Skip to main content
SpringerLink
Log in

Impact of stroke on therapeutic decision making in infective endocarditis

  • Review
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

The diagnosis of infective endocarditis (IE) must be made as soon as possible to initiate antimicrobial therapy and identify patients at high risk for complications who may be best managed by early surgery. Cerebral complications make the timing of cardiac surgery difficult. The safety of cardiopulmonary bypass (CPB) surgery in stroke patients remains controversial. Stroke complicates the outcome of left-sided IE in 20–40% of cases and is associated with poor outcome. The risk of stroke in IE falls rapidly after the initiation of effective antimicrobial therapy. The risk of embolization is highest during the first week of therapy, and in patients with mobile vegetations or vegetations >10 mm in diameter occurring on the anterior mitral leaflet. Indications for valvular surgery are significant congestive heart failure or valvular regurgitation, myocardial abscess, persistent bacteremia and large-size vegetations with high risk of embolism. Decisions regarding surgical intervention in patients with IE should be individualized. In the absence of large prospective studies, optimal timing of surgery is still discussed when stroke complicates IE. A multidisciplinary assessment of the situation, involving cardiologists, cardiac surgeons, infectiologists and neurologists, is recommended. Estimating the risk of recurrence after a first embolic event and careful evaluation of the indication for valve replacement are essential steps in making the therapeutic decision. Surgery should be delayed if possible in the event of large cerebral infarction or ICH in order to prevent neurological deterioration. It has been suggested that valve replacement should be considered within the first 72 h if the patients with brain infarction have severe heart failure, otherwise after 4 weeks. Early surgery appears safe in patients presenting transient ischemic attacks or “silent” cerebral embolism.

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
Fig. 2

Similar content being viewed by others

References

  1. Netzer RO, Zollinger E, Seiler C, Cerny A (2000) Infective endocarditis: clinical spectrum, presentation and outcome: an analysis of 212 cases 1980–1995. Heart 84:25–30

    Article  CAS  PubMed  Google Scholar 

  2. Mylonakis E, Calderwood SB (2001) Infective endocarditis in adults. N Engl J Med 345:1318–1330

    Article  CAS  PubMed  Google Scholar 

  3. Hoen B, Alla F, Selton-Suty C, Beguinot I, Bouvet A, Briancon S, Casalta JP, Danchin N, Delahaye F, Etienne J, Le Moing V, Leport C, Mainardi JL, Ruimy R, Vandenesch F (2002) Changing profile of infective endocarditis: results of a 1-year survey in France. JAMA 288:75–81

    Article  PubMed  Google Scholar 

  4. Beynon RP, Bahl VK, Prendergast BD (2006) Infective endocarditis. Br Med J 333:334–339

    Article  Google Scholar 

  5. Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG Jr, Bayer AS, Karchmer AW, Olaison L, Pappas PA, Moreillon P, Chambers ST, Chu VH, Falcó V, Holland DJ, Jones P, Klein JL, Raymond NJ, Read KM, Tripodi MF, Utili R, Wang A, Woods CW, Cabell CH, International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators (2009) Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 169:463–473

    Article  PubMed  Google Scholar 

  6. Salgado AV, Furlan AJ, Keys TF, Nickols TR, Beck GJ (1989) Neurologic complications of endocarditis: a 12-year experience. Neurology 39:173–178

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  8. Kanter MC, Hart RG (1991) Neurologic complications of infective endocarditis. Neurology 41:1015–1020

    CAS  PubMed  Google Scholar 

  9. Horstkotte D, Follath F, Gutschik E, Lengvel M, Oto A, Pavie A, Soler-Soler J, Thiene G, von Graevenitz A, Priori SG, Garcia MA, Blanc JJ, Budaj A, Cowie M, Dean V, Deckers J, Fernandez Burgos E, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth OA, Lekakis J, Vahanian A, Delahaye F, Parkhomenko A, Filipatos G, Aldershvile J, Vardas P, Task Force Members on Infective Endocarditis of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG); Document Reviewers (2004) Guidelines on prevention, diagnosis and treatment of infective endocarditis: the task force on infective endocarditis of the European Society of Cardiology. Eur Heart J 25:267–276

    Article  PubMed  Google Scholar 

  10. Thuny F, Avierinos JF, Tribouilloy C, Giorgi R, Casalta JP, Milandre L, Brahim A, Nadji G, Riberi A, Collart F, Renard S, Raoult D, Habib G (2007) Impact of cerebrovascular complications on mortality and neurologic outcome during infective endocarditis: a prospective multicentre study. Eur Heart J 28:1155–1161

    Article  PubMed  Google Scholar 

  11. Snygg-Martin U, Gustafsson L, Rosengren L, Alsiö A, Ackerholm P, Andersson R, Olaison L (2008) Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers. Clin Infect Dis 47:23–30

