Skip to main content

Advertisement

SpringerLink
Log in

Neurologic Complications of Infective Endocarditis: Recent Findings

  • Central Nervous System Infections (K Bloch, Section Editor)
  • Published:
Current Infectious Disease Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this paper is to provide recent insights in management of neurologic complications of left-sided infective endocarditis (IE).

Recent Findings

Cerebral lesions observed in IE patients are thought to involve synergistic pathophysiological mechanisms including thromboembolism, sepsis, meningitis, and small-vessel cerebral vasculitis. Brain MRI represents a major tool for the detection of asymptomatic events occurring in the majority of patients. The latter can impact therapeutic decisions and prognosis, especially when cardiac surgery is indicated. In patients presenting with neurologic complications, surgery could be safely performed earlier than previously thought.

Summary

Symptomatic cerebral ischemic or hemorrhagic events occur in 20–55% of IE patients, whereas asymptomatic events are detected in 60–80% of patients undergoing systematic brain MRI. Management of such patients requires an experienced multidisciplinary team. Recent studies suggest that early cardiac surgery, when indicated, can be performed safely in patients with cerebral ischemic events. Other important issues include the appropriate use of anti-infective and anti-thrombotic agents, and endovascular treatment for mycotic aneurysms. Altered mental status at IE onset, which is associated with brain injury, is a major determinant of short-term outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Pigretti S, Zurru MC, Arias A, Parcerisa F, Luzzi A, Belziti C. Neurologic complications of infective endocarditis: do they have an impact on prognosis? Medicina. 2017;77(2):89–94.

    PubMed  Google Scholar 

  2. Sonneville R, Mirabel M, Hajage D, Tubach F, Vignon P, Perez P, et al. Neurologic complications and outcomes of infective endocarditis in critically ill patients: the ENDOcardite en REAnimation prospective multicenter study. Crit Care Med. 2011;39(6):1474–81. https://doi.org/10.1097/CCM.0b013e3182120b41.

    Article  PubMed  Google Scholar 

  3. Murdoch DR, Corey GR, Hoen B, Miro 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. https://doi.org/10.1001/archinternmed.2008.603.

    Article  PubMed  PubMed Central  Google Scholar 

  4. •• 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). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075–128. https://doi.org/10.1093/eurheartj/ehv319. Current European guidelines for the management of IE patients.

    Article  PubMed  Google Scholar 

  5. Thuny F, Grisoli D, Collart F, Habib G, Raoult D. Management of infective endocarditis: challenges and perspectives. Lancet. 2012;379(9819):965–75. https://doi.org/10.1016/S0140-6736(11)60755-1.

    Article  PubMed  Google Scholar 

  6. Leroy O, Georges H, Devos P, Bitton S, De Sa N, Dedrie C, et al. Infective endocarditis requiring ICU admission: epidemiology and prognosis. Ann Intensive Care. 2015;5(1):45. https://doi.org/10.1186/s13613-015-0091-7.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Duval X, Iung B, Klein I, Brochet E, Thabut G, Arnoult F, et al. Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a prospective study. Ann Intern Med. 2010;152(8):497–504, W175. https://doi.org/10.7326/0003-4819-152-8-201004200-00006.

    Article  PubMed  Google Scholar 

  8. Garcia-Cabrera E, Fernandez-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. https://doi.org/10.1161/CIRCULATIONAHA.112.000813.

    Article  PubMed  Google Scholar 

  9. Lucas MJ, Brouwer MC, van der Ende A, van de Beek D. Endocarditis in adults with bacterial meningitis. Circulation. 2013;127(20):2056–62. https://doi.org/10.1161/CIRCULATIONAHA.113.001545.

    Article  PubMed  Google Scholar 

  10. Heiro M, Helenius H, Hurme S, Savunen T, Engblom E, Nikoskelainen J, et al. Short-term and one-year outcome of infective endocarditis in adult patients treated in a Finnish teaching hospital during 1980-2004. BMC Infect Dis. 2007;7:78. https://doi.org/10.1186/1471-2334-7-78.

