Infective endocarditis complicated by rupture of intracranial mycotic aneurysm during pregnancy

We report a case of a pregnant woman who developed infective endocarditis further complicated by an intracranial mycotic aneurysm. She presented with massive intracranial haemorrhage in the third trimester of pregnancy. The disease process of infective endocarditis and peri-operative management of ruptured intracranial mycotic aneurysm during pregnancy are discussed.     

Valve replacement in infective endocarditis with mycotic aneurysm

We successfully performed craniotomy and mitral valve replacement on a patient with bacterial endocarditis and ruptured intracranial aneurysm. A 15-year-old woman with fever and heart murmur was admitted to another hospital. Infective endocarditis and mitral valve regurgitation was diagnosed and treated with antibiotics. About one month after admission the patient suddenly showed severe headache and hemiparesis. Brain CT demonstrated intracerebral and subarachnoidal hemorrhage. The patient was unconscious when transferred to Mitsui Memorial Hospital where cerebral angiography showed anterior cerebral aneurysm and echocardiography showed mitral valve vegetation. We judged the necessary mitral valve replacement could be delayed until the aneurysm had been stabilized. We therefore began treatment using a different antibiotic but, in spite of this, 10 days later the aneurysm had enlarged dramatically. As conservative treatment was ineffective, a clipping operation was done to prevent re-rupture at the time of mitral valve replacement which could not be delayed much longer. 10 days later, cerebral 4 vessel study was done which showed no abnormality. Mitral valve replacement was then done and the patient was discharged in good health 64 days after the valve replacement.     

Valve replacement in a patient with infective endocarditis and ruptured mycotic cerebral aneurysm]

A 55-year-old man with a mild fever and sweating developed severe headache for the days before admission. Cerebral computed tomography and selected cerebral angiography on the day of admission revealed subarachnoid hemorrhage due to rupture of an aneurysm of a distal branch of the left middle cerebral artery. Detection of vegetation on the aortic valve by two dimensional echocardiography confirmed the diagnosis of infective endocarditis with a ruptured mycotic cerebral aneurysm. Because of rapid growth of the vegetation on the aortic valve and progression of heart failure despite antibiotic therapy, emergency cardiac surgery was performed. To prevent re-rupture of the aneurysm, the aortic valve was replaced with a bioprosthetic valve, and no anticoagulant was administered postoperatively. Repeated cerebral angiography revealed that the aneurysm was becoming progressively smaller during the next 9 months. No cerebrovascular accident occurred postoperatively. We believe that it is safe to treat a ruptured mycotic cerebral aneurysm without involvement of a hematoma mass in the brain conservatively, and that use of a bioprosthetic valve, if valve replacement is mandatory, and avoidance of anticoagulant therapy during the postoperative period are advisable in the treatment of a patient with infective endocarditis and a ruptured cerebral mycotic aneurysm.     

Operative experience with infective endocarditis and intracerebral mycotic aneurysm

The surgical management of eight patients with infective endocarditis and intracerebral mycotic aneurysm is presented. Three patients had craniotomy before valve replacement and four patients had valve replacement before craniotomy. There were no deaths related to the valve replacement or craniotomy. Two of the eight patients died in the hospital of continuing sepsis resulting from undrained foci of infection. It is concluded that the drug-addicted patient with a mycotic aneurysm and hemodynamic decompensation from endocarditis can be successfully treated by staging the operations according to the more severe problem.     

A case report of early valve replacement surgery in infective endocarditis with mycotic cerebral aneurysm

Mycotic cerebral aneurysm is a relatively infrequent complication of infective endocarditis. However, rupture and intra-cranial hemorrhage involves so high a mortality that few patients can be saved from this condition. We reported a 22-year-old woman with mitral regurgitation and ruptured mycotic cerebral aneurysm caused by infective endocarditis. Vegetation floating between the left atrium and the ventricle was observed by UCG. It was difficult to decide which operation should be done first, valve replacement or excision of cerebral aneurysm. To avoid further intracerebral bleeding caused by anticoagulant therapy connected with cardiotomy, the cerebral aneurysm was excised prior to the valve replacement. Mitral valve was replaced with a Bj?rk-Shiley prosthetic valve 48 hours after the craniotomy. The postoperative course was uneventful and no neurological deficit was found. This report indicates that valve replacement surgery can be successfully performed only 48 hours after craniotomy without any bleeding complications.     

