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Chapter 6
Neurologic Manifestations of Infective Endocarditis S. Williams and Jared R. Brosch
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Figure 6-1 Embolization to various cerebral structures is responsible for most of the neurologic complications of IE. Emboli that lodge in the lumen of cerebral vessels may lead to ischemic stroke and can lead to arteritis or mycotic aneurysm formation with resultant vessel rupture and cerebral hemorrhage. Emboli to the meninges may produce meningitis, and emboli to the brain parenchyma, especially when associated with cerebral ischemia, may result in meningoencephalitis or abscess.
(From Solenski NJ, Haley EC Jr: Neurologic complications of infective endocarditis. p In Roos KL (ed): Central Nervous System Infectious Diseases and Therapy. Marcel Dekker, New York, 1997, with permission.)
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Figure 6-2 This patient presented with fever, new cardiac murmur, mental status changes, and right hemiparesis. A and B, Contrast-enhanced axial T1-weighted magnetic resonance imaging (MRI) shows multiple ring-enhancing lesions suggesting septic microembolization. C, Axial diffusion-weighted imaging (DWI) sequences show restricted diffusion associated with the lesions.
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Figure 6-3 This patient presented with left hemiparesis and mitral valve endocarditis. A, Noncontrast head CT showed a focal low-density lesion in the right internal capsule and lentiform nucleus with a central area of hemorrhage (increased density) and cortical hemorrhage in the insula. B, With contrast, large confluent areas of enhancement representing leaky blood–brain barrier can be seen in the right caudate and lentiform nuclei, the insula, and the temporal cortex. C, Fluid-attenuated inversion recovery (FLAIR) MRI 2 days after the head CT showed diffuse increased signal in the regions of CT enhancement and the right thalamus. D, After gadolinium, ring-like enhancement in the area of a previous infarct can be seen, representing possible secondary infection. This pattern is sometimes referred to as a “septic infarction.” This enhancement pattern resolved with antibiotic treatment and without development of a macroabscess.
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Figure 6-4 This patient presented with fever, new systolic murmur, sudden headache, and altered mental status without focal neurologic deficits. Noncontrast head CT showed a small subarachnoid hemorrhage (not shown). Sagittal CTA (A) demonstrated a mycotic aneurysm in the distal MCA, confirmed by conventional angiography (B). This aneurysm enlarged despite adequate antibiotic therapy, and the patient subsequently underwent successful clipping.
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Figure 6-5 This patient had tricuspid valve endocarditis secondary to intravenous drug abuse. Initially, the patient had no neurologic symptoms but left the hospital against medical advice after completing 6 days of antibiotic therapy. He returned 2 days later with a decreased level of consciousness and a right gaze preference. A toxicology screen was positive for cocaine. Noncontrast axial head CT at that time showed an approximately 3-×4-cm hemorrhage in the right frontal lobe with intraventricular extension and subfalcial herniation. Cerebral angiography did not show a mycotic aneurysm. Echocardiography showed a large patent foramen ovale with right-to-left shunting and vegetations on the tricuspid valve. This case underscores several clinical points: (1) neurologic complications of endocarditis are more common during uncontrolled infection; (2) neurologically asymptomatic patients may have silent cerebral emboli, particularly in the nondominant hemisphere; and (3) patients with right-sided endocarditis may develop cerebral embolization via a right-to-left shunt.
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Figure 6-6 Suggested management algorithm for patients with focal neurologic deficits and known or suspected IE. Factors favoring either surgical or medical treatment of mycotic aneurysms are presented; management of these cases is highly individualized. Repeat angiography at the conclusion of medical therapy is suggested for all patients with known mycotic aneurysms and may be considered either for patients with intracerebral hemorrhage and a negative initial angiogram or for patients with ischemic stroke who require long-term anticoagulation. CTA, computed tomography angiography; ICH, intracerebral hemorrhage; LP, lumbar puncture; MRA, magnetic resonance angiography.
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