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Semin Neurol 2019; 39(04): 495-506
DOI: 10.1055/s-0039-1688826
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

Thiago Santos Carneiro
1   Department of Neurology, Boston Medical Center, Boston, Massachusetts
,
Eric Awtry
2   Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
,
Nikola Dobrilovic
3   Department of Cardiac and Thoracic Surgery, Boston Medical Center, Boston, Massachusetts
,
Maura A. Fagan
2   Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
,
Simeon Kimmel
2   Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
,
Zoe M. Weinstein
2   Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
,
Anna M. Cervantes-Arslanian
1   Department of Neurology, Boston Medical Center, Boston, Massachusetts
4   Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
5   Department of Internal Medicine, Boston Medical center, Boston University School of Medicine, Boston, Massachusetts
› Author Affiliations
Further Information

Publication History

Publication Date:
18 September 2019 (online)

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Abstract

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

Keywords

infectious endocarditis - infectious intracranial aneurysms - valvular surgery
 

  • References

  • 1 Baddour LM, Wilson WR, Bayer AS. , et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. 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 (15) 1435-1486
    CrossrefPubMedGoogle Scholar
  • 2 Habib G, Lancellotti P, Antunes MJ. , et al. Ghid de management al endocarditei infecţioase 2015. Rom J Cardiol 2016; 26 (03) 343-405
    PubMedGoogle Scholar
  • 3 Pigretti S, Zurrú MC, Arias A, Parcerisa F, Luzzi A, Belziti C. Neurologic complications of infective endocarditis: do they have an impact on prognosis? [in Spanish]. Medicina (B Aires) 2017; 77 (02) 89-94
    PubMedGoogle Scholar
  • 4 Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the U.S., 1998-2009: a nationwide study. PLoS One 2013; 8 (03) e60033
    CrossrefPubMedGoogle Scholar
  • 5 Pant S, Patel NJ, Deshmukh A. , et al. Trends in infective endocarditis incidence, microbiology, and valve replacement in the United States from 2000 to 2011. J Am Coll Cardiol 2015; 65 (19) 2070-2076
    CrossrefPubMedGoogle Scholar
  • 6 Thuny F, Di Salvo G, Belliard O. , et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation 2005; 112 (01) 69-75
    CrossrefPubMedGoogle Scholar
  • 7 Habib G. Embolic risk in subacute bacterial endocarditis: determinants and role of transesophageal echocardiography. Curr Cardiol Rep 2003; 5 (02) 129-136
    CrossrefPubMedGoogle Scholar
  • 8 Morris NA, Matiello M, Lyons JL, Samuels MA. Neurologic complications in infective endocarditis: identification, management, and impact on cardiac surgery. Neurohospitalist 2014; 4 (04) 213-222
    CrossrefPubMedGoogle Scholar
  • 9 Steckelberg JM, Murphy JG, Ballard D. , et al. Emboli in infective endocarditis: the prognostic value of echocardiography. Ann Intern Med 1991; 114 (08) 635-640
    PubMedGoogle Scholar
  • 10 Mills J, Drew D. Serratia marcescens endocarditis: a regional illness associated with intravenous drug abuse. Ann Intern Med 1976; 84 (01) 29-35
    PubMedGoogle Scholar
  • 11 Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med 2013; 368 (15) 1425-1433
    CrossrefPubMedGoogle Scholar
  • 12 Murdoch DR, Corey GR, Hoen B. , et al; International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. 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 (05) 463-473
