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Risk factors for neurological complications in left-sided infective endocarditis

Published:August 20, 2022DOI:https://doi.org/10.1016/j.jns.2022.120386

      Highlights

      • Large vegetations are a risk factor for stroke in infective endocarditis (IE)
      • Staphylococcus aureus infection is a risk factor for cerebral microbleeds in IE
      • Younger individuals are at a higher risk of developing mycotic aneurysms in IE

      Abstract

      Background and purpose

      Neurological complications following infective endocarditis (IE) directly contribute to long-term morbidity. We examined the risk factors for different neurological complications of left-sided IE.

      Methods

      Using a database of consecutive adults admitted to a health system with left-sided IE from 2015 to 2019, the frequency of cerebral infarcts, intraparenchymal hemorrhage, cerebral microbleeds (CMB), mycotic aneurysm, and encephalopathy was determined. Variables with significant differences comparing each neurological complication (p < 0.1) were entered into regression models along with age to determine predictors.

      Results

      211 patients with mean age 54 (±18) years, and 69 (33%) females were included. Infarcts were found in 118 (56%) patients, intraparenchymal hemorrhage was found in 17 (8%) patients, CMB were found in 58 (27%) patients, mycotic aneurysms were found in 22 (10%) patients, and encephalopathy occurred in 16 (8%) patients. In multivariable models, vegetation size ≥15 mm was associated with a higher risk of infarcts (aOR 2.26, 95% CI (1.12–4.57)), and the presence of a mycotic aneurysm was a risk factor for intraparenchymal hemorrhage (aOR 18.79, 95% CI (3.97–88.97)). Prosthetic valves (aOR 2.89, 95% CI (1.11–7.54)) and Staphylococcus aureus infection (aOR 3.50, 95% CI (1.08–11.36)) were associated with CMB. No risk factors emerged as predictors of encephalopathy.

      Conclusions

      Large vegetation size is associated with stroke in patients with IE. Mycotic aneurysms are found at a higher frequency in young patients and are the primary cause of intraparenchymal hemorrhage. CMB may be related to prosthetic valves and Staphylococcus aureus infection.

