Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management.
Neurological complications are frequent in infective endocarditis (IE) and increase morbidity and mortality rates. A wide spectrum of neurological disorders may be observed, including stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Ischemic lesions account for 40% to 50% of IE central nervous system complications. Systematic brain MRI may reveal cerebral abnormalities in up to 80% of patients, including cerebral embolism in 50%, mostly asymptomatic. Neurological complications affect both medical and surgical treatment and should be managed by an experimented multidisciplinary team including cardiologists, neurologists, intensive care specialists, and cardiac surgeons. Oral anticoagulant therapy given to patients presenting with cerebral ischemic lesions should be replaced by unfractionated heparin for at least 2 weeks, with a close monitoring of coagulation tests. Recently published data suggest that after an ischemic stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Surgery should be postponed for 2 to 3 weeks for patients with intracranial hemorrhage. Endovascular treatment is recommended for cerebral mycotic aneurysms, if there is no severe mass effect. Recent data suggests that neurological failure, which is associated with the location and extension of brain injury, is a major determinant for short-term prognosis.
Service de réanimation médicale et des maladies infectieuses, université Paris-Diderot, Sorbonne Paris-Cité, hôpital Bichat-Claude-Bernard, Assistance Publique-hôpitaux de Paris, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
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E
Novy
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R
Sonneville
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M
Mazighi
I F
IF
Klein
E
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Mariotte
B
B
Mourvillier
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L
Bouadma
M
M
Wolff
D000890:Anti-Infective Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D001922:Brain Abscess / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D001927:Brain Diseases / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D002545:Brain Ischemia / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D003131:Combined Modality Therapy; D058128:Compression Bandages; D019468:Disease Management; D004696:Endocarditis / Q000150:complications* / Q000188:drug therapy / Q000601:surgery; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology; D008581:Meningitis / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D059906:Neuroimaging / Q000379:methods; D019851:Thrombophilia / Q000188:drug therapy / Q000628:therapy
D000890:Anti-Infective Agents; D000925:Anticoagulants; D005343:Fibrinolytic Agents
Accident vasculaire cérébral; Anévrismes mycotiques; Endocardites; Endocarditis; IRM; Magnetic resonance imagery; Mycotic aneurysm; Stroke