Table 1.
Summary of Author Recommendations.
| Neurologic Complication | Epidemiology | Clinical Manifestations in IE | Management | Implications for Cardiac Surgery if Indicated |
|---|---|---|---|---|
| Ischemic stroke | Clinically present in 20% to 40% of patients with IE Asymptomatic ischemia can be found in an additional 30% to 40% of patients with IE | Focal deficits, encephalopathy, and seizure | Avoid IV tPA, antiplatelet agents, and anticoagulation | Clinically silent/small infarcts should not delay cardiac surgery Larger infarcts may warrant delaying surgical intervention for up to 4 weeks |
| Intracerebral hemorrhage | Present in 4% to 27% of patients with IE Microhemorrhage is present in up to 57% of patients with IE | Focal deficits, headache, encephalopathy, and seizure | NVE: avoid all antiplatelets and anticoagulants PVE: prophylactically, convert oral anticoagulants to IV heparin and should hemorrhage develop stop anticoagulation for 10 to 14 days | Postpone cardiac surgery for 4 weeks following clinically significant hemorrhage |
| Infectious intracranial aneurysms | Present in at least 2% to 4% of patients with IE | Headache, seizures, focal deficits, encephalopathy, ophthalmoplegia, and rarely proptosis | Antibiotics and serial imaging for stable, small, unruptured aneurysms. Endovascular repair of large or enlarging unruptured aneurysms if amenable. Open surgical clipping for large or enlarging unruptured aneurysms not amenable to endovascular techniques or in eloquent areas where surgical anastamoses may spare function | Postpone cardiac surgery for 1 to 2 weeks following aneurysmal repair |
| Cerebral abscess | Present in 1% to 7% of patients with IE | Focal deficits, headache, encephalopathy, persistent fever, and seizure | Antibiotics alone for small or multifocal abscesses. Surgical drainage for abscesses that are large or do not respond to antibiotics. Neurosurgical intervention as appropriate for hydrocephalus or significant mass effect | Typically will not interfere with surgical planning. Prioritize neurosurgical intervention in the setting of hydrocephalus or significant mass effect. If hemorrhage accompanies, manages as mentioned earlier |
| Meningitis | Present in 1% to 20% of patients with IE | Headache, encephalopathy, seizure, neck/back pain, nuchal rigidity, and photophobia | At least 4 weeks of antibiotics | Typically will not interfere with surgical planning |
Abbreviations: IE, infective endocarditis; IV, intravenous; tPA, tissue plasminogen activator; PVE, prosthetic valve endocarditis; NVE, native valve endocarditis.