Introduction: Intracranial hemorrhage (ICH) is a known complication of infective endocarditis (IE). We aimed to explore radiologic findings that may explain the cause of ICH and the prognosis of these patients.
Methods: We reviewed records of infective endocarditis cases with intraparenchymal hemorrhage (IPH) and subarachnoid hemorrhage (SAH) who underwent magnetic resonance imaging (MRI) and cerebral angiography at a single tertiary center from 2010 to 2014. All patients fulfilled modified Duke’s criteria for infective endocarditis.
Results: We identified 36 patients our inclusion criteria. Eleven (30%) had IPH only, 10 (28%) had SAH, and 15 (42%) had both. The most common presenting symptoms were focal neurological deficit (39%, n=14), encephalopathy (25%, n=9), followed by headache (19%, n=7). The hemorrhage was silent in (19%, n=7) cases. Twelve patients (33%) had mycotic aneurysms but only 4 had evidence of rupture (11%). Ten (28%) had distal arterial irregularities on angiography suggestive of vasculitis. Thirteen (36%) had evidence of microabscesses on MRI, and 22 (61%) had cerebral ischemia on MRI, of which 6 had a hemorrhagic transformation. In 24 out of 25 SAH cases cortical sulcal hemorrhage was seen and only one SAH was in the basal cistern. In 14 (56%) of these cortical SAHs had adjacent restricted diffusion lesion on the MRI. Among 21 patients undergoing valvular repair, only 2 (1%) were complicated with new intracranial hemorrhage that had no relation to the presence of microhemorrhages on MRI (p=0.42).
Conclusion: Intracranial hemorrhage in infective endocarditis is rarely related to mycotic aneurysms. Parenchymal involvement of infection or vascular inflammation may be the underlying causes for IPH and SAH in these patients.