    Article  PubMed  Google Scholar 

  12. Subramaniam S, Puetz V, Dzialowski I, Barber BA (2006) Cerebral microhemorrhages in a patient with mycotic aneurysm: relevance of T2-GRE imaging in SBE. Neurology 67:1697

    Article  PubMed  Google Scholar 

  13. Klein I, Iung B, Wolff M, Brochet E, Longuet P, Laissy JP, Duval X (2007) Silent T2* cerebral microbleeds: a potential new imaging clue in infective endocarditis. Neurology 68:2043

    Article  CAS  PubMed  Google Scholar 

  14. Gillinov AM, Shah RV, Curtis WE, Stuart RS, Cameron DE, Baumgartner WA, Green PS (1996) Valve replacement in patients with endocarditis and neurologic deficit. Ann Thorac Surg 61:1125–1130

    Article  CAS  PubMed  Google Scholar 

  15. Piper C, Wiemer M, Schulte HD, Horstkotte D (2001) Stroke is not a contraindication for urgent valve replacement in acute infective endocarditis. J Heart Valve Dis 10:703–711

    CAS  PubMed  Google Scholar 

  16. Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, Ferrieri P, Gerber MA, Tani LY, Gewitz MH, Tong DC, Steckelberg JM, Baltimore RS, Shulman ST, Burns JC, Falace DA, Newburger JW, Pallasch TJ, Takahashi M, Taubert KA (2005) Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 111:394–434

    Article  Google Scholar 

  17. Heiro M, Nikoskelainen J, Engblom E, Kotilainen E, Marttila R, Kotilainen P (2000) Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland. Arch Intern Med 160:2781–2787

    Article  CAS  PubMed  Google Scholar 

  18. Mugge A, Daniel WG, Frank G, Lichtlen PR (1989) Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 14:631–638

    Article  CAS  PubMed  Google Scholar 

  19. Rohmann S, Erbel R, Görge G, Makowski T, Mohr-Kahaly S, Nixdorff U, Drexler M, Meyer J (1992) Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis. Eur Heart J 12:446–452

    Google Scholar 

  20. Di Salvo G, Habib G, Pergola V, Avierinos JF, Philip E, Casalta JP, Vailloud JM, Derumeaux G, Gouvernet J, Ambrosi P, Lambert M, Ferracci A, Raoult D, Luccioni R (2001) Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 37:1069–1076

    Article  CAS  PubMed  Google Scholar 

  21. Vilacosta I, Graupner C, San Roman JA, Sarria C, Ronderos R, Fernandez C, Mancini L, Sanz O, Sanmartin JV, Stoermann W (2002) Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 39:1489–1495

    Article  PubMed  Google Scholar 

  22. Thuny F, Di Salvo G, Belliard O, Avierinos JF, Pergola V, Rosenberg V, Casalta JP, Gouvernet J, Derumeaux G, Iarussi D, Ambrosi P, Calabro R, Riberi A, Collart F, Metras D, Lepidi H, Raoult D, Harle JR, Weiller PJ, Cohen A, Habib G (2005) Risk of embolism and death in infective endocarditis: prognostic value of echocardiography. A prospective multicenter study. Circulation 112:69–75

    Article  PubMed  Google Scholar 

  23. Steckelberg JM, Murphy JG, Ballard D, Bailey K, Tajik AJ, Taliercio CP, Guiliani ER, Wilson WR (1991) Emboli in infective endocarditis: the prognostic value of echocardiography. Ann Intern Med 114:635–640

    CAS  PubMed  Google Scholar 

  24. Dickerman SA, Abrutyn E, Barsic B, Bouza E, Cecchi E, Moreno A, Doco-Lecompte T, Eisen DP, Fortes CQ, Fowler VG Jr, Lerakis S, Miro JM, Pappas P, Peterson GE, Rubinstein E, Sexton DJ, Suter F, Tornos P, Verhagen DW, Cabell CH, ICE Investigators (2007) 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 154:1086–1094

    Article  CAS  PubMed  Google Scholar 

  25. Anderson DJ, Goldstein LB, Wilkinson WE, Corey GR, Cabell CH, Sanders LL, Sexton DJ (2003) Stroke location, characterization, severity, and outcome in mitral versus aortic valve endocarditis. Neurology 61:1341–1346

    CAS  PubMed  Google Scholar 

  26. Sanfilippo AJ, Picard MH, Newell JB, Rosas E, Davidoff R, Thomas JD, Weyman AE (1991) Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol 18:1191–1199

    Article  CAS  PubMed  Google Scholar 

  27. Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz CD, Iversen S, Oelert H, Meyer J (1988) Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal: a prospective study. Eur Heart J 9:43–53

