Cerebral ischemic events in patients with infective endocarditis: results of a single center retrospective study

Cerebral ischemic events, including ischemic stroke (IS) and transient ischemic attack (TIA), are among the most common extracardiac complications of infective endocarditis (IE).

Objective: to evaluate cerebral ischemic events (prevalence, clinical and neuroimaging characteristics, predictors, prognosis) in patients with “left-sided” IE, who underwent cardiac surgery, according to the registry of the Federal Center for Cardiovascular Surgery.

Material and methods. A retrospective review of data from the hospital information system was performed in one of the federal centers for cardiovascular surgery of the Russian Ministry of Health. Inclusion criteria in the study: age of patients ≥18 years, significant or probable (Duke criteria) IE of the left heart – aortic and/or mitral valves. Patients with isolated right heart IE (tricuspid valve, pacemaker-associated endocarditis), nonbacterial thromboendocarditis, and chronic IE were excluded from the study. For the analysis, 222 cases of IE in 216 patients were used. IS was observed in 43 (19.4%) patients with “left-sided” IE, TIA – in 4 (1.8%). In ²/₃ of cases, patients suffered a minor stroke (NIHSS <5), while every fifth patient had symptoms of encephalopathy. Logistic regression was used to determine the predictors of cerebral embolism. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for each of the significant risk factors, and time to first clinical event (death) was estimated using the Kaplan–Meier method.

Results. On neuroimaging in IE, the following signs were frequently detected: involvement of different cerebral vascular territories (65.1%), multifocal (≥1 focus) infarcts (74.4%), hemorrhagic transformation (37.2%). Cortical and/or subcortical distribution of infarcts was observed in 97.7% of patients. According to multivariate analysis, IS and TIA were predicted by vegetations >10 mm (OR 3.552; 95% CI 1.066–11.8463; p=0.039), mobile vegetations (OR 6.112; 95% CI 1.105–33.784; p=0.038) and multiple vegetations (OR 5.2 08, 95% CI 1.189–22.805, p=0.029). The impact of cerebral embolism on prognosis (in-hospital and long-term mortality) in patients undergoing cardiac surgery was not established.

Conclusion. According to the neuroimaging data, cerebral infarcts in IE correspond to the main signs of cardioembolism. The characteristics of the vegetations (size >10 mm, mobility, multiplicity) are a crucial indicator of the embolic potential of IE.

1. Garcia-Cabrera E, Fernandez-Hidalgo N,Almirante B, et al; Group for the Study of Cardiovascular Infections of the Andalusian Society of Infectious Diseases; Spanish Network for Research in Infectious Diseases. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation. 2013 Jun 11;127(23):2272-84. doi: 10.1161/CIRCULATIONAHA.112.000813

2. Rizzi M, Ravasio V, Carobbio A, et al;Investigators of the Italian Study on Endocarditis. 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 Apr 29;14:230. doi: 10.1186/1471-2334-14-230

3. Valenzuela I, Hunter MD, Sundheim K, et al. Clinical risk factors for acute ischaemic and haemorrhagic stroke in patients with infective endocarditis. Intern Med J. 2018 Sep;48(9):1072-80. doi: 10.1111/imj.13958

4. Chen CC, Wu VC, Chang CH, et al. Long-term Outcome of Neurological Complications after Infective Endocarditis. Sci Rep. 2020 Mar 4;10(1):3994. doi: 10.1038/s41598-020-60995-3

5. Кulesh АА, Demin DА. Intravenous thrombolysis in ischemic stroke: 10 rules for the practical neurologist. Meditsinskiy sovet = Medical Council. 2022;(21):175-83. doi: 10.21518/2079-701X-2022-16-21-175-183 (In Russ.)].

6. Demin DA, Kulesh AA, Vinogradov OI, et al. Neurological complications of infective endocarditis: 10 rules of patient management. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2022;14(4):4-11. doi: 10.14412/2074-27112022-4-4-115 (In Russ.)].

7. Das AS, McKeown M, Jordan SA, et al.Risk factors for neurological complications in left-sided infective endocarditis. J Neurol Sci. 2022 Nov 15;442:120386. doi: 10.1016/j.jns.2022.120386

8. Yang A, Tan C, Daneman N, et al. Clinicaland echocardiographic predictors of embolism in infective endocarditis: systematic review and meta-analysis. Clin Microbiol Infect. 2019 Feb;25(2):178-87. doi: 10.1016/j.cmi.2018.08.010

9. Iung B, Tubiana S, Klein I, et al; ECHO-IMAGE Study Group. Determinants of cerebral lesions in endocarditis on systematic cerebral magnetic resonance imaging: a prospective study. Stroke. 2013 Nov;44(11):3056-62. doi: 10.1161/STROKEA-HA.113.001470

10. Deprele C, Berthelot P, Lemetayer F, et al. Risk factors for systemic emboli in infective endocarditis. Clin Microbiol Infect. 2004 Jan;10(1):46-53. doi: 10.1111/j.1469-0691.2004.00735.x

11. Monteiro TS, Correia MG, Golebiovski WF, et al. Asymptomatic and symptomatic embolic events in infective endocarditis: associated factors and clinical impact. Braz J Infect Dis. 2017 MayJun;21(3):240-7. doi: 10.1016/j.bjid.2017.01.006

12. Misfeld M, Girrbach F, Etz CD, et al. Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients. J Thorac Cardiovasc Surg. 2014 Jun;147(6):1837-44. doi: 10.1016/j.jtcvs.2013.10.076

13. Salaun E, Touil A, Hubert S, et al. Intracranial haemorrhage in infective endocarditis. Arch Cardiovasc Dis. 2018 Dec;111(12):712-21. doi: 10.1016/j.acvd.2018.03.009

14. Selton-Suty C, Delahaye F, Tattevin P, et al; AEPEI (Association pour l’Etude et la Prevention de l’Endocardite Infectieuse). Symptomatic and Asymptomatic Neurological Complications of Infective Endocarditis: Impact on Surgical Management and Prognosis. PLoS One. 2016 Jul 11;11(7):e0158522. doi: 10.1371/journal.pone.0158522

15. Pericart L, Fauchier L, Bourguignon T, et al. Long-Term Outcome and Valve Surgery for Infective Endocarditis in the Systematic Analysis of a Community Study. Ann Thorac Surg. 2016 Aug;102(2):496-504. doi: 10.1016/j.athoracsur.2016.02.010

16. Moiseev VS, Kobalava ZD, Pisaryuk AS, et al. Infective Endocarditis in Moscow General Hospital: Clinical Characteristics and Outcomes (Single-Center 7 Years’ Experience). Kardiologiya. 2018;58(12):66-75. doi: 10.18087/cardio.2018.12.10192 (In Russ.)].