Intracranial Hemorrhage Following Thrombolytic Use for Stroke Caused by Infective Endocarditis

Introduction: Intracranial hemorrhage (ICH) is common in infective endocarditis (IE). We explored the imaging characteristics, predictors, and clinical implications of ICHs including intraparenchymal hemorrhage (IPH), and subarachnoid hemorrhage (SAH) and, subdural hematoma (SDH). Methods: We reviewed records of 116 consecutive acute IE patients by Duke’s criteria with neurological consultation or admission to stroke neurology service in a single tertiary referral center from January 2015 to July 2016. ICHs were defined as IPH, SAH, or SDH seen on CT. Microhemorrhages were identified on susceptibility weighted imaging (SWI) on MRI. Patient’s radiographic characteristics and complications were collected. Results: Of 116 patients, 25 persons (21.6%, median age 58) had ICHs, 14 with IPHs, 7 with SAHs, 3 with both IPH and SAH, and 1 SDH. Of 17 (14.7%) IPHs (median NIH Stroke Scale 6 and median volume 38.6cc), 10 (8.6%) IPHs were symptomatic and 7 IPHs were silent. Eleven persons (65%) with IPH also had ischemic strokes. Mycotic aneurysms were identified only in 1 (4.8%) in 21 persons with ICH who underwent cerebral angiogram. MRIs identified 66 persons with microhemorrhages (56.9%, median age 58.5) among 85 who underwent MRI. Eighteen (72%) of 25 persons with ICHs had microhemorrhages in SWI. In multivariate logistic regression analysis, ICH was associated with the presence of >5 microhemorrhages (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.04-1.50) and staphylococcus aureus (OR: 1.25, 95% CI: 1.03-1.51). Ten persons (40%) with ICH died (7 with IPH and 4 with SAH) in the same hospitalization. Thirteen persons (52%) with ICH (median 21.4cc in 9 IPHs) underwent valve replacement at median of 13.5 days and 2 persons had new non-fatal strokes (1 IPH and 1 ischemic stroke). Conclusions: Intracranial macro- or micro-hemorrhages are seen in 73 (63%) persons with IE. The mortality of intracranial hemorrhage is high but the perioperative stroke risk appears low.

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Abstract WMP35: The Characteristics of Infectious Intracranial Aneurysm and Indication of Cerebral Angiogram in Infective Endocarditis (IE)

Stroke ◽

10.1161/str.48.suppl_1.wmp35 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Sung-Min Cho ◽

Robert Marquardt ◽

Lucy Zhang ◽

Prateek Thatikunta ◽

Ken Uchino ◽

...

Keyword(s):

Infective Endocarditis ◽

Intracranial Aneurysm ◽

Intracerebral Hemorrhage ◽

Intracranial Hemorrhage ◽

Cerebral Angiogram ◽

Tertiary Referral Center ◽

Valvular Surgery ◽

Imaging Characteristics ◽

Perioperative Complication ◽

Glue Embolization

Introduction: Infectious intracranial aneurysm (IIA) can complicate infective endocarditis (IE). We aim to describe the characteristics of IIA and to assess indications for cerebral angiography. Methods: We reviewed IIAs among 116 consecutive active IE by Duke’s criteria with neurological consultation or admission to stroke neurology service in a single tertiary referral center from January 2015 to July 2016. Susceptibility weighted imaging (SWI) hemorrhage was defined as low signal on SWI in sulci or parenchyma that was not apparent on CT. Results: Of 116 patients, 74 persons (63.8%, mean age of 54) underwent digital subtraction angiography (DSA). IIAs were identified in 13 (17.6%). All of 13 IIAs were unruptured and only one IIA had unrelated intracranial hemorrhage on CT. None of the IIA was seen with CTA or MRA. Eleven (85%) IIAs had clinical strokes (10 ischemic strokes, 1 intracerebral hemorrhage, median NIH stroke scale 3), and 2 neurologically asymptomatic with abnormal MRI. Six of 9 IIAs had SWI hemorrhage in sulci or parenchyma (5 in sulci, 5 in parenchyma, and 1 in both) and all of the lesions were in the vicinity of IIA. Contrast MRI was performed in 7 IIAs, and 4 IIAs had enhancements, all of which were present near the location of IIAs. Ischemic stroke, intracranial hemorrhage, intravenous drug abuse, and type of valve were not associated with the presence of IIA. Of 13 IIAs, 3 remained on antibiotic alone, 5 had antibiotic with coil embolization, and, 5 had antibiotic with glue embolization. Ten patients with IIAs had valvular surgery, including one person with untreated IIA. Out of all patients with IIA, only one intracerebral hemorrhage occurred as perioperative complication unrelated to treated IIA. Conclusions: IIAs were found in approximately one fifth of IE persons who underwent DSA. Imaging characteristics such as SWI hemorrhage in sulci or parenchyma and contrast enhancement appear to correlate with the presence of IIA. DSA should be performed when they are present.

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Cerebral Microbleeds Predict Impending Intracranial Hemorrhage in Infective Endocarditis

Cerebrovascular Diseases ◽

10.1159/000331475 ◽

2011 ◽

Vol 32 (5) ◽

pp. 483-488 ◽

Cited By ~ 42

Author(s):

Shuhei Okazaki ◽

Manabu Sakaguchi ◽

BooHan Hyun ◽

Keiko Nagano ◽

Masafumi Tagaya ◽

...

