Neurological Complications of Infective Endocarditis

TLDR

The study aimed to determine the incidence, risk factors, clinical impact, and surgical outcomes of neurological complications in infective endocarditis patients. It was a retrospective analysis of prospectively collected data from 1,345 left‑sided infective endocarditis episodes across eight Spanish centers. Among these patients, 25% experienced neurological complications (14% ischemic, 6% encephalopathy/meningitis, 4% hemorrhage, 1% abscess); larger vegetations, Staphylococcus aureus, mitral involvement, and anticoagulation increased risk, while early antibiotics reduced it, and complications raised mortality to 45% versus 24% in those without, with hemorrhagic events and early surgery within 4 weeks further worsening outcomes.

Abstract

The purpose of this study was to assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery.This was a retrospective analysis of prospectively collected data on a multicenter cohort of 1345 consecutive episodes of left-sided infective endocarditis from 8 centers in Spain. Cox regression models were developed to analyze variables predictive of neurological complications and associated mortality. Three hundred forty patients (25%) experienced such complications: 192 patients (14%) had ischemic events, 86 (6%) had encephalopathy/meningitis, 60 (4%) had hemorrhages, and 2 (1%) had brain abscesses. Independent risk factors associated with all neurological complications were vegetation size ≥3 cm (hazard ratio [HR] 1.91), Staphylococcus aureus as a cause (HR 2.47), mitral valve involvement (HR 1.29), and anticoagulant therapy (HR 1.31). This last variable was particularly related to a greater incidence of hemorrhagic events (HR 2.71). Overall mortality was 30%, and neurological complications had a negative impact on outcome (45% of deaths versus 24% in patients without these complications; P<0.01), although only moderate to severe ischemic stroke (HR 1.63) and brain hemorrhage (HR 1.73) were significantly associated with a poorer prognosis. Antimicrobial treatment reduced (by 33% to 75%) the risk of neurological complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% versus 40% in later surgery).Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of infective endocarditis. Early appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.