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Mycotic aneurysm, subarachnoid hemorrhage, and indications for cerebral angiography in infective endocarditis
A V Salgado1, A J Furlan, T F Keys
1Department of Neurology, Cleveland Clinic Foundation, OH 44106.
Abstract:
We compared the clinical course of 68 patients with infective endocarditis and mycotic aneurysm and 147 patients with infective endocarditis but no mycotic aneurysm. Among the patients with mycotic aneurysm, 57% had subarachnoid hemorrhage without warning. Forty-three percent had a neurologic prodrome 2 days to 18 months (median 17 days) prior to discovery of the mycotic aneurysm. A focal deficit consistent with embolism was the most common prodrome (23%). However, there was no significant difference in the frequency of neurologic symptoms between patients with and without mycotic aneurysm. During an average follow-up of 40 months, there were no instances of subarachnoid hemorrhage/mycotic aneurysm among 121 patients discharged after a full course of antibiotic therapy. Therefore, the risk of rupture of an unsuspected mycotic aneurysm following a full course of antibiotics is low. When a prodrome does precede a mycotic aneurysm, it most often is a focal deficit consistent with embolism. We favor angiography in all patients with infective endocarditis who experience a focal deficit with good recovery. The timing and other indications for angiography in infective endocarditis are discussed.
Insights
Infective endocarditis patients with mycotic aneurysms face high subarachnoid hemorrhage risk. However, completing antibiotic therapy significantly lowers aneurysm rupture risk, suggesting a low risk post-treatment.
Area of Science:
- Neurology
- Infectious Diseases
- Cardiology
Background:
- Infective endocarditis can lead to mycotic aneurysms, posing significant risks.
- Mycotic aneurysms are associated with neurological complications, including subarachnoid hemorrhage.
Purpose of the Study:
- To compare the clinical course of patients with infective endocarditis and mycotic aneurysm versus those without.
- To evaluate the risk of subarachnoid hemorrhage and aneurysm rupture in infective endocarditis patients.
Main Methods:
- Retrospective comparison of 68 patients with infective endocarditis and mycotic aneurysm against 147 patients with infective endocarditis alone.
- Analysis of clinical presentation, neurological prodromes, and long-term follow-up outcomes.
Main Results:
- 57% of mycotic aneurysm patients experienced subarachnoid hemorrhage without warning.
- Neurologic prodromes occurred in 43% of mycotic aneurysm patients, often a focal deficit.
- No subarachnoid hemorrhage or aneurysm rupture occurred in patients completing antibiotic therapy during follow-up.
Conclusions:
- The risk of mycotic aneurysm rupture after a full antibiotic course is low.
- Focal deficits consistent with embolism are common prodromes for mycotic aneurysms.
- Angiography is recommended for infective endocarditis patients with focal deficits and good recovery.