Neurological Complications of Infective Endocarditis
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.
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.
KeywordsInfective endocarditis Mycotic aneurysm Neurological complications Stroke Cardiac surgery Thrombectomy
Compliance with Ethical Standards
Conflict of Interest
José M. Ferro reports grants from Bayer, personal fees from Boehringer Ingelheim, outside the submitted work. Filipa Dourado Sotero, Madalena Rosário, and Ana Catarina Fonseca each declares that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.• Ambrosioni J, Hernandez-Meneses M, Téllez A, Pericàs J, Falces C, Tolosana J, et al. The changing epidemiology of infective endocarditis in the twenty-first century. Curr Infect Dis Rep. 2017;19(5):21. A review of the recent changes in the epidemiology of infective endocarditis. CrossRefPubMedGoogle Scholar
- 5.García-Cabrera E, Fernández-Hidalgo N, Almirante B, Ivanova-Georgieva R, Noureddine M, Plata A, et al. Neurological complications of infective endocarditis risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation. 2013;127(23):2272–84.CrossRefPubMedGoogle Scholar
- 6.Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG Jr, Bayer AS, et al. Clinical presentation, etiology and outcome of infective endocarditis in the 21st century: the international collaboration on endocarditis-prospective cohort study. Arch Intern Med. 2009;169(5):463–73.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Cantier M, Mazighi M, Klein I, Desilles JP, Wolff M, Timsit JF, et al. Neurologic complications of infective endocarditis: recent findings. Curr Infect Dis Rep. 2017;19(11).Google Scholar
- 11.Hoen B, Duval X. Infective endocarditis. N Engl J Med. 2013:300–13.Google Scholar
- 13.Cooper HA, Thompson EC, Laureno R, Fuisz A, Mark AS, Lin M, et al. Subclinical brain embolization in left-sided results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses ( EMBOLISM ) pilot study. Circulation. 2009;120(7):585–91.CrossRefPubMedGoogle Scholar
- 17.• Cho SM, Rice C, Marquardt RJ, Zhang LQ, Khoury J, Thatikunta P, et al. Magnetic resonance imaging susceptibility-weighted imaging lesion and contrast enhancement may represent infectious intracranial aneurysm in infective endocarditis. Cerebrovasc Dis. 2017;44(3–4):210–6. A retrospective single-center study showing that sulcal SWI lesion are associated with infectious intracranial aneurysm. CrossRefPubMedGoogle Scholar
- 18.• Chakraborty T, Scharf E, Rabinstein AA, DeSimone D, El Rafei A, Brinjikji W, et al. Utility of brain magnetic resonance imaging in the surgical management of infective endocarditis. J Stroke Cerebrovasc Dis. 2017;26(11):2527–35. A retrospective single-center study indicating that preoperative MRI findings were not associated with differences in posoperative outcomes. CrossRefPubMedGoogle Scholar
- 27.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(5):524–8.CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435–86.CrossRefPubMedGoogle Scholar
- 32.Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 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). Eur Heart J. 2015;36:3075–128.CrossRefPubMedGoogle Scholar
- 36.• Ambrosioni J, Urra X, Hernández-Meneses M, Almela M, Falces C, Tellez A, et al. Mechanical thrombectomy for acute ischemic stroke secondary to infective endocarditis. Clin Infect Dis. 2018;66(8):1286–9. Report of the safety and efficacy of mechanical thrombectomy in 6 cases of acute ischemic stroke with large vessel occlusion secondary to infective endocarditis. CrossRefPubMedGoogle Scholar
- 37.• Scharf EL, Chakraborty T, Rabinstein A, Miranpuri AS. Endovascular management of cerebral septic embolism: three recent cases and review of the literature. J Neurointerv Surg. 2017;9(5):463–5. Report of 3 cases of endovascular management of cerebral septic embolism with a review of the literature. CrossRefPubMedGoogle Scholar
- 40.• Bolognese M, von Hessling A, Müller M. Successful thrombectomy in endocarditis-related stroke: case report and review of the literature. Interv Neuroradiol. 2018;24(5):529–32. Report of 1 case of endovascular management of cerebral septic embolism with a review of the literature. CrossRefPubMedGoogle Scholar
- 42.Chu VH, Park LP, Athan E, Delahaye F, Freiberger T, Lamas C, et al. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis a prospective study from the international collaboration on endocarditis. Circulation. 2015;131(2):131–40.CrossRefPubMedGoogle Scholar
- 43.•• Tam DY, Yanagawa B, Verma S, Ruel M, Fremes SE, Mazine A, et al. Early vs late surgery for patients with endocarditis and neurological injury: a systematic review and meta-analysis. Can J Cardiol. 2018;34:1185–99. Systematic review and meta-analysis of 27 observational studies comparing early vs. late surgery for infective endocarditis complicated by neurological events. CrossRefPubMedGoogle Scholar
- 44.• Ghoreishi M, Foster N, Pasrija C, Shah A, Watkins AC, Evans CF, et al. Early operation in patients with mitral valve infective endocarditis and acute stroke is safe. Ann Thorac Surg. 2018;105(1):69–75. Large observational study pointing that mitral valve surgery for infective endocaditis can be performed early with a low risk of posoperative neurological complications. CrossRefPubMedGoogle Scholar