    Article  PubMed  PubMed Central  Google Scholar 

  11. • Mirabel M, Sonneville R, Hajage D, Novy E, Tubach F, Vignon P, et al. Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis. Eur Heart J. 2014;35(18):1195–204. https://doi.org/10.1093/eurheartj/eht303. This study found no impact of surgical timing on outcomes in patients with critical IE.

    Article  PubMed  Google Scholar 

  12. Lee SJ, Oh SS, Lim DS, Na CY, Kim JH. Clinical significance of cerebrovascular complications in patients with acute infective endocarditis: a retrospective analysis of a 12-year single-center experience. BMC Neurol. 2014;14:30. https://doi.org/10.1186/1471-2377-14-30.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Patrat-Delon S, Rouxel A, Gacouin A, Revest M, Flecher E, Fouquet O, et al. EuroSCORE II underestimates mortality after cardiac surgery for infective endocarditis. Eur J Cardiothorac Surg. 2016;49(3):944–51. https://doi.org/10.1093/ejcts/ezv223.

    Article  PubMed  Google Scholar 

  14. Kang DH, Kim YJ, Kim SH, Sun BJ, Kim DH, Yun SC, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466–73. https://doi.org/10.1056/NEJMoa1112843.

    Article  CAS  PubMed  Google Scholar 

  15. Klein I, Iung B, Labreuche J, Hess A, Wolff M, Messika-Zeitoun D, et al. Cerebral microbleeds are frequent in infective endocarditis: a case-control study. Stroke. 2009;40(11):3461–5. https://doi.org/10.1161/STROKEAHA.109.562546.

    Article  PubMed  Google Scholar 

  16. Okazaki S, Yoshioka D, Sakaguchi M, Sawa Y, Mochizuki H, Kitagawa K. Acute ischemic brain lesions in infective endocarditis: incidence, related factors, and postoperative outcome. Cerebrovasc Dis. 2013;35(2):155–62. https://doi.org/10.1159/000346101.

    Article  PubMed  Google Scholar 

  17. Hess A, Klein I, Iung B, Lavallee P, Ilic-Habensus E, Dornic Q, et al. Brain MRI findings in neurologically asymptomatic patients with infective endocarditis. AJNR Am J Neuroradiol. 2013;34(8):1579–84. https://doi.org/10.3174/ajnr.A3582.

    Article  CAS  PubMed  Google Scholar 

  18. Ay H, Sahin G, Saatci I, Soylemezoglu F, Saribas O. Primary angiitis of the central nervous system and silent cortical hemorrhages. AJNR Am J Neuroradiol. 2002;23(9):1561–3.

    PubMed  Google Scholar 

  19. Salvarani C, Brown RD Jr, Calamia KT, Christianson TJ, Huston J 3rd, Meschia JF, et al. Primary central nervous system vasculitis presenting with intracranial hemorrhage. Arthritis Rheum. 2011;63(11):3598–606. https://doi.org/10.1002/art.30594.

    Article  PubMed  Google Scholar 

  20. Terruso V, Bonanni I, Dinia L, Canepa C, Gandolfo C, Del Sette M. Neurological complication of infective endocarditis mimicking temporal arteritis. Eur Neurol. 2008;59(3–4):198–9. https://doi.org/10.1159/000114045.

    Article  PubMed  Google Scholar 

  21. Alvarez Soria MJ, de Leon CGS, Hernandez Gonzalez A. Isolated Sylvian vasculitis as presentation of a subacute bacterial endocarditis. Neurologia. 2009;24(4):280.

    CAS  PubMed  Google Scholar 

  22. Hart RG, Foster JW, Luther MF, Kanter MC. Stroke in infective endocarditis. Stroke. 1990;21(5):695–700.

    Article  CAS  PubMed  Google Scholar 

  23. Wang KY, Shimajiri S, Yoshida T, Yamada S, Sasaguri Y. An autopsy case of microscopic polyangiitis associated with bacterial endocarditis. J UOEH. 2010;32(3):273–9.

