Introduction: Intracranial hemorrhage (ICH) is common in infective endocarditis (IE). We explored the imaging characteristics, predictors, and clinical implications of ICHs including intraparenchymal hemorrhage (IPH), and subarachnoid hemorrhage (SAH) and, subdural hematoma (SDH).
Methods: We reviewed records of 116 consecutive acute IE patients by Duke’s criteria with neurological consultation or admission to stroke neurology service in a single tertiary referral center from January 2015 to July 2016. ICHs were defined as IPH, SAH, or SDH seen on CT. Microhemorrhages were identified on susceptibility weighted imaging (SWI) on MRI. Patient’s radiographic characteristics and complications were collected.
Results: Of 116 patients, 25 persons (21.6%, median age 58) had ICHs, 14 with IPHs, 7 with SAHs, 3 with both IPH and SAH, and 1 SDH. Of 17 (14.7%) IPHs (median NIH Stroke Scale 6 and median volume 38.6cc), 10 (8.6%) IPHs were symptomatic and 7 IPHs were silent. Eleven persons (65%) with IPH also had ischemic strokes. Mycotic aneurysms were identified only in 1 (4.8%) in 21 persons with ICH who underwent cerebral angiogram. MRIs identified 66 persons with microhemorrhages (56.9%, median age 58.5) among 85 who underwent MRI. Eighteen (72%) of 25 persons with ICHs had microhemorrhages in SWI. In multivariate logistic regression analysis, ICH was associated with the presence of >5 microhemorrhages (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.04-1.50) and staphylococcus aureus (OR: 1.25, 95% CI: 1.03-1.51). Ten persons (40%) with ICH died (7 with IPH and 4 with SAH) in the same hospitalization. Thirteen persons (52%) with ICH (median 21.4cc in 9 IPHs) underwent valve replacement at median of 13.5 days and 2 persons had new non-fatal strokes (1 IPH and 1 ischemic stroke).
Conclusions: Intracranial macro- or micro-hemorrhages are seen in 73 (63%) persons with IE. The mortality of intracranial hemorrhage is high but the perioperative stroke risk appears low.