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Neurologische Komplikationen bei infektiöser Endokarditis

Neurological complications of infective endocarditis

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Zusammenfassung

In 20–40% beteiligt die infektiöse Endokarditis das Gehirn. Neurologische Symptome sind oft die Erstmanifestation der Erkrankung. Bei der häufigsten neurologischen Komplikation, dem ischämischen Hirninfarkt, ebenso wie bei intrakraniellen Blutungen sind neben einem Herzgeräusch die systemischen Entzündungszeichen wegweisend. Eine Enzephalopathie ist meist durch Hirninfarkte bedingt. Bei Meningitis und Hirnabszess sollte der Nachweis ungewöhnlicher Erreger dringend an eine Endokarditis denken lassen. Therapeutisch ist die antimikrobielle Therapie essenziell. Ein Klappenersatz verbessert die Prognose, ist aber in der akuten Phase nur bei einem Drittel der Patienten nötig. Der Zeitpunkt des Klappenersatzes wird vom Auftreten neurologischer Komplikationen beeinflusst: Bei dringlicher kardiologischer Indikation eines Klappenersatzes ist das Risiko einer perioperativen neurologischen Verschlechterung innerhalb der ersten 3 Tage nach Hirninfarkt vertretbar; bei nicht dringlicher Indikation sollte 2–4 Wochen gewartet werden. Bei Hirnblutungen gibt es kasuistische Berichte von erfolgreichem Klappenersatz innerhalb der ersten 4 Wochen; es wird aber empfohlen, die Operation 4–6 Wochen zu verschieben. Zu den übrigen neurologischen Komplikationen gibt es keine Daten. Ein Patient mit Endokarditis ist auch heute noch eine interdisziplinäre, diagnostische und therapeutische Herausforderung.

Abstract

Infective endocarditis involves the brain in 20–40% of cases. The neurologic syndrome often is the presenting feature. The most frequent neurologic complication is cerebral ischemia. In these patients and those with intracranial hemorrhage, a heart murmur as well as systemic signs of inflammation point to endocarditis. The encephalopathy in endocarditis is mostly due to cerebral infarction. In bacterial meningitis and brain abscess an uncommon isolate arouses suspicion. The most important therapy is antibiotic treatment. Valve replacement improves outcome; in the acute phase of endocarditis, however, it is only necessary in a third of the patients. Neurologic complications interfere with the timing of the valve replacement. If it is urgently required, its risk is reasonable within 3 days after cerebral ischemia; if possible 2–4 weeks should be waited. Cases of successful valve replacement within 4 weeks after intracranial hemorrhage have been reported, but it is recommended to postpone it for 4–6 weeks. There are no data available for the other neurologic complications. Even today patients with endocarditis challenge the diagnostic and therapeutic capacity of various disciplines.

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Abb. 1

Abbreviations

BSG:

Blutkörpersenkgeschwindigkeit

CT:

Computertomographie

ICB:

intrazerebrale Blutung

MRT:

Magnetresonanztomographie

OP:

Operation

SAB:

Subarachnoidalblutung

St. aureus :

Staphylococcus aureus

St. pneumoniae :

Streptococcus pneumoniae

spp.:

Spezies

TEE:

transösophageale Echokardiographie

TTE:

transthorakale Echokardiographie

Literatur

  1. Angstwurm K, Halle E, Wetzel K et al. (2004) Isolated bacterial meningitis as the key syndrome of infective endocarditis. Infection 32:47–50

    CAS  PubMed  Google Scholar 

  2. Austrian R (1957) Pneumococcal endocarditis, meningitis, and rupture of the aortic valve. Arch Intern Med 99:539–544

    CAS  Google Scholar 

  3. Bademosi O, Falase AO, Jaiyesimi F et al. (1976) Neuropsychiatric manifestations of infective endocarditis: a study of 95 patients at Ibadan, Nigeria. J Neurol Neurosurg Psychiatry 39:325–329

    CAS  PubMed  Google Scholar 

  4. Bayer AS, Bolger AF, Taubert KA et al. (1998) Diagnosis and management of infective endocarditis and its complications. Circulation 98:2936–2948

    Google Scholar 

  5. Bohmfalk GL, Story JL, Weissinger JP et al. (1978) Bacterial intracranial aneurysms. J Neurosurg 48:369–382

    CAS  PubMed  Google Scholar 

  6. Brust JCM, Dickinson PCT, Hughes JEO et al. (1990) The diagnosis and treatment of cerebral mycotic aneurysms. Ann Neurol 27:238–246

    Google Scholar 

  7. Cabell CH, Fowler VG (2003) Vegetations in endocarditis: big is bad, but is there more to it? Am Heart J 146:189–190

    Article  PubMed  Google Scholar 

  8. Cabell CH, Pond KK, Perterson GE et al. (2001) The risk of stroke and death with aortic and mitral valve endocarditis. Am Heart J 142:75–80

    Article  CAS  PubMed  Google Scholar 

  9. Chan KL, Dumesnil JG, Cujec B et al. (2003) A randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis. J Am Coll Cardiol 42:775–780

