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Published on: July 24, 2019
Clinical utility of cerebral angiography in the preoperative assessment of endocarditis
Peter P Monteleone1, Nabin K Shrestha1, Jessen Jacob1
1Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Cerebral angiography for infective endocarditis (IE) is rarely useful. Noninvasive tests and absence of neurological deficits can often preclude the need for this invasive procedure in IE patients.
Area of Science:
- Neurology
- Cardiology
- Infectious Diseases
Background:
- Infective endocarditis (IE) poses risks for intracranial complications, including mycotic aneurysms.
- Cerebral angiography is an invasive diagnostic tool used to detect these aneurysms preoperatively.
- Current guidelines for its use in IE patients are lacking.
Purpose of the Study:
- To evaluate the diagnostic utility of cerebral angiography in infective endocarditis patients.
- To identify specific patient subsets who benefit from cerebral angiography.
- To determine clinical and noninvasive screening tests that can obviate the need for cerebral angiography.
Main Methods:
- Retrospective analysis of patients treated for IE between 7/2007 and 1/2012 (surgical) or 7/2007 and 7/2009 (medical).
- Analysis of cerebral angiography findings in 151 IE patients.
- Evaluation of the predictive value of clinical signs and noninvasive imaging (MRI).
Main Results:
- Mycotic aneurysms were identified in only 4.6% of patients undergoing cerebral angiography.
- Viridans group streptococci were the causative organism in 5 of 7 identified aneurysms.
- Absence of intracranial bleed on MRI had a negative predictive value of 0.977.
- Absence of focal neurologic deficit or altered mental status had high negative predictive values (0.990 and 0.944, respectively).
Conclusions:
- Cerebral angiography is infrequently diagnostic for mycotic aneurysms in IE patients.
- Clinical suspicion should be limited to cases with acute neurologic deficits and evidence of intracranial bleeding on noninvasive imaging.
- Noninvasive imaging and neurological assessment can effectively guide the decision to perform cerebral angiography.
Abstract:
Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3-9.3%). Five had viridans group streptococci as the causative IE microorganism (p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879-0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945-0.998) and 0.944 (95% CI 0.883-0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.
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