      Keywords

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      References

        • Baddour L.M.
        • Wilson W.R.
        • Bayer A.S.
        • et al.
        Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications.
        Circulation. 2015; 132: 1435-1486https://doi.org/10.1161/CIR.0000000000000296
        • Klein I.
        • Iung B.
        • Labreuche J.
        • et al.
        Cerebral microbleeds are frequent in infective endocarditis: a case-control study.
        Stroke. 2009; 40: 3461-3465https://doi.org/10.1161/STROKEAHA.109.562546
        • Murai R.
        • Kaji S.
        • Kitai T.
        • et al.
        The clinical significance of cerebral microbleeds in infective endocarditis patients.
        Semin. Thorac. Cardiovasc. Surg. 2019; 31: 51-58https://doi.org/10.1053/J.SEMTCVS.2018.09.020
        • Cho S.M.
        • Marquardt R.J.
        • Rice C.J.
        • et al.
        Cerebral microbleeds predict infectious intracranial aneurysm in infective endocarditis.
        Eur. J. Neurol. 2018; 25: 970-975https://doi.org/10.1111/ENE.13641
        • García-Cabrera E.
        • Fernández-Hidalgo N.
        • Almirante B.
        • et al.
        Neurological complications of infective endocarditis risk factors, outcome, and impact of cardiac surgery: a multicenter observational study.
        Circulation. 2013; 127: 2272-2284https://doi.org/10.1161/CIRCULATIONAHA.112.000813
        • Rizzi M.
        • Ravasio V.
        • Carobbio A.
        • et al.
        Predicting the occurrence of embolic events: An analysis of 1456 episodes of infective endocarditis from the Italian Study on Endocarditis (SEI).
        BMC Infect. Dis. 2014; 14: 1-10https://doi.org/10.1186/1471-2334-14-230/TABLES/5
        • Salaun E.
        • Touil A.
        • Hubert S.
        • et al.
        Intracranial haemorrhage in infective endocarditis.
        Arch. Cardiovasc. Dis. 2018; 111: 712-721https://doi.org/10.1016/J.ACVD.2018.03.009
        • Valenzuela I.
        • Hunter M.D.
        • Sundheim K.
        • et al.
        Clinical risk factors for acute ischemic and hemorrhagic stroke in patients with infective endocarditis.
        Intern. Med. J. 2018; 48: 1072https://doi.org/10.1111/IMJ.13958
        • Thuny F.
        • Disalvo G.
        • Belliard O.
        • et al.
        Risk of embolism and death in infective endocarditis: prognostic value of echocardiography - a prospective multicenter study.
        Circulation. 2005; 112: 69-75https://doi.org/10.1161/CIRCULATIONAHA.104.493155
        • Nalichowski R.
        • Keogh D.
        • Chueh H.C.
        • Murphy S.N.
        Calculating the benefits of a Research Patient Data Repository. AMIA Annual Symposium Proceedings.
        • Das A.S.
        • McKeown M.
        • Jordan S.A.
        • Li K.
        • Regenhardt R.W.
        • Feske S.K.
        Neurological complications and clinical outcomes of infective endocarditis.
        J. Stroke Cerebrovasc. Dis. 2022; 31106626https://doi.org/10.1016/J.JSTROKECEREBROVASDIS.2022.106626
        • Das A.S.
        • Jordan S.A.
        • McKeown M.
        • et al.
        Screening neuroimaging in neurologically asymptomatic patients with infective endocarditis.
        J. Neuroimaging. 2022; https://doi.org/10.1111/JON.13020
        • Li J.S.
        • Sexton D.J.
        • Mick N.
        • et al.
        Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.
        Clin. Infect. Dis. 2000; 30: 633-638https://doi.org/10.1086/313753
        • Wardlaw J.M.
        • Smith E.E.
        • Biessels G.J.
        • et al.
        Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration.
        Lancet Neurol. 2013; 12: 822-838https://doi.org/10.1016/S1474-4422(13)70124-8
        • Greenberg S.M.
        • Vernooij M.W.
        • Cordonnier C.
        • et al.
        Cerebral microbleeds: a guide to detection and interpretation.
        Lancet Neurol. 2009; 8: 165-174https://doi.org/10.1016/S1474-4422(09)70013-4
        • Das A.S.
        • Regenhardt R.W.
        • Vernooij M.W.
        • Blacker D.
        • Charidimou A.
        • Viswanathan A.
        Asymptomatic cerebral small vessel disease: insights from population-based studies.
        J. Stroke. 2019; 21: 121-138https://doi.org/10.5853/jos.2018.03608
        • Heiro M.
        • Nikoskelainen J.
        • Engblom E.
        • Kotilainen E.
        • Marttila R.
        • Kotilainen P.
        Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland.
        Arch. Intern. Med. 2000; 160: 2781-2787https://doi.org/10.1001/ARCHINTE.160.18.2781
        • Vermeer S.E.
        • Den Heijer T.
        • Koudstaal P.J.
        • et al.
        Incidence and risk factors of silent brain infarcts in the population-based Rotterdam scan study.
        Stroke. 2003; 34: 392-396https://doi.org/10.1161/01.STR.0000052631.98405.15
        • Poels M.M.F.
        • Vernooij M.W.
        • Ikram M.A.
        • et al.
        Prevalence and risk factors of cerebral microbleeds: an update of the rotterdam scan study.
        Stroke. 2010; 41: S103-S106https://doi.org/10.1161/STROKEAHA.110.595181
        • An S.J.
        • Kim T.J.
        • Yoon B.W.
        Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: An update.
        J. Stroke. 2017; 19: 3-10https://doi.org/10.5853/jos.2016.00864
        • Roach M.R.
        • Drake C.G.
        Ruptured cerebral aneurysms caused by Micro-organisms.
        N. Engl. J. Med. 2010; 273: 240-244https://doi.org/10.1056/NEJM196507292730503
        • Di Salvo G.
        • Habib G.
        • Pergola V.
        • et al.
        Echocardiography predicts embolic events in infective endocarditis.