    CrossrefPubMedGoogle Scholar
  • 13 Jackson KA, Bohm MK, Brooks JT. , et al. Invasive methicillin-resistant staphylococcus aureus infections among persons who inject drugs - six sites, 2005-2016. MMWR Morb Mortal Wkly Rep 2018; 67 (22) 625-628
    CrossrefPubMedGoogle Scholar
  • 14 Weiss AJ, Elixhauser A, Barrett ML. , et al. Opioid-related inpatient stays and emergency department visits by state, 2009–2014. HCUP Statistical Brief #219. December 2016. Agency for Healthcare Research and Quality, Rockville, MD. 1–16. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb219-Opioid-Hospital-Stays-ED-Visits-by-State.pdf . Accessed April 25, 2019
    PubMedGoogle Scholar
  • 15 Wurcel AG, Anderson JE, Chui KKH. , et al. Increasing infectious endocarditis admissions among young people who inject drugs. Open Forum Infect Dis 2016; 3 (03) ofw157
    CrossrefPubMedGoogle Scholar
  • 16 Ares WJ, Cabrera EA, Desai S. , et al. Intravenous drug use is novel predictor of infectious intracranial aneurysms in patients with infective endocarditis. World Neurosurg 2018; 118: e813-e817
    CrossrefPubMedGoogle Scholar
  • 17 Wakeman SE, Ghoshhajra BB, Dudzinski DM, Wilens T, Slavin PL. Case records of the Massachusetts General Hospital. Case 35-2014: a 31-year-old woman with fevers, chest pain, and a history of HCV infection and substance-use disorder. N Engl J Med 2014; 371 (20) 1918-1926
    CrossrefPubMedGoogle Scholar
  • 18 Suzuki J. Medication-assisted treatment for hospitalized patients with intravenous-drug-use related infective endocarditis. Am J Addict 2016; 25 (03) 191-194
    CrossrefPubMedGoogle Scholar
  • 19 Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies--tackling the opioid-overdose epidemic. N Engl J Med 2014; 370 (22) 2063-2066
    CrossrefPubMedGoogle Scholar
  • 20 Bart G. Maintenance medication for opiate addiction: the foundation of recovery. J Addict Dis 2012; 31 (03) 207-225
    CrossrefPubMedGoogle Scholar
  • 21 Iung B, Tubiana S, Klein I. , et al; ECHO-IMAGE Study Group. Determinants of cerebral lesions in endocarditis on systematic cerebral magnetic resonance imaging: a prospective study. Stroke 2013; 44 (11) 3056-3062
    CrossrefPubMedGoogle Scholar
  • 22 Salaun E, Touil A, Hubert S. , et al. Intracranial haemorrhage in infective endocarditis. Arch Cardiovasc Dis 2018; 111 (12) 712-721
    CrossrefPubMedGoogle Scholar
  • 23 Salvarani C, Brown Jr RD, Calamia KT. , et al. Primary central nervous system vasculitis presenting with intracranial hemorrhage. Arthritis Rheum 2011; 63 (11) 3598-3606
    CrossrefPubMedGoogle Scholar
  • 24 Cantier M, Mazighi M, Klein I. , et al. Neurologic complications of infective endocarditis: recent findings. Curr Infect Dis Rep 2017; 19 (11) 41
    CrossrefPubMedGoogle Scholar
  • 25 Weeks SG, Silva C, Auer RN, Doig CJ, Gill MJ, Power C. Encephalopathy with staphylococcal endocarditis: multiple neuropathological findings. Can J Neurol Sci 2001; 28 (03) 260-264
    PubMedGoogle Scholar
  • 26 Yates PA, Villemagne VL, Ellis KA, Desmond PM, Masters CL, Rowe CC. Cerebral microbleeds: a review of clinical, genetic, and neuroimaging associations. Front Neurol 2014; 4: 205
    PubMedGoogle Scholar
  • 27 Cooper HA, Thompson EC, Laureno R. , et al. Subclinical brain embolization in left-sided infective endocarditis: results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses (EMBOLISM) pilot study. Circulation 2009; 120 (07) 585-591
