Intracranial Hemorrhage as a Marker for Mycotic Aneurysm in Patients With Infective Endocarditis

Thomas J Williams; Matthew Starr; Sami El-Dalati

doi:10.1212/CPJ.0000000000200144

Intracranial Hemorrhage as a Marker for Mycotic Aneurysm in Patients With Infective Endocarditis

Neurol Clin Pract. 2023 Apr;13(2):e200144. doi: 10.1212/CPJ.0000000000200144. Epub 2023 Mar 10.

Authors

Thomas J Williams¹, Matthew Starr¹, Sami El-Dalati¹

Affiliation

¹ Department of Neurology (TJW, MS), University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Infectious Diseases, Department of Internal Medicine, (SE-D) University of Kentucky Medical Center, Lexington, KY.

Abstract

Background and objective: Mycotic aneurysms are a significant complication of IE that can lead to intracranial hemorrhage (ICH) and occasionally require intervention before valve surgery. Digital subtraction angiography (DSA) remains the gold standard for the detection of mycotic aneurysms but is an invasive procedure with contrasted dye exposure. Our objective was to determine predictive factors for the presence of mycotic aneurysms in patients with known infective endocarditis (IE).

Methods: IRB exemption was obtained from the University of Pittsburgh Medical Center. Patients with left-sided or right-sided endocarditis with patent foramen ovale (PFO) were identified. Records were retrospectively reviewed by an independent investigator. Patients were stratified by demographic information, diagnostic imaging, and clinical outcomes. Standard descriptive statistics were used for characterization. The χ² analysis and Fisher exact test were used for categorical comparisons. The Student t test was used for group comparisons.

Results: 36 cases of left-sided or right-sided endocarditis with PFO undergoing evaluation for valve surgery were identified. Twenty-seven patients underwent CNS imaging, and 24 underwent DSA. Six patients were found to have ICH on CNS imaging. Mycotic aneurysms were identified by DSA in 5 patients (13.9%), and of these patients, 4 (80%) presented with ICH and 1 with ischemic stroke. Notably, the patient who presented with ischemic stroke then developed ICH on follow-up CT imaging. The negative predictive value of the absence of ICH on initial CNS imaging for the presence of mycotic aneurysm was 97.4%.

Discussion: Patients with left-sided and right-sided endocarditis with PFO and ICH on CNS imaging were more likely to have mycotic aneurysms detected through DSA than similar patients without ICH. Routine DSA screening for mycotic aneurysms may not be required in patients with endocarditis undergoing evaluation for valve surgery who present without ICH on CNS imaging.