Introduction Mycotic aneurysms of the cerebrovascular system are an uncommonly encountered entity, more often seen in patients with infective endocarditis. While it has been estimated that ruptured mycotic aneurysms result in 5% of the neurologic complications of infective endocarditis, no definitive screening protocol for patients with infective endocarditis has been established, nor is there a universally accepted treatment paradigm.
Methods This is a retrospective review of 169 patients who underwent cerebral angiography with a diagnosis or presumptive diagnosis of infective endocarditis or left ventricular assist device at the Cleveland Clinic spanning from January 2003 to March 2010 in accordance with institutional IRB guidelines. Chart review and review of imaging was performed, identifying patient demographics, presence of occlusions, mycotic aneurysms and treatment modality.
Results There were 16 (9.46%) patients harboring mycotic aneurysms out of 169 patients on angiography. Out of these, 15 presented with hemorrhage (93.7%), and 10 (66.6%) had acute ischemic findings on tomographic imaging. Vegetations were seen on the atrial valve in 6 (37.5%) of the patients and on the mitral valve in 9 (56.2%), with one patient with a left ventricular assist device (6.25%). There were three rehemorrhages (20%) in the aneurysms that presented with hemorrhage, two of which were in during conservative management, one post aneurysm excision. With regards to treatment, 7/16 were treated with excision, 2/16 by embolization, and the remainder by conservative management. In the 156 patients without angiographic evidence of mycotic aneurysm, 48/156 (30.7%) had evidence of hemorrhage, while 115/156 with evidence of stroke, TIA or amaurosis fugax (73.7%). There were 3/156 rehemorrhages (1.9%) in this group. In patients that presented with hemorrhage, 15/63 (23.8%) harbored an aneurysm, while in patients presenting with ischemic changes, it was 10/166 (6%).
Conclusion Patients with infective endocarditis or similar sources of bacterial emboli are prone to neurovascular complications of either hemorrhage or ischemia. Presentation with hemorrhage and endocarditis appears to be more predictive of an underlying aneurysm. As such, in patients with infective endocarditis, presentation with intracranial hemorrhage should prompt vascular imaging. An optimal treatment paradigm has yet to be established.
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