Keyword(s):

Infective Endocarditis ◽

Intracranial Hemorrhage ◽

Cerebral Microbleeds

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Surgical timing in infective endocarditis complicated by intracranial hemorrhage

American Heart Journal ◽

10.1016/j.ahj.2019.07.011 ◽

2019 ◽

Vol 216 ◽

pp. 102-112 ◽

Cited By ~ 2

Author(s):

Rachael A. Venn ◽

MingMing Ning ◽

Gus J. Vlahakes ◽

Jason H. Wasfy

Keyword(s):

Infective Endocarditis ◽

Intracranial Hemorrhage ◽

Surgical Timing

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An uncommon manifestation of Streptococcus gallolyticus infective endocarditis with cerebral septic emboli

Case Reports in Internal Medicine ◽

10.5430/crim.v4n4p16 ◽

2017 ◽

Vol 4 (4) ◽

pp. 16

Author(s):

Wan Tin Lim ◽

Chiara Jiamin Chong ◽

Robert Chen ◽

Tharmmambal Balakrishnan

Keyword(s):

Infective Endocarditis ◽

Intracranial Hemorrhage ◽

Cerebral Arteries ◽

Neurological Manifestations ◽

Septic Emboli ◽

Streptococcus Gallolyticus ◽

Uncommon Presentation ◽

Magnetic Resonance Imaging Mri ◽

Occipital Lobes ◽

High Degree

Infective endocarditis (IE) can often present with neurological manifestations, due to embolization from valvular vegetation, but the presentation is often variable and unpredictable. Septic emboli to both occipital lobes supplied by the posterior cerebral arteries, resulting in visual disturbances are also an uncommon presentation of IE reported in the literature. While S. gallolyticus is a classical cause of IE, it is less common and usually occurs in a less suspecting group of patients with no predisposing cardiac conditions. We report the case of a 48-year-old man, who presented with predominant complaints of blurring of vision and temporal headache, without any other infective symptoms. The procalcitonin level was also normal even in the setting of bacteremia with septic embolism. The initial magnetic resonance imaging (MRI) showed multifocal enhancing lesions in cerebral hemispheres, cerebellum, and brainstem, with leptomeningeal enhancement. Transesophageal echocardiography and blood cultures subsequently confirmed diagnosis of S. gallolyticus IE of the mitral valve. The patient was treated with antibiotics upon diagnosis of IE. However, he developed intracranial hemorrhage secondary to mycotic aneurysms, and partial seizures. He eventually succumbed to the intracranial hemorrhage. This case serves to highlight that neurological manifestations can precede symptoms or signs of IE and the presentation are often variable. A high degree of clinical suspicion is needed to suspect neurological manifestations of IE, especially in patients without risk factors.

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Abstract P658: Epidemiology and Stroke Complications of IVDU-Associated Endocarditis in the Heart of the Opioid Epidemic

Stroke ◽

10.1161/str.52.suppl_1.p658 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

nguyen hoang ◽

Ciaran Powers ◽

Shahid M Nimjee ◽

Patrick Youssef ◽

Varun Shah

Keyword(s):

Drug Abuse ◽

Infective Endocarditis ◽

Intracranial Hemorrhage ◽

Clinical Care ◽

The United States ◽

Intravenous Drug ◽

Opioid Epidemic ◽

Number Of Patients ◽

History Of ◽

Brain Abscesses

Introduction: The United States is experiencing a rapidly increasing rate of opioid drug abuse. Intravenous drug use related endocarditis and resultant septic embolic stroke, intracranial hemorrhage and infectious intracranial aneurysm (IIAs) cause significant morbidity and mortality and have a significant impact on cost and clinical care. Methods: We conducted a retrospective cohort study involving patients treated for infective endocarditis (IE) at a single institution over a 54-month period between 1/1/2014 and 07/01/2018. Concomitant intravenous drug abuse and infective endocarditis was analyzed to identify and demographics, risk factors, and attributed costs. Results: A total of 351 patients met inclusion criteria with 170 patients (48%) having history of IVDU-associated endocarditis. From 2014 to 2018, there was a 630% increased incidence of patients with IVDU-associated endocarditis. Compared to endocarditis of other etiologies, a significant number of patients with IVDU-associated endocarditis were homeless (5.9% v 1.1%, p=0.014), uninsured (10.0% v 2.8%, p=0.005), and unemployed (75.9% v 31.7%, p=0.0001). IVDU was associated with an increased prevalence of overall intracranial hemorrhage (25.9% v 13.9%, p=0.005), including intraparenchymal hemorrhage (12.4% v 5.1%, p=0.012), subarachnoid hemorrhage (17.6 v 4.4%, p=0.0001), and cerebral microbleeds (14.1% v 7.2%, p=0.022). IVDU was also associated with an increased prevalence of IIAs (10.6% v 1.8%, p=0.0001) and brain abscesses (4.7% v 1.1%, p=0.025). Conclusions: The opioid epidemic has increased the incidence of infective endocarditis and resultant neurovascular complications. IVDU-associated endocarditis is associated with increased hemorrhagic stroke and increase healthcare utilization and costs.

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