        J. Am. Coll. Cardiol. 2001; 37: 1069-1076https://doi.org/10.1016/S0735-1097(00)01206-7
        • Snygg-Martin U.
        • Gustafsson L.
        • Rosengren L.
        • et al.
        Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers.
        Clin. Infect. Dis. 2008; 47: 23-30https://doi.org/10.1086/588663
        • Cooper H.A.
        • Thompson E.C.
        • Laureno R.
        • et al.
        Subclinical brain embolization in left-sided infective endocarditis: results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses (EMBOLISM) pilot study.
        Circulation. 2009; 120: 585-591https://doi.org/10.1161/CIRCULATIONAHA.108.834432
        • Iung B.
        • Tubiana S.
        • Klein I.
        • et al.
        Determinants of cerebral lesions in endocarditis on systematic cerebral magnetic resonance imaging: a prospective study.
        Stroke. 2013; 44: 3056-3062https://doi.org/10.1161/STROKEAHA.113.001470
        • Rohmann S.
        • Erbel R.
        • Görge G.
        • et al.
        Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis.
        Eur. Heart J. 1992; 13: 446-452https://doi.org/10.1093/OXFORDJOURNALS.EURHEARTJ.A060195
        • Mangoni E.D.
        • Adinolfi L.E.
        • Tripodi M.F.
        • et al.
        Risk factors for “major” embolic events in hospitalized patients with infective endocarditis.
        Am. Heart J. 2003; 146: 311-316https://doi.org/10.1016/S0002-8703(02)94802-7
        • Vilacosta I.
        • Graupner C.
        • SanRomán J.
        • et al.
        Risk of embolization after institution of antibiotic therapy for infective endocarditis.
        J. Am. Coll. Cardiol. 2002; 39: 1489-1495https://doi.org/10.1016/S0735-1097(02)01790-4
        • Mohananey D.
        • Mohadjer A.
        • Pettersson G.
        • et al.
        Association of vegetation size with embolic risk in patients with infective endocarditis: a systematic review and Meta-analysis.
        JAMA Intern. Med. 2018; 178: 502-510https://doi.org/10.1001/JAMAINTERNMED.2017.8653
        • Dahl A.
        • Rasmussen R.V.
        • Bundgaard H.
        • et al.
        Enterococcus faecalis infective endocarditis: a pilot study of the relationship between duration of gentamicin treatment and outcome.
        Circulation. 2013; 127: 1810-1817https://doi.org/10.1161/CIRCULATIONAHA.112.001170
        • Munita J.M.
        • Arias C.A.
        • Murray B.E.
        Enterococcal endocarditis: can we win the war?.
        Curr. Infect. Dis. Rep. 2012; 14: 339https://doi.org/10.1007/S11908-012-0270-8
        • McDonald J.R.
        • Olaison L.
        • Anderson D.J.
        • et al.
        Enterococcal endocarditis: 107 cases from the international collaboration on endocarditis merged database.
        Am. J. Med. 2005; 118: 759-766https://doi.org/10.1016/J.AMJMED.2005.02.020
        • Valenzuela I.
        • Hunter M.D.
        • Sundheim K.
        • et al.
        Clinical risk factors for acute ischemic and hemorrhagic stroke in patients with infective endocarditis.
        Intern. Med. J. 2018; 48: 1072https://doi.org/10.1111/IMJ.13958
        • Okazaki S.
        • Sakaguchi M.
        • Hyun B.
        • et al.
        Cerebral microbleeds predict impending intracranial hemorrhage in infective endocarditis.
        Cerebrovasc. Dis. 2011; 32: 483-488https://doi.org/10.1159/000331475
        • Breiding P.S.
        • Duerrenmatt J.T.
        • Meinel F.G.
        • et al.
        Prevalence and evolution of susceptibility-weighted imaging lesions in patients with artificial heart valves.
        J. Am. Hear. Assoc. Cardiovasc. Cerebrovasc. Dis. 2019; 8https://doi.org/10.1161/JAHA.119.012814
        • Rizzi M.
        • Ravasio V.
        • Carobbio A.
        • et al.
        Predicting the occurrence of embolic events: an analysis of 1456 episodes of infective endocarditis from the Italian study on endocarditis (SEI).
        BMC Infect. Dis. 2014; 14https://doi.org/10.1186/1471-2334-14-230
        • Yang A.
        • Tan C.
        • Daneman N.
        • et al.
        Clinical and echocardiographic predictors of embolism in infective endocarditis: systematic review and meta-analysis.
        Clin. Microbiol. Infect. 2019; 25: 178-187https://doi.org/10.1016/J.CMI.2018.08.010
        • Murai R.
        • Kaji S.
        • Kitai T.
        • et al.
        The clinical significance of cerebral microbleeds in infective endocarditis patients.
        Semin. Thorac. Cardiovasc. Surg. 2019; 31: 51-58https://doi.org/10.1053/J.SEMTCVS.2018.09.020
        • Durante-Mangoni E.
        • Bradley S.
        • Selton-Suty C.
        • et al.
        Current features of infective endocarditis in elderly patients: results of the international collaboration on endocarditis prospective cohort study.
        Arch. Intern. Med. 2008; 168: 2095-2103https://doi.org/10.1001/ARCHINTE.168.19.2095
        • Ducruet A.F.
        • Hickman Z.L.
        • Zacharia B.E.
        • et al.
        Intracranial infectious aneurysms: a comprehensive review.
        Neurosurg. Rev. 2010; 33: 37-46https://doi.org/10.1007/S10143-009-0233-1
        • Yuan S.M.
        • Wang G.F.
        Cerebral mycotic aneurysm as a consequence of infective endocarditis: a literature review.
        Cor. Vasa. 2017; 59: e257-e265https://doi.org/10.1016/J.CRVASA.2016.11.004
        • Kanter M.C.
        • Hart R.G.
        Neurologic complications of infective endocarditis.
        Neurology. 1991; 41: 1015-1520https://doi.org/10.1212/WNL.41.7.1015
        • Hui F.K.
        • Bain M.
        • Obuchowski N.A.
        • et al.
        Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis.
        J. Neurointerv. Surg. 2015; 7: 449-452https://doi.org/10.1136/NEURINTSURG-2014-011124