    CAS  PubMed  Google Scholar 

  28. Pergola V, Di Salvo G, Habib G, Avierinos JF, Philip E, Vailloud JM, Thuny F, Casalta JP, Ambrosi P, Lambert M, Riberi A, Ferracci A, Mesana T, Metras D, Harle JR, Weiller PJ, Raoult D, Luccioni R (2001) Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens. Am J Cardiol 88:871–875

    Article  CAS  PubMed  Google Scholar 

  29. Kupferwasser LI, Hafner G, Mohr-Kahaly S, Erbel R, Meyer J, Darius H (1999) The presence of infection-related antiphospholipid antibodies in infective endocarditis determines a major risk factor for embolic events. J Am Coll Cardiol 33:1365–1371

    Article  CAS  PubMed  Google Scholar 

  30. Ruttmann E, Willeit J, Ulmer H, Chevtchik O, Höfer D, Poewe W, Laufer G, Müller LC (2006) Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke 37:2094–2099

    Article  PubMed  Google Scholar 

  31. Eishi K, Kawazoe K, Kuriyama Y, Kitoh Y, Kawashima Y, Omae T (1995) Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan. J Thorac Cardiovasc Surg 110:1745–1755

    Article  CAS  PubMed  Google Scholar 

  32. Angstwurm K, Borges AC, Halle E, Schielke E, Einhäupl KM, Weber JR (2004) Timing the valve replacement in infective endocarditis involving the brain. J Neurol 251:1220–1226

    Article  PubMed  Google Scholar 

  33. Peters PJ, Harrison T, Lennox JL (2006) A dangerous dilemma: management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis 6:742–748

    Article  PubMed  Google Scholar 

  34. Bingham WF (1977) Treatment of mycotic intracranial aneurysms. J Neurosurg 46:428–437

    Article  CAS  PubMed  Google Scholar 

  35. Ahmadi J, Tung H, Giannotta SL, Destian S (1993) Monitoring of infectious intracranial aneurysms by sequential computed tomographic/magnetic resonance imaging studies. Neurosurgery 32:45–49

    Article  CAS  PubMed  Google Scholar 

  36. Corr P, Wright M, Handler LC (1995) Endocarditis-related cerebral aneurysms: radiologic changes with treatment. Am J Neuroradiol 16:745–748

    CAS  PubMed  Google Scholar 

  37. Bohmfalk GL, Story JL, Wissinger JP, Brown WE Jr (1978) Bacterial intracranial aneurysm. J Neurosurg 48:369–382

    Article  CAS  PubMed  Google Scholar 

  38. Wilson WR, Giuliani ER, Danielson GK, Geraci JE (1982) Management of complications of infective endocarditis. Mayo Clin Proc 57:162–170

    CAS  PubMed  Google Scholar 

  39. Moskowitz MA, Rosenbaum AE, Tyler HR (1974) Angiographically monitored resolution of cerebral mycotic aneurysms. Neurology 24:1103–1108

    CAS  PubMed  Google Scholar 

  40. Chapot R, Houdart E, Saint-Maurice JP, Aymard A, Mounayer C, Lot G, Merland JJ (2002) Endovascular treatment of cerebral mycotic aneurysms. Radiology 222:389–396

    Article  PubMed  Google Scholar 

  41. Chun JY, Smith W, Halbach VV, Higashida RT, Wilson CB, Lawton MT (2001) Current multimodality management of infectious intracranial aneurysms. Neurosurgery 48:1203–1213

    Article  CAS  PubMed  Google Scholar 

  42. Asai T, Usui A, Miyachi S, Ueda Y (2002) Endovascular treatment for intracranial mycotic aneurysms prior to cardiac surgery. Eur J Cardiothorac Surg 21:948–950

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

The authors would like to thank Miss Frédérique Groga-Bada for her help in the preparation of this manuscript.

Conflict of interest statement

None.

Author information

Authors and Affiliations

  1. Unité de Soins Intensifs Neurovasculaires, Department of Neurology, Hôpital Neurologique, University of Lyon, 59 boulevard Pinel, 69003, Lyon, France

    Laurent Derex

  2. Department of Cardiology, Hôpital Cardiologique, University of Lyon, Lyon, France

    Eric Bonnefoy & François Delahaye

Authors
  1. Laurent Derex
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eric Bonnefoy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. François Delahaye
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Laurent Derex.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Derex, L., Bonnefoy, E. & Delahaye, F. Impact of stroke on therapeutic decision making in infective endocarditis. J Neurol 257, 315–321 (2010). https://doi.org/10.1007/s00415-009-5364-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-009-5364-3

Keywords

Search

Navigation