    Article  PubMed  Google Scholar 

  24. Weeks SG, Silva C, Auer RN, Doig CJ, Gill MJ, Power C. Encephalopathy with staphylococcal endocarditis: multiple neuropathological findings. Can J Neurol Sci Le journal canadien des sciences neurologiques. 2001;28(3):260–4.

    Article  CAS  Google Scholar 

  25. Christiansen JG, Oscarson M, Jensen HE, Jensen LK, Koch J, Aalbaek B, et al. Embolic encephalitis in a porcine model of endocarditis. In vivo. 2013;27(5):591–7.

    PubMed  Google Scholar 

  26. Karstrup CC, Jensen HE, Aalbaek B, Leifsson PS, Boye M, Agerholm JS. Endocarditis-associated brain lesions in slaughter pigs. J Comp Pathol. 2011;144(4):289–95. https://doi.org/10.1016/j.jcpa.2010.10.009.

    Article  CAS  PubMed  Google Scholar 

  27. 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. https://doi.org/10.3389/fneur.2013.00205.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Schreiber S, Bueche CZ, Garz C, Braun H. Blood brain barrier breakdown as the starting point of cerebral small vessel disease?—new insights from a rat model. Exp Transl Stroke Med. 2013;5(1):4. https://doi.org/10.1186/2040-7378-5-4.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Jeon SB, Lee JW, Kim SJ, Chung CH, Kwon SU, Choi CG, et al. New cerebral lesions on T2*-weighted gradient-echo imaging after cardiac valve surgery. Cerebrovasc Dis. 2010;30(2):194–9. https://doi.org/10.1159/000317108.

    Article  PubMed  Google Scholar 

  30. Mook-Kanamori BB, Fritz D, Brouwer MC, van der Ende A, van de Beek D. Intracerebral hemorrhages in adults with community associated bacterial meningitis in adults: should we reconsider anticoagulant therapy? PLoS One. 2012;7(9):e45271. https://doi.org/10.1371/journal.pone.0045271.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Goulenok T, Klein I, Mazighi M, Messika-Zeitoun D, Alexandra JF, Mourvillier B, et al. Infective endocarditis with symptomatic cerebral complications: contribution of cerebral magnetic resonance imaging. Cerebrovasc Dis. 2013;35(4):327–36. https://doi.org/10.1159/000348317.

    Article  CAS  PubMed  Google Scholar 

  32. • Selton-Suty C, Delahaye F, Tattevin P, Federspiel C, Le Moing V, Chirouze C, et al. Symptomatic and asymptomatic neurological complications of infective endocarditis: impact on surgical management and prognosis. PLoS One. 2016;11(7):e0158522. https://doi.org/10.1371/journal.pone.0158522. This study highlighted that asymptomatic neurologic events in IE patients are associated with higher rate of surgery and lower mortality rate, suggesting a protective role of surgery guided by systematic neuroimaging results.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Misfeld M, Girrbach F, Etz CD, Binner C, Aspern KV, Dohmen PM, et al. Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients. J Thorac Cardiovasc Surg. 2014;147(6):1837–44. https://doi.org/10.1016/j.jtcvs.2013.10.076.

    Article  PubMed  Google Scholar 

  34. Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, et al. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke. 2009;40(11):3646–78. https://doi.org/10.1161/STROKEAHA.108.192616.

    Article  PubMed  Google Scholar 

  35. Cooper HA, Thompson EC, Laureno R, Fuisz A, Mark AS, Lin M, 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(7):585–91. https://doi.org/10.1161/CIRCULATIONAHA.108.834432.

