eMedicine Specialties > Neurology > Neurological Infections

Neurological Sequelae of Infectious Endocarditis: Treatment & Medication

Author: Aiesha Ahmed, MD, Fellow, Department of Neuromuscular Medicine, Pennsylvania State University, Milton S Hershey Medical Center
Coauthor(s): Kevin Hargrave, MD, Consulting Staff in Medicine/Neurology, Comprehensive Neurologics and Sleep; Justin R Fisher, MD, Fellow, Department of Neurophysiology, Penn State Milton S Hershey Medical Center; Milind J Kothari, DO, Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Hershey Medical Center
Contributor Information and Disclosures

Updated: Feb 17, 2009

Treatment

Medical Care

All medical care should be directed by an infectious disease specialist and the primary care physician.

  • Antibiotics
    • Embolization primarily occurs prior to the initiation of antibiotics or within the first week of starting antibiotic therapy.
    • Antibiotics resolve 50% of formed mycotic aneurysms. They also decrease the risk of bleeding and delay bleeding from mycotic aneurysms from approximately 2-10 days.
  • Anticoagulants
    • Anticoagulants are contraindicated in individuals with NVE because of the increased risk of CNS hemorrhage. Some studies show that, even after an embolic event, anticoagulants should not be administered. They often are not warranted because with adequate control of infection within the first week, the risk of CNS embolization declines sharply.
    • If not anticoagulated, patients with PVE are more likely to have embolic phenomena (50-70% risk). The risk of neurologic complications is not increased in patients with infective endocarditis who are on anticoagulants at the time of onset of infective endocarditis. Therefore, unless neurologic complications exist, anticoagulation therapy is continued in patients with prosthetic valves but with a lower goal international normalized ratio (INR) of 1.5. Anticoagulation increases the risk of bleeding from mycotic aneurysms. Early angiography should be performed to guide therapy if aneurysms are present or suspected.

Surgical Care

Whether mycotic aneurysms should be observed, clipped, or treated endovascularly is controversial and depends on the need for cardiac surgery. Forty percent of patients with infective endocarditis will need cardiac surgery, primarily for valve repair or replacement. Indications for surgery include hemodynamic instability, uncontrolled infection, and peripheral embolic events, and these are described in detail in guidelines published by the American College of Cardiology and the American Heart Association in 1998.8 Timing of surgery remains controversial.

  • One study evaluated patients with ruptured and unruptured mycotic aneurysms treated medically or surgically. Of patients with ruptured aneurysms, 10 were treated medically and 6 surgically; 8 of the medically treated aneurysms resolved (the other 2 patients had poor outcomes), and all of the surgically treated patients fared well. Of patients with unruptured aneurysms, 4 were treated medically and 1 surgically; all had good outcomes.
  • If cardiac valve replacement is planned, an accessible cerebral aneurysm is often clipped or occluded endovascularly prior to surgery to avoid the risk of hemorrhage with the subsequent cardiac surgery and its inherent anticoagulation perioperatively.
  • Timing of surgery in patients with infective endocarditis and embolic stroke remains controversial, but a recent report suggested that surgery can be performed relatively safely within 3 days of stroke if heart failure is severe; otherwise, a delay of 2-4 weeks is preferable. In patients with associated hemorrhage, a delay of at least 4-6 weeks is preferred.
    • Operative mortality is variable but has been reported as 7.6%, with risk factors for death being cardiogenic shock, insidious illness, and increased age. The 9-year survival rate has been reported to be 71%; risk factors for death include preoperative neurologic complications.
    • Risk of neurologic deterioration after valve replacement for infective endocarditis is 20% in the first 72 hours, 20-50% 4-14 days postoperatively, less than 10% beyond 14 days postoperatively, and less than 1% after 4 weeks.9

Consultations

  • Infectious disease specialist, internist
  • Neurologist, neurosurgeon
  • Cardiologist, cardiothoracic surgeon
  • Psychiatrist, drug rehabilitation specialist, social services counselor

Medication

See Infective Endocarditis article for treatment of underlying infection and Prosthetic Heart Valves article for anticoagulation therapy.

More on Neurological Sequelae of Infectious Endocarditis

Overview: Neurological Sequelae of Infectious Endocarditis
Differential Diagnoses & Workup: Neurological Sequelae of Infectious Endocarditis
Treatment & Medication: Neurological Sequelae of Infectious Endocarditis
References
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References

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Further Reading

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Keywords

infectious endocarditis, bacterial endocarditis, BE, acute bacterial endocarditis, ABE, subacute bacterial endocarditis, SBE, nonbacterial thrombotic endocarditis, NBTE, marantic endocarditis, IE

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Contributor Information and Disclosures

Author

Aiesha Ahmed, MD, Fellow, Department of Neuromuscular Medicine, Pennsylvania State University, Milton S Hershey Medical Center
Aiesha Ahmed, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Kevin Hargrave, MD, Consulting Staff in Medicine/Neurology, Comprehensive Neurologics and Sleep
Kevin Hargrave, MD is a member of the following medical societies: American Academy of Neurology and American Medical Association
Disclosure: Nothing to disclose.

Justin R Fisher, MD, Fellow, Department of Neurophysiology, Penn State Milton S Hershey Medical Center
Justin R Fisher, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Milind J Kothari, DO, Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Hershey Medical Center
Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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