Management of Cerebral Events in Patients with Infective Endocarditis

Diagnosis and Initial Monitoring

The American Heart Association recommends immediate brain imaging (CT or MRI) for all patients with suspected cerebral events and infective endocarditis 1, 2
MRI with gadolinium contrast allows for higher sensitivity in detecting cerebral lesions and may influence the timing of surgery 3
A multidisciplinary team including infectious disease specialists, cardiologists, cardiothoracic surgeons, and neurologists should be established for immediate discussion of case management 1
Transthoracic (TTE) and transesophageal (TEE) echocardiography should be performed to assess valve involvement and the risk of further embolic events 1

The European Society of Cardiology recommends that after a transient ischemic attack (TIA), minor ischemic stroke, or silent microembolism, cardiac surgery should be performed without delay if there is an indication for surgery 2, 1
In patients with symptomatic ischemic stroke, cardiac surgery should be considered without delay if there is heart failure, uncontrolled infection, myocardial abscess, or high persistent embolic risk, provided the patient is not in a coma and has no significant hemorrhagic transformation 2, 3

After an intracerebral hemorrhage, cardiac surgery should generally be delayed for at least one month 2, 3
In cases of small, unruptured cerebral mycotic aneurysms, earlier surgery may be considered based on the urgency of the cardiac surgery 1
Vascular imaging (CT angiography or angiography) should be performed in patients with intracerebral hemorrhage to rule out a ruptured mycotic aneurysm 1

Mycotic aneurysms occur in 2-4% of infective endocarditis cases but may be more common due to asymptomatic cases 2
Cerebral mycotic aneurysms should be sought in patients with infective endocarditis and neurological symptoms 2
Neurosurgical or endovascular treatment is recommended for large, expanding, or ruptured cerebral mycotic aneurysms 2
In patients with unruptured cerebral mycotic aneurysms, pre-surgical neurosurgical evaluation is recommended to prevent delays in cardiac surgery 1

In patients with infective endocarditis and cerebral abscess, cardiac surgery should not be delayed 1

Prompt diagnosis and initiation of appropriate antimicrobial therapy are crucial for preventing first or recurrent neurological complications 2
In patients with mechanical valves and infective endocarditis with embolic stroke, anticoagulation should be discontinued for at least two weeks of antibiotic treatment to prevent hemorrhagic transformation 1
Heparin should be used cautiously in patients with infective endocarditis 1
When choosing prosthetic valves in the context of embolic stroke, bioprosthetic valves are preferred to avoid the need for postoperative oral anticoagulation 1

Neurological complications occur in 15-30% of patients with infective endocarditis, mostly before or at the time of endocarditis diagnosis 2
Staphylococcus aureus infection is more commonly associated with neurological complications compared to other bacteria 2
Patients with neurological complications tend to have higher morbidity and mortality 2
In the selection of prosthetic valves in the context of embolic stroke, bioprosthetic valves are preferred to avoid the need for postoperative oral anticoagulation 1

Silent microembolism/TIA/minor ischemic stroke: surgery without delay 1, 2
Ischemic stroke: surgery without delay if there is heart failure, uncontrolled infection, myocardial abscess, or high persistent embolic risk, provided there is no coma or significant hemorrhagic transformation 2
Intracerebral hemorrhage: delay surgery for about 4 weeks, unless the lesion is small and surgery is urgent 1, 2
Mycotic aneurysm: neurosurgical evaluation and intervention for large/expanding/ruptured aneurysms 1, 2
Cerebral abscess: surgery without delay 1