ischemic stroke, 4 received thrombolytics and had hemorrhagic conversion. Overall mortality of IES was 56% (10 of 18). Mortality in pure ischemic IES patients was 29% (2 of 7, median National Institute of Health Stroke Scale [NIHSS] 13) in those not receiving thrombolytics and 75% (3 of 4, median NIHSS 14) in those receiving thrombolytics.

CONCLUSIONS

Though diagnosis of IE in the acute stroke setting is difficult, features of the history, examination, and laboratory data may raise concern for IE. In this case series, thrombolytics in patients with IE-associated stroke were associated with very poor outcomes.

Septic embolism in the intensive care unit

Septic embolism encompasses a wide range of presentations and clinical considerations. From asymptomatic, incidental finding on advanced imaging to devastating cardiovascular or cerebral events, this important clinico-pathologic entity continues to affect critically ill patients. Septic emboli are challenging because they represent two insults—the early embolic/ischemic insult due to vascular occlusion and the infectious insult from a deep-seated nidus of infection frequently not amenable to adequate source control. Mycotic aneurysms and intravascular or end-organ abscesses can occur. The diagnosis of septic embolism should be considered in any patient with certain risk factors including bacterial endocarditis or infected intravascular devices. Treatment consists of long-term antibiotics and source control when possible. This manuscript provides a much-needed synopsis of the different forms and clinical presentations of septic embolism, basic diagnostic considerations, general clinical approaches, and an overview of potential complications.

Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature

Infective endocarditis represents a classical contra-indication to thrombolysis for acute ischemic stroke due to a potential increased risk of intracranial hemorrhage. However, some case reports have suggested safety and potential efficacy of intravenous or intra-arterial thrombolysis in stroke related to infective endocarditis. We present a case of ischemic stroke related to infective endocarditis who was treated with intravenous tissue plasminogen activator within the first 3 h of symptoms onset and subsequently developed symptomatic multifocal intracerebral hemorrhages, and summarize currently available data on this issue.

Current treatment of active infective endocarditis with brain complications

We describe the optimal timing of surgery in active infective endocarditis patients with brain complications. (1) Non-hemorrhagic infarction: elective surgery has been recommended in patients with non-hemorrhagic infarction. However, the timing is changing to an earlier phase. Recent studies have shown that silent brain embolism and small-size infarction (15-20 mm) without coma can be operated safely without delay. On the other hand, in patients with large non-hemorrhagic infarction with impaired consciousness, early surgery is not recommended. (2) Non-ruptured infectious intracranial aneurysm: treatment strategies for patients with infectious aneurysms without rupture remain controversial. However, the treatments are generally as follows. If the intracranial aneurysm without rupture decreases in size by administration of effective antibiotics, neurosurgery will not be required and cardiac surgery can be prioritized without delay. When the aneurysm without rupture enlarges and changes its morphology, neurosurgery or endovascular surgery should be prioritized to prevent its rupture. (3) Hemorrhagic stroke: this type is classified into primary intra-cerebral hemorrhage due to simple necrotic arteritis, hemorrhagic transformation of ischemic infarcts, and rupture of intracranial infectious aneurysms. Among these, primary intracerebral hemorrhage is the most frequently observed. In patients with the primary intracerebral hemorrhage, surgery must be postponed for at least 4 weeks to prevent exacerbation of bleeding. In patients with ruptured infectious aneurysm, neurosurgery or endovascular surgery is performed initially and cardiac surgery should be postponed at least 2-3 weeks.

The association of septic thrombophlebitis with septic pulmonary embolism in adults

Background:

There have been an increasing number of pediatric reports of septic pulmonary embolism in the setting of septic thrombophlebitis adjacent to a primary infectious source.

Methods:

Retrospective review at an urban hospital. A total of five adults with a documented primary infectious source, adjacent septic thrombophlebitis and septic pulmonary embolism were identified between 2000 and 2011.

Results:

The predominant symptoms on presentation were fever and pleuritic chest pain, followed by chills and cough. S. aureus was the pathogen in 4 patients. Only one case had echocardiographic evidence of endocarditis. All patients received IV antibiotics and anticoagulation therapy. No new embolic events or central nervous system complications were noted.

