CCU

𝐍𝐞𝐮𝐫𝐨𝐥𝐨𝐠𝐢𝐜 𝐂𝐨𝐦𝐩𝐥𝐢𝐜𝐚𝐭𝐢𝐨𝐧𝐬 𝐨𝐟 𝐈𝐧𝐟𝐞𝐜𝐭𝐢𝐯𝐞 𝐄𝐧𝐝𝐨𝐜𝐚𝐫𝐝𝐢𝐭𝐢𝐬.

====================================
Symptomatic neurologic complications of IE are frequent, and asymptomatic cerebral embolism diagnosed by magnetic resonance imaging (MRI) occurs in many more patients.

Neurologic complications increase mortality
and complicate surgical decision-making.

The most common neurologic complication is Stroke due to septic embolism.

Other Complications include :-
~~~~~~~~~~~~~~~~~~~~~
• Micro- and macro-abscesses,
• lnfectious aneurysms, and
• More general toxic-metabolic encephalopathies,
• Cerebrospinal fluid (CSF) pleocytosis, and
• Seizures.

Neurologic complications influence diagnosis, management, and prognosis. MRI should be obtained in all patients with suspected IE and may identify cerebral abnormalities in many IE patients who do not have neurologic symptoms.

MRI sequences should include diffusion weighted imaging (DWI) and gradient echo (GRE) to detect ischemic and hemorrhagic infarction.

The detection of clinically silent ischemic or hemorrhagic brain lesions may affect
performance or timing of surgery,
choice of valve prosthesis, and
antimicrobial or anticoagulant therapeutic planning.

Neurologists should recommend urgent cerebral angiography in the setting of intracranial hemorrhage so that endovascular treatment of mycotic (infectious) aneurysms can be planned.

Patients with large vegetations by echocardiography should be considered for surgery before embolism occurs.

They should be referred to centers with extensive surgical experience in debridement of infected tissue and infectious disease expertise in antibiotic choice.

Additional indications for surgery
To replace the affected valve include :-
~~~~~~~~~~~~~~~~~~~~~~~~~~~
• Heart failure,
• Difficult-to-treat pathogens (such as fungi),
• Elevated LV or atrial pressure due to valvular regurgitation, and
• Perivalvular abscess.

Patients with cerebral embolism due to IE
Should not be Anticoagulated.

Anticoagulation should be stopped
as soon as a diagnosis of IE is suspected,
particularly if S. aureus infection is likely.

Early surgery is recommended for those with transient ischemic attacks and small infarctions. Neurologists can assist the surgical team by providing neurological preoperative clearance for surgical intervention.

Contraindications to early valve replacement include coma, large cerebral infarctions and intracranial hemorrhage.
——————————————
ESC Recommendations for indications and timing
of cardiac surgery after neurological complications
in active infective endocarditis

▪️After a transient ischaemic attack,
cardiac surgery, if indicated,
is recommended without delay.

▪️After a stroke, surgery is recommended
without any delay in the presence of HF ,
uncontrolled infection, abscess, or persistent
high embolic risk, as long as coma is absent
and the presence of cerebral haemorrhage
has been excluded by cranial CT or MRI.

▪️Following intracranial haemorrhage,
delaying cardiac surgery >1 month, if possible,
with frequent reassessment of the patient's
clinical condition and imaging should considered.

▪️In patients with intracranial haemorrhage and
unstable clinical status due to HF uncontrolled
infection or persistent high embolic risk,
urgent or emergency surgery should considered
weighing likelihood of meaningful neurological outcome.
——————————
CT, computed tomography; HF resonance imaging.