Introduction: Surgical valve repair is often delayed for infective endocarditis (IE) patients with stroke. We compared neurological outcome of early and delayed valve surgery and identified pre-surgical imaging characteristics that were associated with perioperative neurological complications.
Methods: We reviewed 228 patients with acute IE diagnosed by modified Duke’s Criteria who underwent cerebral angiogram (CA) between January 2010 - December 2016 at a single center. Patients without pre-surgical CT and MRI were excluded. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis, delayed as >14 days. Peri-operative neurological complication is any new clinical or radiologic diagnosis of ischemic or hemorrhagic stroke, and seizure.
Results: 148 of 228 patients underwent valve surgery. 69 patients (46.6%) had early surgery at median 9 days after IE diagnosis, and 79 patients (53.4%) had delayed surgery at median 28 days. On pre-surgical imaging, acute to subacute ischemic stroke was seen in 81% of the early group (n=56) and 78% of the delayed group (n=62, p=0.69). However, 22.8% of patients (n=18) in the delayed group had evidence of subarachnoid hemorrhage (SAH) compared to 10.1 % of patients in the early group (n=7, p=0.04). Despite this finding, delayed group did not have higher rate of perioperative neurological complication than that of the early group (24.1% vs 13%, p=0.95). Overall, 15 surgical patients (10.1%) had perioperative neurological complications: 4 with acute ischemic stroke, 9 with ICH, 1 with both an infarct and ICH, and 3 with seizures. 33.3% of patients who had a perioperative neurological complication had evidence of SAH on pre-surgical imaging (n=6) compared to 14.6% of patients who did not have any neurological complications (n=19, p=0.012). In the group of patients with complications, SAH found prior to surgery were all cortical in the sulci, and 3 cases of SAH were associated with presence of infectious intracranial aneurysm found on pre-surgical CA.
Conclusion: In IE patients with stroke, presence of sulcal SAH on pre-surgical imaging is associated with developing perioperative neurological complications irrespective of surgical timing.