    Article  CAS  PubMed  Google Scholar 

  10. Chukwudelunzu FE, Brown RD, Steckelberg JM et al. (1998) Neurologic complications of infective endocarditis: Mayo Clinic experience 1980–1996. Neurology 50:A213–A213

    Google Scholar 

  11. Chukwudelunzu FE, Brown RD, Wijdicks EF et al. (2002) Subarachnoid haemorrhage associated with infectious endocarditis: case report and literature review. Eur J Neurol 9:423–427

    Article  CAS  PubMed  Google Scholar 

  12. Chun JY, Smith W, Halnach VV et al. (2001) Current multimodality management of infectious intracranial aneurysms. Neurosurgery 48:1213–1214

    Google Scholar 

  13. Davenport J, Hart RG (1990) Prosthetic valve endocarditis 1976–1987. Antibiotics, anticoagulation, and stroke. Stroke 21:993–999

    CAS  PubMed  Google Scholar 

  14. Dodds GA, Sexton DJ, Durack DT et al. (1996) Negative predictive value of the Duke criteria for infective endokarditis. Am J Cardiol 77:403–407

    Article  CAS  PubMed  Google Scholar 

  15. Durand ML, Calderwood SB, Weber DJ et al. (1993) Acute bacterial meningitis in adults. N Engl J Med 328:21–28

    Article  CAS  PubMed  Google Scholar 

  16. Eishi K, Kawazoe K, Kuriyama Y et al. (1995) Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan. J Thorac Cardiovasc Surg 110:1745–1755

    CAS  PubMed  Google Scholar 

  17. Gilbert DN, Moellering RC, Sande MA (2002) The Sanford guide to antimicrobial therapy, 32nd edn., pp 18–21

  18. Gillinov AM, Shah RV, Curtis WE et al. (1996) Valve replacement in patients with endocarditis and acute neurologic deficit. Ann Thorac Surg 61:1125–1129

    Article  CAS  PubMed  Google Scholar 

  19. Hart RG, Kagan-Hallet K, Joerns SE (1987) Mechanisms of intracranial hemorrhage in infective endocarditis. Stroke 18:1048–1056

    CAS  PubMed  Google Scholar 

  20. Hart RG, Foster JW, Luther MF et al. (1990) Stroke in infective endocarditis. Stroke 21:695–700

    CAS  PubMed  Google Scholar 

  21. Heiro M, Nikoskelainen J, Engblom E et al. (2000) Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland. Arch Intern Med 160:2781–2787

    Article  CAS  PubMed  Google Scholar 

  22. Hornig CR, Bauer T, Simon C et al. (1993) Hemorrhagic transformation in cardioembolic cerebral infarction. Stroke 24:465–468

    CAS  PubMed  Google Scholar 

  23. Horstkotte D, Follath F, Gutschik E et al. (2003) Guidelines for prevention, diagnosis and treatment of infective endocarditis. The task force on infective endocarditis of the European Society of Cardiology. http://www.escardio.org/scinfo/Tforceguidelines.htm

  24. Jones H-R, Siekert RG, Geraci JE (1969) Neurologic manifestations of bacterial endocarditis. Ann Intern Med 71:21–28

    PubMed  Google Scholar 

  25. Kanter MC, Hart RG (1991) Neurologic complications of infective endocarditis. Neurology 41:1015–1020

    CAS  PubMed  Google Scholar 

  26. Korkmaz S, Ileri M, Hisar E et al. (2001) Increased levels of soluble adhesion molecules, E-selectin and P-selectin, in patients with infective endocarditis and embolic events. Eur Heart J 22:874–878

    Article  CAS  PubMed  Google Scholar 

  27. Kupferwasser LI, Hafner G, Mohr-Kahaly S et al. (1999) The presence of infection-related antiphospholipid antibodies in infective endocarditis determines a major risk factor for embolic events. J Am Coll Cardiol 33:1365–1371

    Article  CAS  PubMed  Google Scholar 

  28. Le Cam B, Guivarch G, Boles JM et al. (1984) Neurologic complications in a group of 86 bacterial endocarditis. Eur Heart J 5(Suppl C):97–100

    Google Scholar 

  29. Li JS, Sexton DJ, Mick N et al. (2000) Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 30:633–638

    Article  CAS  PubMed  Google Scholar 

  30. Maruyama M, Kuriyama Y, Sawada T et al. (1989) Brain damage after open heart surgery in patients with acute cardioembolic stroke. Stroke 20:1305–1310

    CAS  PubMed  Google Scholar 

  31. Masuda J, Yutani C, Waki R et al. (1992) Histopathological analysis of the mechanisms of intracranial hemorrhage complicating infective endocarditis. Stroke 23:843–850

    CAS  PubMed  Google Scholar 

  32. Matsushita K, Kuriyama Y, Sawada T et al. (1993) Hemorrhagic and ischemic cerebrovascular complications of active infective endocarditis of native valve. Eur Neurol 33:267–274