Conclusions:

The triad of extrapulmonary infection, contiguous septic thrombophlebitis and septic pulmonary embolism is present in adult as well as pediatric populations. The use of systemic anticoagulation with appropriate antibiotics resulted in clinical and radiologic improvement but no significant complications.

Vascular complications of infective endocarditis

The complications of infective endocarditis (IE) are frequent and severe. Our objectives were to analyze the clinical, paraclinical, and prognostic features of IE vascular complications observed in two cardiology units, in Dakar.

PATIENTS AND METHODS

We retrospectively studied 90 patients presenting with of IE, hospitalized between January 2005 and February 2011. The diagnostic criteria for IE were modified Duke University criteria. We selected in our study population, patients with vascular complications.

RESULTS

Seventeen patients (18.8%) presented with one or more vascular complications of IE: eight male and nine female patients, with a mean age of 28 years. Infective endocarditis occurred on an abnormal valve in 15 cases. We identified 22 vascular lesions: ten neurological complications, seven arterial complications in the limbs, two myocardial infarctions, two cases of pulmonary embolism, and one splenic infarction. The vascular complication revealed an IE in seven cases. The vascular complication occurred during antibiotic treatment, in 15 cases including seven cases before the 14th day, nine of the 17 patients died. Death was related to vascular complications in six cases, in one case it was related to septic shock.

CONCLUSION

Vascular complications of IE are frequent, the most common are neurological. Their prevention requires early and adequate management of IE.

A first report of Rothia aeria endocarditis complicated by cerebral hemorrhage

We herein report the first case of infective endocarditis attributable to Rothia aeria, which had a fatal outcome after cerebral hemorrhagic infarction and was not susceptible to vancomycin. If Gram-positive bacillary or filamentous bacteria that form white, coarse, dry colonies are detected, keeping the possibility of Rothia species in mind is advisable because members of this species can cause severe infections.

Epidemic of illicit drug use, mechanisms of action/addiction and stroke as a health hazard

Drug abuse robs individuals of their jobs, their families, and their free will as they succumb to addiction; but may cost even more: a life of disability or even life lost due to stroke. Many illicit drugs have been linked to major cardiovascular events and other comorbidities, including cocaine, amphetamines, ecstasy, heroin, phencyclidine, lysergic acid diethylamide, and marijuana. This review focuses on available epidemiological data, mechanisms of action, particularly those leading to cerebrovascular events, and it is based on papers published in English in PubMed during 1950 through February 2011. Each drug's unique interactions with the brain and vasculature predispose even young, healthy people to ischemic or hemorrhagic stroke. Cocaine and amphetamines have the strongest association with stroke. However, the level of evidence firmly linking other drugs to stroke pathogenesis is weak. Large epidemiological studies and systematic evaluation of each drug's action on the brain and cardiovascular system are needed to reveal the full impact of drug use on the population.

A short segment intracranial-intracranial jump graft bypass followed by proximal arterial occlusion for a distal MCA aneurysm

Background:

To describe the use of a short segment cortical intracranial–intracranial (IC–IC) bypass for the treatment of a distal middle cerebral artery (MCA) aneurysm.

Case Description:

A 54-year-old woman presented with a loss of consciousness followed by multiple seizures and was found to have a partially thrombosed distal MCA aneurysm. This possibly mycotic aneurysm was treated by creating a short segment jump graft between a normal cortical artery and a nearby cortical branch arising from the aneurysmal M3 arterial segment. The bypass allowed for subsequent occlusion of the aneurysmal vessel without ischemic consequence. At surgery, the anterior division of the superficial temporal artery (STA) was exposed and dissected. Intraoperative angiography was utilized to localize a cortical artery arising from the involved segment as well as a nearby cortical artery arising from a distinct, uninvolved MCA branch. A segment of the STA was harvested, and then 10-0 suture was utilized to anastomose this short segment, to both the involved and normal cortical arteries. This created a short jump graft allowing for subsequent sacrifice of the diseased artery. Following surgery, the patient immediately underwent coil embolization of the aneurysm back into the parent artery resulting in local vascular sacrifice. The remainder of the patient's hospital course was uneventful. She was discharged home in good condition.

