Infective endocarditis with cerebrovascular complications: timing of surgical intervention

Abstract

Management of infective endocarditis (IE) with cerebrovascular complications is difficult due to absence of concrete evidence. These patients usually have multiple neurological deficits and the optimal timing for cardiac operation remains controversial. The aims of this study were to present cases and discuss the treatment options for IE with cerebrovascular complications. From 1998 to 2010, 51 patients underwent operations for IE at our institution. From a review of medical records, 10 patients (19.6%) with preoperative neurological complications were identified. Data on these 10 patients were analysed. Cerebrovascular complications included cerebral infarction (n = 4, 40.0%), mycotic aneurysm (n = 1, 10.0%), mycotic aneurysm plus cerebral infarction (n = 3, 30.0%), meningitis (n = 1, 10.0%) and mycotic aneurysm with cerebral haemorrhage plus meningitis (n = 1, 10.0%). Of 5 patients having mycotic aneurysms, 3 underwent clipping before cardiac operations. The mean interval from craniotomy to cardiac operations was 26.7 ± 21.8 days. A cardiac operation was performed initially on seven patients. The mean interval from the onset of neurological deficit to cardiac operation was 7.4 ± 9.8 days. The mortality rate was 10.0%. Postoperative deterioration was not observed. Management of IE with cerebrovascular complications should be based on case-by-case multidisciplinary assessment of potential risks and benefits of intracranial and cardiac operations.

Mycotic aneurysm as a complication of infective endocarditis - a case report

“…5,13 This complication is rare, occurring in around 2-4% of cases, and as reported, more than half (57.4%) are located in the distal branches of the medium cerebral artery. 7,13,14,15 The cerebral hemorrhage presented by the patient can be justified by the fact that mycotic aneurysms generally present a fine and fragile wall. 7 A multicenter study conducted in France showed that 65-80% of mycotic aneurysms are asymptomatic, diagnosed only by imaging exams.…”

“…In the case of rupture, however -as in the case presented here, in which the patient experienced convulsions and changes to her level of consciousness -, mortality reaches 80%. 5,10,11,14,16 In contrast with ruptured aneurysms, unruptured ones have a much lower mortality rate (30%) and treatment is generally based on antibiotics and patient monitoring. 5,14 In addition to the difficulty in diagnosis, the treatment of this complication does not yet have defined protocols, which makes conduct individualized and based on the clinical symptoms of the patient, as well as on the cost-benefit analysis of the treatment strategies.…”

“…5,10,11,14,16 In contrast with ruptured aneurysms, unruptured ones have a much lower mortality rate (30%) and treatment is generally based on antibiotics and patient monitoring. 5,14 In addition to the difficulty in diagnosis, the treatment of this complication does not yet have defined protocols, which makes conduct individualized and based on the clinical symptoms of the patient, as well as on the cost-benefit analysis of the treatment strategies. 10 The majority of the Guidelines advise waiting 6 to 8 weeks for performing cardiac surgery on patients with a hemorrhagic event secondary to IE.…”

Management of Infective Endocarditis with Cerebral Complications

“…13) Patients were examined according to our IE management algorithm. 12) Cerebral computed tomography (CT) was systematically performed on admission and antibiotic therapy was started immediately after diagnosis. Cerebrovascular complications included cerebral infarction, cerebral hemorrhage, intracranial mycotic aneurysm, brain abscess and meningitis.…”

“…Prospective randomized assessments of the proposed plans have also been lacking. We have developed an algorithm for the management of IE patients 12) and have applied this algorithm to all IE patients treated in our institution since 2002. In this study, we summarized the clinical characteristics, pathology and surgical outcomes within a comparison between IE patients with cerebrovascular complication (CVC) and without CVC.…”