Marie Cantier1,2, Mikael Mazighi3,4, Isabelle Klein5, J P Desilles3, Michel Wolff6, J F Timsit6, Romain Sonneville7,8. 1. Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France. marie.cantier@aphp.fr. 2. INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France. marie.cantier@aphp.fr. 3. INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France. 4. Department of Neurology, Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France. 5. Imaging Department, Clinique Alleray Labrouste, Paris, France. 6. Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France. 7. Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France. romain.sonneville@aphp.fr. 8. INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France. romain.sonneville@aphp.fr.
Abstract
PURPOSE OF REVIEW: The purpose of this paper is to provide recent insights in management of neurologic complications of left-sided infective endocarditis (IE). RECENT FINDINGS: Cerebral lesions observed in IE patients are thought to involve synergistic pathophysiological mechanisms including thromboembolism, sepsis, meningitis, and small-vessel cerebral vasculitis. Brain MRI represents a major tool for the detection of asymptomatic events occurring in the majority of patients. The latter can impact therapeutic decisions and prognosis, especially when cardiac surgery is indicated. In patients presenting with neurologic complications, surgery could be safely performed earlier than previously thought. Symptomatic cerebral ischemic or hemorrhagic events occur in 20-55% of IE patients, whereas asymptomatic events are detected in 60-80% of patients undergoing systematic brain MRI. Management of such patients requires an experienced multidisciplinary team. Recent studies suggest that early cardiac surgery, when indicated, can be performed safely in patients with cerebral ischemic events. Other important issues include the appropriate use of anti-infective and anti-thrombotic agents, and endovascular treatment for mycotic aneurysms. Altered mental status at IE onset, which is associated with brain injury, is a major determinant of short-term outcome.
PURPOSE OF REVIEW: The purpose of this paper is to provide recent insights in management of neurologic complications of left-sided infective endocarditis (IE). RECENT FINDINGS: Cerebral lesions observed in IE patients are thought to involve synergistic pathophysiological mechanisms including thromboembolism, sepsis, meningitis, and small-vessel cerebral vasculitis. Brain MRI represents a major tool for the detection of asymptomatic events occurring in the majority of patients. The latter can impact therapeutic decisions and prognosis, especially when cardiac surgery is indicated. In patients presenting with neurologic complications, surgery could be safely performed earlier than previously thought. Symptomatic cerebral ischemic or hemorrhagic events occur in 20-55% of IE patients, whereas asymptomatic events are detected in 60-80% of patients undergoing systematic brain MRI. Management of such patients requires an experienced multidisciplinary team. Recent studies suggest that early cardiac surgery, when indicated, can be performed safely in patients with cerebral ischemic events. Other important issues include the appropriate use of anti-infective and anti-thrombotic agents, and endovascular treatment for mycotic aneurysms. Altered mental status at IE onset, which is associated with brain injury, is a major determinant of short-term outcome.
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