    CrossrefPubMedGoogle Scholar
  • 28 Powers WJ, Rabinstein AA, Ackerson T. , et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49 (03) e46-e110
    CrossrefPubMedGoogle Scholar
  • 29 Glenn J, Strecker-McGraw M, McGraw I, Jabbar K, James NA, Stone CK. Rupture of an occult intracranial mycotic aneurysm after intravenous thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke. J Emerg Med 2017; 53 (05) 717-721
    CrossrefPubMedGoogle Scholar
  • 30 Ambrosioni J, Urra X, Hernández-Meneses M. , et al. Mechanical thrombectomy for acute ischemic stroke secondary to infective endocarditis. Clin Infect Dis 2018; 66 (08) 1286-1289
    CrossrefPubMedGoogle Scholar
  • 31 Ruttmann E, Willeit J, Ulmer H. , et al. Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke 2006; 37 (08) 2094-2099
    CrossrefPubMedGoogle Scholar
  • 32 García-Cabrera E, Fernández-Hidalgo N, Almirante B. , et al; Group for the Study of Cardiovascular Infections of the Andalusian Society of Infectious Diseases; Spanish Network for Research in Infectious Diseases. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation 2013; 127 (23) 2272-2284
    CrossrefPubMedGoogle Scholar
  • 33 Goulenok T, Klein I, Mazighi M. , et al; IMAGE study group. Infective endocarditis with symptomatic cerebral complications: contribution of cerebral magnetic resonance imaging. Cerebrovasc Dis 2013; 35 (04) 327-336
    CrossrefPubMedGoogle Scholar
  • 34 Greenberg SM, Vernooij MW, Cordonnier C. , et al; Microbleed Study Group. Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol 2009; 8 (02) 165-174
    CrossrefPubMedGoogle Scholar
  • 35 Klein I, Iung B, Labreuche J. , et al; IMAGE Study Group. Cerebral microbleeds are frequent in infective endocarditis: a case-control study. Stroke 2009; 40 (11) 3461-3465
    CrossrefPubMedGoogle Scholar
  • 36 Duval X, Iung B, Klein I. , et al; IMAGE (Resonance Magnetic Imaging at the Acute Phase of Endocarditis) Study Group. Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a prospective study. Ann Intern Med 2010; 152 (08) 497-504 , W175
    CrossrefPubMedGoogle Scholar
  • 37 Malhotra A, Schindler J, Mac Grory B. , et al. Cerebral microhemorrhages and meningeal siderosis in infective endocarditis. Cerebrovasc Dis 2017; 43 (1–2): 59-67
    CrossrefPubMedGoogle Scholar
  • 38 Okazaki S, Sakaguchi M, Hyun B. , et al. Cerebral microbleeds predict impending intracranial hemorrhage in infective endocarditis. Cerebrovasc Dis 2011; 32 (05) 483-488
    CrossrefPubMedGoogle Scholar
  • 39 Hess A, Klein I, Iung B. , et al. Brain MRI findings in neurologically asymptomatic patients with infective endocarditis. AJNR Am J Neuroradiol 2013; 34 (08) 1579-1584
    CrossrefPubMedGoogle Scholar
  • 40 Murai R, Kaji S, Kitai T. , et al. The clinical significance of cerebral microbleeds in infective endocarditis patients. Semin Thorac Cardiovasc Surg 2019; 31 (01) 51-58
    CrossrefPubMedGoogle Scholar
  • 41 Jones Jr HR, Siekert RG. Neurological manifestations of infective endocarditis. Review of clinical and therapeutic challenges. Brain 1989; 112 (Pt 5): 1295-1315
    CrossrefPubMedGoogle Scholar
  • 42 Bohmfalk GL, Story JL, Wissinger JP, Brown Jr WE. Bacterial intracranial aneurysm. J Neurosurg 1978; 48 (03) 369-382
    CrossrefPubMedGoogle Scholar
  • 43 Ducruet AF, Hickman ZL, Zacharia BE. , et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev 2010; 33 (01) 37-46
    CrossrefPubMedGoogle Scholar
