Successful cardic surgery 24 hours after craniotomy in a patient with infective endocarditis and embolic cerebellar infarction: case report
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Updated: Aug 24, 2026
Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Tobias A Rupprecht1, Sabine Weil, Peter A Winkler
1Department of Neurology, Neurological Intensive Care Unit, Ludwigs-Maximilian University, Munich, Germany.
Insights
Managing endocarditic stroke patients after decompressive craniotomy is challenging. This case study shows successful early mitral valve replacement 24 hours post-neurosurgery, preventing re-embolization and improving outcomes.
Area of Science:
- Cardiology
- Neurosurgery
- Infectious Diseases
Background:
- Managing space-occupying endocarditic stroke post-decompressive craniotomy presents challenges.
- Early valve replacement is ideal but often contraindicated after neurosurgery due to bleeding risks.
Observation:
- A critically ill patient with bacterial endocarditis and cerebellar infarction with impending herniation was treated.
Findings:
- Mitral valve replacement was successfully performed 24 hours after decompressive craniotomy.
- Maximal hemostasis, hypothermia (21°C), mild hyperventilation, and adequate perfusion pressure were used during surgery.
- A bioprosthesis was chosen to minimize anticoagulation duration.
- The patient experienced no new infarcts, only minor hemorrhagic transformation, and showed minimal neurological deficits at 5 months.
Implications:
- Early valve replacement is feasible and safe shortly after decompressive craniotomy in selected endocarditic stroke patients.
- This approach can mitigate re-embolization risks while managing critical neurological compromise.
- Careful surgical planning and intraoperative management are crucial for successful outcomes.
Abstract:
Follow up management in a patient already treated with decompressive craniotomy for a space-occupying endocarditic stroke is difficult. While immediate valve replacement eliminates the focus and therefore the high risk of re-embolization, a neurosurgical intervention is considered a contraindication to early cardiosurgery. Herein, the first report is presented of a critically ill patient with bacterial endocarditis and a space-occupying cerebellar infarction with imminent herniation, who successfully underwent mitral valve replacement only 24 h after decompressive craniotomy. To prevent rebleeding, maximal hemostasis was ensured during the neurosurgical intervention. For cardiosurgery, the patient was cooled to 21 degrees C, mildly hyperventilated, and maintained at an adequate perfusion pressure during cardiopulmonary bypass. A bioprosthesis was used to reduce the time of anticoagulation. The patient did not develop new infarcts after either intervention, and there was only a very small hemorrhagic transformation without a relevant mass effect. At five months after surgery the patient had minimal neurological abnormalities and was able to conduct his daily life without help.