    Article  PubMed  Google Scholar 

  36. Iung B, Tubiana S, Klein I, Messika-Zeitoun D, Brochet E, Lepage L, et al. Determinants of cerebral lesions in endocarditis on systematic cerebral magnetic resonance imaging: a prospective study. Stroke. 2013;44(11):3056–62. https://doi.org/10.1161/STROKEAHA.113.001470.

    Article  PubMed  Google Scholar 

  37. Yoshioka D, Sakaguchi T, Yamauchi T, Okazaki S, Miyagawa S, Nishi H, et al. Impact of early surgical treatment on postoperative neurologic outcome for active infective endocarditis complicated by cerebral infarction. Ann Thorac Surg. 2012;94(2):489–495; discussion 96. https://doi.org/10.1016/j.athoracsur.2012.04.027.

    Article  PubMed  Google Scholar 

  38. Thuny F, Avierinos JF, Tribouilloy C, Giorgi R, Casalta JP, Milandre L, et al. Impact of cerebrovascular complications on mortality and neurologic outcome during infective endocarditis: a prospective multicentre study. Eur Heart J. 2007;28(9):1155–61. https://doi.org/10.1093/eurheartj/ehm005.

    Article  PubMed  Google Scholar 

  39. • Barsic B, Dickerman S, Krajinovic V, Pappas P, Altclas J, Carosi G, et al. Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis. 2013;56(2):209–17. https://doi.org/10.1093/cid/cis878. This study found no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke.

    Article  PubMed  Google Scholar 

  40. • Oh TH, Wang TK, Pemberton JA, Raudkivi PJ. Early or late surgery for endocarditis with neurological complications. Asian Cardiovasc Thorac Ann. 2016;24(5):435–40. https://doi.org/10.1177/0218492316646903. This study showed no excess of mortality or neurological outcomes after early cardiac surgery in IE patients with previous ischemic stroke.

    Article  PubMed  Google Scholar 

  41. • Yoshioka D, Toda K, Sakaguchi T, Okazaki S, Yamauchi T, Miyagawa S, et al. 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(6):1082–8. https://doi.org/10.1093/ejcts/ezt547. This study suggest that early surgery in IE patients with brain hemorrhage is not associated with increased mortality or neurological deterioration.

    Article  PubMed  Google Scholar 

  42. Diab M, Guenther A, Scheffel P, Sponholz C, Lehmann T, Hedderich J, et al. Can radiological characteristics of preoperative cerebral lesions predict postoperative intracranial haemorrhage in endocarditis patients? Eur J Cardiothorac Surg. 2016;49(5):e119–26. https://doi.org/10.1093/ejcts/ezw014.

    Article  PubMed  Google Scholar 

  43. Okita Y, Minakata K, Yasuno S, Uozumi R, Sato T, Ueshima K, et al. Optimal timing of surgery for active infective endocarditis with cerebral complications: a Japanese multicentre study. Eur J Cardiothorac Surg. 2016;50(2):374–82. https://doi.org/10.1093/ejcts/ezw035.

    Article  PubMed  Google Scholar 

  44. Byrne JG, Rezai K, Sanchez JA, Bernstein RA, Okum E, Leacche M, et al. Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline. Ann Thorac Surg. 2011;91(6):2012–9. https://doi.org/10.1016/j.athoracsur.2011.01.106.

    Article  PubMed  Google Scholar 

  45. •• Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, 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(15):1435–86. https://doi.org/10.1161/CIR.0000000000000296. Current American guidelines for the management of IE patients.

    Article  CAS  PubMed  Google Scholar 

  46. Ducruet AF, Hickman ZL, Zacharia BE, Narula R, Grobelny BT, Gorski J, et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev. 2010;33(1):37–46. https://doi.org/10.1007/s10143-009-0233-1.

    Article  PubMed  Google Scholar 

  47. Hui FK, Bain M, Obuchowski NA, Gordon S, Spiotta AM, Moskowitz S, et al. Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg. 2015;7(6):449–52. https://doi.org/10.1136/neurintsurg-2014-011124.