  • 44 Lucas MJ, Brouwer MC, van der Ende A, van de Beek D. Endocarditis in adults with bacterial meningitis. Circulation 2013; 127 (20) 2056-2062
    CrossrefPubMedGoogle Scholar
  • 45 Molnar A, Beyer R, Florian S. , et al. Drainage of cerebral abscesses prior to valve replacement in stable patients with acute left-sided infective endocarditis. CNS Neurol Disord Drug Targets 14 (04) 534-539
    PubMedGoogle Scholar
  • 46 Mirabel M, Sonneville R, Hajage D. , et al; ENDOREA Study Group. Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis. Eur Heart J 2014; 35 (18) 1195-1204
    CrossrefPubMedGoogle Scholar
  • 47 Jauch EC. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44 (03) 870-947
    CrossrefPubMedGoogle Scholar
  • 48 Champey J, Pavese P, Bouvaist H, Kastler A, Krainik A, Francois P. Value of brain MRI in infective endocarditis: a narrative literature review. Eur J Clin Microbiol Infect Dis 2016; 35 (02) 159-168
    CrossrefPubMedGoogle Scholar
  • 49 Cho S-M, Marquardt RJ, Rice CJ. , et al. Cerebral microbleeds predict infectious intracranial aneurysm in infective endocarditis. Eur J Neurol 2018; 25 (07) 970-975
    CrossrefPubMedGoogle Scholar
  • 50 Dammert S, Krings T, Moller-Hartmann W. , et al. Detection of intracranial aneurysms with multislice CT: comparison with conventional angiography. Neuroradiology 2004; 46 (06) 427-434
    PubMedGoogle Scholar
  • 51 Hui FK, Bain M, Obuchowski NA. , et al. Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg 2015; 7 (06) 449-452
    CrossrefPubMedGoogle Scholar
  • 52 Iversen K, Ihlemann N, Gill SU. , et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med 2019; 380 (05) 415-424
    CrossrefPubMedGoogle Scholar
  • 53 Ribera E, Gómez-Jimenez J, Cortes E. , et al. Effectiveness of cloxacillin with and without gentamicin in short-term therapy for right-sided Staphylococcus aureus endocarditis. A randomized, controlled trial. Ann Intern Med 1996; 125 (12) 969-974
    CrossrefPubMedGoogle Scholar
  • 54 Cosgrove SE, Vigliani GA, Fowler Jr VG. , et al. Initial low-dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic. Clin Infect Dis 2009; 48 (06) 713-721
    CrossrefPubMedGoogle Scholar
  • 55 Bhattacharyya S, Darby RR, Raibagkar P, Gonzalez Castro LN, Berkowitz AL. Antibiotic-associated encephalopathy. Neurology 2016; 86 (10) 963-971
    CrossrefPubMedGoogle Scholar
  • 56 Lee HA, Lin CY, Chen YC. , et al. Surgical interventions of isolated active mitral valve endocarditis: predisposing factors and impact of neurological insults on final outcome. Medicine (Baltimore) 2018; 97 (11) e0054
    PubMedGoogle Scholar
  • 57 Pang PYK, Sin YK, Lim CH. , et al. Surgical management of infective endocarditis: an analysis of early and late outcomes. Eur J Cardiothorac Surg 2015; 47 (05) 826-832
    CrossrefPubMedGoogle Scholar
  • 58 Diab M, Guenther A, Sponholz C. , et al. Pre-operative stroke and neurological disability do not independently affect short- and long-term mortality in infective endocarditis patients. Clin Res Cardiol 2016; 105 (10) 847-857
    CrossrefPubMedGoogle Scholar
  • 59 Wilbring M, Tugtekin SM, Matschke K. The impact of preoperative neurologic events in patients suffering from native infective valve endocarditis. Thorac Cardiovasc Surg 2013; 61 (S01): SC138
    Article in Thieme ConnectPubMedGoogle Scholar
  • 60 Vilacosta I, Graupner C, San Román JA. , et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 2002; 39 (09) 1489-1495
    CrossrefPubMedGoogle Scholar