    CAS  PubMed  Google Scholar 

  33. Mylonakis E, Calderwood SB (2001) Infective endocarditis in adults. N Engl J Med 345:1318–1330

    Google Scholar 

  34. Naber C, Kern P, Shah PM et al. (2003) Empfehlungen zur kalkulierten parenteralen Initialtherapie bakterieller Erkrankungen bei Erwachsenen. Kapitel 9 Endokarditis/Meningitis. http://www.p-e-g.de/empfehlungen/empfehlungen.htm

  35. Osler W (1885) The goulstonian lectures on malignant endocarditis. Brit Med J 1:467–577

    Google Scholar 

  36. Parrino PE, Kron IL, Ross SD et al. (1999) Does a focal neurologic deficit contraindicate operation in a patient with endocarditis? Ann Thorac Surg 67:59–64

    Article  CAS  PubMed  Google Scholar 

  37. Paschalis C, Pugsley W, John R et al. (1990) Rate of cerebral embolic events in relation to antibiotic and anticoagulant therapy in patients with bacterial endocarditis. Eur Neurol 30:87–89

    CAS  Google Scholar 

  38. Piper C, Wiemer M, Schulte HD et al. (2001) Stroke is not a contraindication for urgent valve replacement in acute infective endocarditis. J Heart Valve Dis 10:703–711

    CAS  Google Scholar 

  39. Pruitt AA, Rubin RH, Karchmer AW et al. (1978) Neurologic complications of bacterial endocarditis. Medicine (Baltimore) 57:329–343

  40. Renzulli A, Carozza A, Marra C et al. (2000) Are blood and valve cultures predictive for long-term outcome following surgery for infective endocarditis? Eur J Cardio Thorac Surg 17:228–233

    Article  CAS  Google Scholar 

  41. Roder BL, Wandall DA, Espersen F et al. (1997) Neurologic manifestations in Staphylococcus aureus endocarditis: a review of 260 bacteremic cases in nondrug addicts. Am J Med 102:379–386

    Article  CAS  PubMed  Google Scholar 

  42. Salgado AV, Furlan AJ, Keys TF (1987) Mycotic aneurysm, subarachnoid hemorrhage, and indications for cerebral angiography in infective endocarditis. Stroke 18:1057–1060

    CAS  PubMed  Google Scholar 

  43. Salgado AV, Furlan AJ, Keys TF et al. (1989) Neurologic complications of endocarditis: a 12-year experience. Neurology 39:173–178

    CAS  PubMed  Google Scholar 

  44. Siekert RG, Jones HR (1970) Transient cerebral ischemic attacks associated with subacute bacterial endocarditis. Stroke 1:178–193

    CAS  PubMed  Google Scholar 

  45. Steckelberg JM, Murphy JG, Ballard D et al. (1991) Emboli in infective endocarditis: the prognostic value of echocardiography. Ann Intern Med 114:635–340

    CAS  PubMed  Google Scholar 

  46. Ting W, Silverman M, Levitsky S (1991) Valve replacement in patients with endocarditis and cerebral septic emboli. Ann Thorac Surg 51:18–21

    CAS  PubMed  Google Scholar 

  47. Tischler MD, Vaitkus PT (1997) The ability of vegetation size on echocardiography to predict clinical complications: a meta-analysis. J Am Soc Echocardiogr 10:562–568

    CAS  PubMed  Google Scholar 

  48. Toone EC (1941) Cerebral manifestations of bacterial endocarditis. Ann Intern Med 14:1551–1574

    Google Scholar 

  49. Tornos P, Alimirante B, Mirabet S et al. (1999) Infective endocarditis due to Staphylococcus aureus: deleterious effect of anticoagulant therapy. Arch Intern Med 159:473–475

    Article  CAS  Google Scholar 

  50. Vilacosta I, Graupner C, San Roman JA et al. (2002) Risk of embolisation after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 39:1489–1498

    Article  PubMed  Google Scholar 

  51. Wallace AG, Young GW, Osterhout (1965) Treatment of acute bacterial endocarditis by valve excision and replacement. Circulation 31:450–453

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Klinik und Poliklinik für Neurologie, Charité Universitätsmedizin, Berlin, Deutschland

    K. Angstwurm & J. R. Weber

  2. Medizinische Klinik und Poliklinik, Schwerpunkt Kardiologie, Angiologie, Pulmologie, Charité Universitätsmedizin, Berlin, Deutschland

    A. C. Borges

  3. Institut für Mikrobiologie und Hygiene, Campus Mitte, Charité Universitätsmedizin, Berlin, Deutschland

    E. Halle

  4. Klinik für Neurologie, Vivantes Auguste-Viktoria-Krankenhaus, Berlin, Deutschland

    E. Schielke

  5. Klinik und Poliklinik für Neurologie, CCM, Charité Universitätsmedizin, 10098, Berlin, Deutschland

    K. Angstwurm

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Correspondence to K. Angstwurm.

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Angstwurm, K., Borges, A.C., Halle, E. et al. Neurologische Komplikationen bei infektiöser Endokarditis . Nervenarzt 75, 734–741 (2004). https://doi.org/10.1007/s00115-004-1685-8

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