    Article  PubMed  Google Scholar 

  48. Monteleone PP, Shrestha NK, Jacob J, Gordon SM, Fraser TG, Rehm SJ, et al. Clinical utility of cerebral angiography in the preoperative assessment of endocarditis. Vasc Med. 2014;19(6):500–6. https://doi.org/10.1177/1358863X14557152.

    Article  PubMed  Google Scholar 

  49. Dammert S, Krings T, Moller-Hartmann W, Ueffing E, Hans FJ, Willmes K, et al. Detection of intracranial aneurysms with multislice CT: comparison with conventional angiography. Neuroradiology. 2004;46(6):427–34. https://doi.org/10.1007/s00234-003-1155-1.

    Article  CAS  PubMed  Google Scholar 

  50. Dickerman SA, Abrutyn E, Barsic B, Bouza E, Cecchi E, Moreno A, et al. The relationship between the initiation of antimicrobial therapy and the incidence of stroke in infective endocarditis: an analysis from the ICE Prospective Cohort Study (ICE-PCS). Am Heart J. 2007;154(6):1086–94. https://doi.org/10.1016/j.ahj.2007.07.023.

    Article  CAS  PubMed  Google Scholar 

  51. Bhattacharyya S, Darby RR, Raibagkar P, Gonzalez Castro LN, Berkowitz AL. Antibiotic-associated encephalopathy. Neurology. 2016;86(10):963–71. https://doi.org/10.1212/WNL.0000000000002455.

    Article  CAS  PubMed  Google Scholar 

  52. Neuville M, El-Helali N, Magalhaes E, Radjou A, Smonig R, Soubirou JF, et al. Systematic overdosing of oxa- and cloxacillin in severe infections treated in ICU: risk factors and side effects. Ann Intensive Care. 2017;7(1):34. https://doi.org/10.1186/s13613-017-0255-8.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Yanagawa B, Pettersson GB, Habib G, Ruel M, Saposnik G, Latter DA, et al. Surgical management of infective endocarditis complicated by embolic stroke: practical recommendations for clinicians. Circulation. 2016;134(17):1280–92. https://doi.org/10.1161/CIRCULATIONAHA.116.024156.

    Article  PubMed  Google Scholar 

  54. Ong E, Mechtouff L, Bernard E, Cho TH, Diallo LL, Nighoghossian N, et al. Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature. J Neurol. 2013;260(5):1339–42. https://doi.org/10.1007/s00415-012-6802-1.

    Article  PubMed  Google Scholar 

  55. Haider AS, Garg P, Watson IT, Leonard D, Khan U, Haque A, et al. Mechanical thrombectomy for acute ischemic stroke after cardiac surgery. Cureus. 2017;9(4):e1150. https://doi.org/10.7759/cureus.1150.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique – Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France

    Marie Cantier, Michel Wolff, J. F. Timsit & Romain Sonneville

  2. INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France

    Marie Cantier, Mikael Mazighi, J. P. Desilles & Romain Sonneville

  3. Department of Neurology, Lariboisière University Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France

    Mikael Mazighi

  4. Imaging Department, Clinique Alleray Labrouste, Paris, France

    Isabelle Klein

Authors
  1. Marie Cantier
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mikael Mazighi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Isabelle Klein
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. P. Desilles
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michel Wolff
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. J. F. Timsit
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Romain Sonneville
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Marie Cantier or Romain Sonneville.

Ethics declarations

Conflict of Interest

The authors declare no conflicts of interest relevant to this article.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

Additional information

This article is part of the Topical Collection on Central Nervous System Infections

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cantier, M., Mazighi, M., Klein, I. et al. Neurologic Complications of Infective Endocarditis: Recent Findings. Curr Infect Dis Rep 19, 41 (2017). https://doi.org/10.1007/s11908-017-0593-6

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11908-017-0593-6

Keywords

Search

Navigation