Conclusions:

We suggest that cortical IC–IC bypass followed by endovascular arterial sacrifice as performed in our case represents a simple and safe option for treating unclippable distal MCA aneurysms including mycotic lesions.

Warfarin therapy and incidence of cerebrovascular complications in left-sided native valve endocarditis

Anticoagulant therapy has been anticipated to increase the risk of cerebrovascular complications (CVC) in native valve endocarditis (NVE). This study investigates the relationship between ongoing oral anticoagulant therapy and the incidence of symptomatic CVC in left-sided NVE. In a prospective cohort study, the CVC incidence was compared between NVE patients with and without ongoing warfarin. Among 587 NVE episodes, 48 (8%) occurred in patients on warfarin. A symptomatic CVC was seen in 144 (25%) patients, with only three on warfarin. CVC were significantly less frequent in patients on warfarin (6% vs. 26%, odds ratio [OR] 0.20, 95% confidence interval [CI] 0.06-0.6, p = 0.006). No increase in haemorrhagic lesions was detected in patients on warfarin. Staphylococcus aureus aetiology (adjusted OR [aOR] 6.3, 95% CI 3.8-10.4) and vegetation length (aOR 1.04, 96% CI 1.01-1.07) were risk factors for CVC, while warfarin on admission (aOR 0.26, 95% CI 0.07-0.94), history of congestive heart failure (adjusted OR 0.22, 95% CI 0.1-0.52) and previous endocarditis (aOR 0.1, 95% CI 0.01-0.79) correlated with lower CVC frequency.

Successful surgical treatment with mitral valve replacement and coronary embolectomy in a patient with active infective endocarditis complicated by multiple septic embolisms involving cerebral arteries and the right coronary artery

The proper management of a patient with active infective endocarditis (IE) remains to be determined, especially when his or her condition is complicated with intracranial mycotic aneurysm. Here we present a 46-year-old company employee hospitalized with a subarachnoid hemorrhage caused by a ruptured mycotic aneurysm. Cardiac echography showed a verruca on the posterior mitral cusp and leaflet destruction, resulting in severe valvular regurgitation (determined pathogen was α-streptococcus). High-dose antibiotic infusion and restriction of physical activity to prevent heart failure were combined with emergency craniotomy drainage and coiling of the necks of two cerebral mycotic aneurysms. After 2 months of conservative therapy for IE, he suddenly collapsed with hypotension and bradycardia because of embolic occlusion of the proximal right coronary artery (RCA). An emergent operation was carried out to remove the emboli in the RCA and to replace the mitral valve with a mechanical prosthesis. The postoperative course was uneventful. Although disturbances of spatial recognition and manual dexterity remained, he was able to walk and talk. After postoperative sufficient-duration antibiotic therapy, which lasted 20 days, he was transferred to a rehabilitation center.

Significance of the T2*-weighted gradient echo brain imaging in patients with infective endocarditis

BACKGROUND

Although aneurysm formation accompanying parenchymal hemorrhage is one of devastating complications in the central nerves system (CNS), imaging studies of the brain are not routinely warranted in patients with infective endocarditis (IE). To assess the clinical importance for detecting silent lesions in the central nervous system, we investigated hypointense signal spots detected on the brain T2*-weighted MR imaging in patients with IE.

METHODS AND RESULTS

Eleven patients with IE were retrospectively reviewed. Seven patients (63.6%) showed hypointense signal spots on T2*-weighted MR images. The number of hypointense signal spots increased within only a few weeks in five patients.

CONCLUSION

The brain T2*-weighted MR imaging in patients with IE may have a potential role to detect CNS lesions with clinical significance of potentially high risk of intracranial hemorrhage. T2*-weighted hypointense signal spots may be specific to brain involvement, and be quite useful in monitoring CNS lesions associated with IE, even if they are asymptomatic.

