Clinical Course of Cerebral Haemorrhage in Infective Endocarditis: Focus on Microbleed and Small-Area Haemorrhage

This study aimed to review the surgical details and postoperative outcomes of on-pump valve surgery for preoperative central nervous system complications, especially infective endocarditis (IE) with cerebral microbleeds and small cerebral haemorrhage, in patients with acute IE.

Between January 2015 and June 2024, we performed 54 surgeries for IE, with intracranial haemorrhage occurring in 13 of the 30 patients with preoperative central nervous system complications.

Among the 13 patients with intracranial haemorrhage, 11 had cerebral infarction, 6 had cerebral microbleed, 2 had small haemorrhages not meeting the definition of cerebral microbleed, and 5 had conventional haemorrhage. The median time from bleeding to surgery was 1, 2, and 20 days for cerebral microbleeds, small haemorrhages, and conventional haemorrhages, respectively. The main valve procedures were double valve replacement (5 patients), mitral valve replacement (6patients), and aortic valve replacement (2patients). Postoperative computed tomography (CT) showed worsening cerebral haemorrhage in 3 patients (23.1%, 95% CI, 5.0%-53.8%), including 1 with cerebral microbleed and 2 with small haemorrhage. Two patients with small haemorrhage required postoperative neurosurgical embolization (15.4%, 95% CI, 1.9%-45.4%). Postoperative complications included in-hospital death in 1 patient with conventional haemorrhage (7.7%, 95% CI, 0.2%-36.0%), but no deaths due to central nervous system complications were observed.

In our cohort, over half of the patients with IE presented with central nervous system complications, with cerebral haemorrhage accounting for 43%. Postoperative haemorrhage worsened in all patients with small haemorrhage who underwent early intervention. Although the prognostic impact was minimal, small haemorrhages that were not cerebral microbleeds had a high rate of exacerbations requiring neurosurgery and should be treated with caution.