title: Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis.
abstract: BACKGROUND
  Infective endocarditis (IE) is commonly complicated by cerebral embolization and hemorrhage secondary to intracranial mycotic aneurysms (ICMAs). These complications are associated with poor outcome and may require diagnostic and therapeutic plans to be modified. However, routine screening by brain CT and CT angiography (CTA) is not standard practice. We aimed to study the impact of routine cerebral CTA on treatment decisions for patients with IE.
  
  
  METHODS
  From July 2007 to December 2012, we prospectively recruited 81 consecutive patients with definite left-sided IE according to modified Duke's criteria. All patients had routine brain CTA conducted within one week of admission. All patients with ICMA underwent four-vessel conventional angiography. Invasive treatment was performed for ruptured aneurysms, aneurysms ≥ 5 mm, and persistent aneurysms despite appropriate therapy. Surgical clipping was performed for leaking aneurysms if not amenable to intervention.
  
  
  RESULTS
  The mean age was 30.43 ± 8.8 years and 60.5% were males. Staph aureus was the most common organism (32.3%). Among the patients, 37% had underlying rheumatic heart disease, 26% had prosthetic valves, 23.5% developed IE on top of a structurally normal heart and 8.6% had underlying congenital heart disease. Brain CT/CTA revealed that 51 patients had evidence of cerebral embolization, of them 17 were clinically silent. Twenty-six patients (32%) had ICMA, of whom 15 were clinically silent. Among the patients with ICMAs, 11 underwent endovascular treatment and 2 underwent neurovascular surgery. The brain CTA findings prompted different treatment choices in 21 patients (25.6%). The choices were aneurysm treatment before cardiac surgery rather than at follow-up, valve replacement by biological valve instead of mechanical valve, and withholding anticoagulation in patients with prosthetic valve endocarditis for fear of aneurysm rupture.
  
  
  CONCLUSIONS
  Routine brain CT/CTA resulted in changes in the treatment plan in a significant proportion of patients with IE, even those without clinically evident neurological disease. Routine brain CT/CTA may be indicated in all hospitalized patients with IE.
authors.affiliation: Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt.
authors.forename: Marwa Sayed
authors.initials: MS
authors.lastname: Meshaal
authors.affiliation: Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt.
authors.forename: Hussein Heshmat
authors.initials: HH
authors.lastname: Kassem
authors.affiliation: Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Samir
authors.affiliation: Department of Radiology, Cairo University, Cairo, Egypt.
authors.forename: Ayman
authors.initials: A
authors.lastname: Zakaria
authors.affiliation: Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt.
authors.forename: Yasser
authors.initials: Y
authors.lastname: Baghdady
authors.affiliation: Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt.
authors.forename: Hussein Hassan
authors.initials: HH
authors.lastname: Rizk
mesh_terms: D000328:Adult; D001921:Brain / Q000473:pathology; D020520:Brain Infarction / Q000150:complications / Q000175:diagnosis; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000150:complications / Q000175:diagnosis; D000066491:Clinical Decision-Making; D004696:Endocarditis / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000175:diagnosis; D008297:Male; D014057:Tomography, X-Ray Computed; D055815:Young Adult
references.citation: Eur J Radiol. 2004 Mar;49(3):212-23
references.pmid: 14962650
references.citation: Arch Intern Med. 2000 Oct 9;160(18):2781-7
references.pmid: 11025788
references.citation: Ann Intern Med. 2010 Apr 20;152(8):497-504, W175
references.pmid: 20404380
references.citation: Clin Infect Dis. 2000 Apr;30(4):633-8
references.pmid: 10770721
references.citation: Invest Radiol. 1993 Apr;28(4):373-82
references.pmid: 8478178
references.citation: Acta Radiol. 2011 Jul 1;52(6):670-4
references.pmid: 21525105
references.citation: Radiology. 2002 Feb;222(2):389-96
references.pmid: 11818604
references.citation: N Engl J Med. 2013 Apr 11;368(15):1425-33
references.pmid: 23574121
references.citation: Circulation. 2000 Oct 31;102(18):2300-8
references.pmid: 11056108
references.citation: Int J Infect Dis. 2010 May;14(5):e394-8
references.pmid: 19800277
references.citation: Eur Heart J Cardiovasc Imaging. 2012 Aug;13(8):703-10
references.pmid: 22334638
references.citation: J Neurosurg. 2012 Aug;117(2):309-15
references.pmid: 22680242
references.citation: Tex Heart Inst J. 2004;31(2):165-7
references.pmid: 15212129
references.citation: Circulation. 2009 Aug 18;120(7):585-91
references.pmid: 19652096
references.citation: Stroke. 2009 Jun;40(6):2276-93
references.pmid: 19423857
references.citation: Med Clin North Am. 1985 Mar;69(2):385-98
references.pmid: 3838785
references.citation: Am J Cardiol. 2008 Nov 1;102(9):1247-51
references.pmid: 18940301
references.citation: Stroke. 2013 Nov;44(11):3056-62
references.pmid: 24003046
references.citation: Circulation. 2005 Jun 14;111(23):e394-434
references.pmid: 15956145
references.citation: Eur Heart J. 2007 May;28(9):1155-61
references.pmid: 17363448
references.citation: Turk Kardiyol Dern Ars. 2009 Jan;37(1):9-18
references.pmid: 19225248
references.citation: Circulation. 2009 Apr 28;119(16):2235-49
references.pmid: 19349327
references.citation: Radiology. 2001 Jun;219(3):739-49
references.pmid: 11376263
references.citation: Diagn Interv Radiol. 2005 Jun;11(2):77-82
references.pmid: 15957092
references.citation: JAMA. 2005 Jun 22;293(24):3022-8
references.pmid: 15972564
references.citation: Neuroradiology. 2003 Jun;45(6):404-9
references.pmid: 12719951
references.citation: Eur Heart J. 2009 Oct;30(19):2369-413
references.pmid: 19713420
references.citation: Arq Neuropsiquiatr. 2008 Dec;66(4):790-4
references.pmid: 19099112
references.citation: JAMA. 2002 Jul 3;288(1):75-81
references.pmid: 12090865
references.citation: Clin Neurol Neurosurg. 2014 Nov;126:177-84
references.pmid: 25270230
references.citation: Int J Cardiol. 2005 Feb 15;98(2):253-60
references.pmid: 15686775
references.citation: Magn Reson Med Sci. 2008;7(4):169-78
references.pmid: 19110511
references.citation: Circulation. 2005 Jul 5;112(1):69-75
references.pmid: 15983252
references.citation: Neurol India. 2001 Mar;49(1):41-6
references.pmid: 11303240