  • 61 Maruyama M, Kuriyama Y, Sawada T, Yamaguchi T, Fujita T, Omae T. Brain damage after open heart surgery in patients with acute cardioembolic stroke. Stroke 1989; 20 (10) 1305-1310
    CrossrefPubMedGoogle Scholar
  • 62 Angstwurm K, Borges AC, Halle E, Schielke E, Einhäupl KM, Weber JR. Timing the valve replacement in infective endocarditis involving the brain. J Neurol 2004; 251 (10) 1220-1226
    CrossrefPubMedGoogle Scholar
  • 63 Eishi K, Kawazoe K, Kuriyama Y, Kitoh Y, Kawashima Y, Omae T. Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan. J Thorac Cardiovasc Surg 1995; 110 (06) 1745-1755
    CrossrefPubMedGoogle Scholar
  • 64 Barsic B, Dickerman S, Krajinovic V. , et al; International Collaboration on Endocarditis–Prospective Cohort Study Investigators. Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis 2013; 56 (02) 209-217
    CrossrefPubMedGoogle Scholar
  • 65 Morita K, Sasabuchi Y, Matsui H, Fushimi K, Yasunaga H. Outcomes after early or late timing of surgery for infective endocarditis with ischaemic stroke: a retrospective cohort study. Interact Cardiovasc Thorac Surg 2015; 21 (05) 604-609
    CrossrefPubMedGoogle Scholar
  • 66 Hosono M, Sasaki Y, Hirai H. , et al. Considerations in timing of surgical intervention for infective endocarditis with cerebrovascular complications. J Heart Valve Dis 2010; 19 (03) 321-325
    PubMedGoogle Scholar
  • 67 Kim YK, Choi CG, Jung J. , et al. Effect of cerebral embolus size on the timing of cardiac surgery for infective endocarditis in patients with neurological complications. Eur J Clin Microbiol Infect Dis 2018; 37 (03) 545-553
    CrossrefPubMedGoogle Scholar
  • 68 Murai R, Funakoshi S, Kaji S. , et al. Outcomes of early surgery for infective endocarditis with moderate cerebral complications. J Thorac Cardiovasc Surg 2017; 153 (04) 831.e8-840.e8
    PubMedGoogle Scholar
  • 69 Tam DY, Yanagawa B, Verma S. , et al. Early vs late surgery for patients with endocarditis and neurological injury: a systematic review and meta-analysis. Can J Cardiol 2018; 34 (09) 1185-1199
    CrossrefPubMedGoogle Scholar
  • 70 Yoshioka D, Toda K, Sakaguchi T. , et al; OSCAR study group. Valve surgery in active endocarditis patients complicated by intracranial haemorrhage: the influence of the timing of surgery on neurological outcomes. Eur J Cardiothorac Surg 2014; 45 (06) 1082-1088
    CrossrefPubMedGoogle Scholar
  • 71 Wang H, Guo LL, Fang LG. , et al. Risk factors and prognosis of neurological complications in patients with infective endocarditis [in Chinese]. Zhonghua Nei Ke Za Zhi 2016; 55 (08) 595-598
    PubMedGoogle Scholar
  • 72 Oh THT, Wang TKM, Pemberton JA, Raudkivi PJ. Early or late surgery for endocarditis with neurological complications. Asian Cardiovasc Thorac Ann 2016; 24 (05) 435-440
    CrossrefPubMedGoogle Scholar
  • 73 Gillinov AM, Shah RV, Curtis WE. , et al. Valve replacement in patients with endocarditis and acute neurologic deficit. 1996; 61 (04) 1125-1129
    PubMedGoogle Scholar
  • 74 Asaithambi G, Adil MM, Qureshi AI. Thrombolysis for ischemic stroke associated with infective endocarditis: results from the nationwide inpatient sample. Stroke 2013; 44 (10) 2917-2919
    CrossrefPubMedGoogle Scholar
  • 75 Ambrosioni J, Urra X, Hernández-Meneses M. , et al; Hospital Clínic Infective Endocarditis Study Group. Mechanical thrombectomy for acute ischemic stroke secondary to infective endocarditis. Clin Infect Dis 2018; 66 (08) 1286-1289
    CrossrefPubMedGoogle Scholar