Endovascular treatment for intracranial infectious aneurysms

OBJECTIVE

To re-enforce an alternative, less aggressive treatment modality in the management of intracranial infectious aneurysms.

METHOD

We present a series of five patients with infectious endocarditis and intracranial infectious aneurysms (mycotic aneurysms) managed by means of endovascular treatment.

RESULTS

Endovascular treatment was executed technically uneventfully in all patients. Three patients had favorable clinical outcome: two were classified as Glasgow Outcome Scale 4/5, and one had total neurological recovery (GOS 5/5). Two patients died (GOS 1/5), one in consequence of the initial intracranial bleeding and the other after cardiac complications from endocarditis and open-heart surgery.

CONCLUSION

Endovascular techniques are an expanding option for the treatment of IIAs. It has been especially useful for infectious endocarditis patients with IIA, who will be submitted to cardiac surgery with cardiopulmonary bypass and anticoagulation, with the risk of intracranial bleeding.

Effectiveness of Thrombolytic Therapy in Acute Embolic Stroke due to Infective Endocarditis

Objective. To identify the role of thrombolytic therapy in acute embolic stroke due to infective endocarditis. Design. Case report. Setting. University hospital. Patient. A 70-year-old male presented with acute onset aphasia and hemiparesis due to infective endocarditis. His head computerized tomographic scan revealed left parietal sulcal effacement. He was given intravenous tissue plasminogen activator with significant resolution of the neurologic deficits without complications. Main Outcome Measures. Physical examination, National Institute of Health Stroke Scale, radiologic examination results. Conclusions. Thrombolytic therapy in selected cases of stroke due to infective endocarditis manifesting as major neurologic deficits can be considered as an option after careful consideration of risks and benefits. The basis for such favorable response rests in the presence of fibrin as a major constituent of the vegetation. The risk of precipitating hemorrhage with thrombolytic therapy especially with large infarcts and mycotic aneurysms should be weighed against the benefits of averting a major neurologic deficit.

Intracranial hemorrhage following thrombolytic use for stroke caused by infective endocarditis

BACKGROUND AND PURPOSE

Stroke is one of the most common neurological manifestations of infective endocarditis. The use of intravenous tissue plasminogen activator (t-PA) in the management of acute ischemic stroke is the accepted standard of practice. Current guidelines for intravenous (IV) t-PA therapy in acute ischemic stroke do not exclude patients with infective endocarditis. We present three patients who received IV t-PA for acute ischemic stroke in the setting of infective endocarditis and developed multifocal intracranial hemorrhage as a complication.

CONCLUSION

Infective endocarditis related strokes are associated with a higher risk of hemorrhagic complications and our experience suggests that IV t-PA use may potentiate that risk.

Brain magnetic resonance findings in infective endocarditis with neurological complications

PURPOSE

Diagnosing infective endocarditis and its complications can be difficult because of the nonspecific symptoms. We reviewed findings of intracranial abnormalities on magnetic resonance imaging (MRI) in 14 patients with neurological complications and herein discuss the overall intracranial MRI findings.

MATERIALS AND METHODS

We retrospectively reviewed patients with infective endocarditis from August 2004 to August 2006. Brain MRI, the causative bacteria, and abnormal neurological symptoms were reviewed for 14 patients with neurological complications.

RESULTS

Of the 14 patients, 13 showed intracranial abnormalities on MRI. Embolization was seen in 10 patients, hemorrhage in 3, abscess formation in 3, and encephalitis in 2. Hyperintense lesions with a central hypointense area on T2-weighted and/or T2*-weighted imaging (Bull's-eye-like lesion) were seen in four patients. A combination of these intracranial abnormalities was observed in 6 patients.

CONCLUSION

The MRI findings associated with infective endocarditis are wide-ranging: embolization, hemorrhage, meningitis, cerebritis, abscess, the bull's-eye-like lesion. Clinicians should consider the possibility of infective endocarditis in patients with unknown fever and neurological abnormality. Brain MRI should be promptly performed for those patients, and T2*-weighted imaging is recommended for an early diagnosis of infective endocarditis.