Infective endocarditis with splenic abscess and cerebral hemorrhage

A 65-year-old man was admitted with ataxic gait and high fever. Brain magnetic resonance imaging (MRI) showed multiple cerebral hemorrhages and echocardiogram showed vegetations attached to the mitral valve and moderate mitral regurgitation. No microorganisms were identified by blood culture examination. Despite adequate treatment with antibiotics, large multiple splenic abscesses were detected by computed tomography (CT), the patient complained of fever and the value of CRP was increased again. We decided to first perform splenectomy, followed by mitral valve repair and maze operation. The pathology of the spleen showed findings consistent with large abscesses due to septic emboli. The postoperative course was uneventful.     

Valve replacement in infective endocarditis with mycotic cerebral aneurysm. Report of a case with successful operation

A 49 year-old woman was hospitalized with headache and left-sided weakness. Computed tomographic scan and carotid angiogram revealed mycotic aneurysms of the bilateral middle cerebral artery with intracranial bleeding. Although all blood cultures were sterile, her physical examination suspected mitral regurgitation due to infective endocarditis and mycotic cerebral aneurysms. Severe congestive heart failure developed immediately after successful clipping for ruptured mycotic aneurysm of the right middle cerebral artery and then mitral valve replacement with prosthetic valve was performed 3 months after craniotomy. At operation, infective endocarditis on the mitral valve was confirmed. Her postoperative course was uneventful and the second craniotomy for aneurysm of the left middle cerebral artery has been planning.     

A case of heart operation in infective endocarditis after brain surgery for mycotic cerebral aneurysm

Complications of infective aneurysm are not rare in patients with infective endocarditis. An optimal timing of heart operation after brain surgery for hemorrhage is controversial. We reported a 19-year-old woman with ventricular septal defect (type II), mitral regurgitation and ruptured cerebral aneurysm with infective endocarditis. Cerebral aneurysm had been ruptured during infective endocarditis treatment. Resection of the aneurysm was performed next day. Vessel spasm occurred, resulting in cerebral infarction 7 days after the operation. Conservative therapy was continued for infective endocarditis until heart failure appeared. Heart operation was successfully performed 41 days after brain surgery without cerebral complication. This report indicates that heart operation might be avoided at the early postoperative stage of brain surgery for cerebral aneurysm with hemorrhage.     

CNS aspergillosis with mycotic aneurysm,cerebral granuloma and infarction

Summary We are reporting a case of an immunocompromised patient with invasive aspergillosis (IA) who developed aspergillotic granulomas and a mycotic aneurysm of the superior cerebellar artery. The route of infection of the central nervous system (CNS) was hematogenous spread from a pulmonary focus. IA was detected with the Galactomannan (GM) technique. However, despite treatment with amphotericin B, progressive involvement of the vessel wall occurred causing fatal subarachnoid hemorrhage and massive brainstem and cerebellar infarction.This case provides pathologic-imaging correlation of one of the most devastating types of fungal involvement affecting the CNS with a fungal aneurysm. Finally the literature regarding the pathogenetic, and diagnostic investigations and the management of CNS aspergillosis is reviewed.     

A mital valve reconstruction of infective endocarditis with brain abscess and intracranial mycotic aneurysm

A case is reported of a brain abscess and an intracranial mycotic aneurysm associated with infective endocarditis caused by streptococcus intermedius. A 60-year-old man with a history of fever presented aphasia and right hemiparesis. A computed tomographic scan of the head revealed a low-density area with ring enhancement in the left parietal lobe consistent with a brain abscess. An angiography demonstrated an aneurysm on the distal branch of the middle cerebral artery compatible with a mycotic aneurysm. Doppler echo cardiography showed severe mitral regurgitation by chordal ruptures. The brain abscess and intracranial mycotic aneurysm were resolved under appropriate antibiotic therapy for eight weeks. Then, the mitral valve was reconstructed by replacement of the chordae tendineae with expanded polytetrafloroethylene suture and annuloplasty. The patient had no neurologic deficit except for paresthesia in the right hand, and had no mitral regurgitation at discharge.     

Infective endocarditis and an embolomycotic aneurysm in a 25-month-old child

Infective endocarditis in young children is uncommon, especially where there is no underlying structural heart disease. While septic embolization in adults occurs in up to 43% of the cases of endocarditis, there is little data on systemic embolization in cases of children. We present an unusual case of a 25-month-old child with infective endocarditis and an embolomycotic aneurysm treated by mitral valve replacement and aortoiliac reconstruction.     

Infective endocarditis in chronic haemodialysis: two treatment strategies.

BACKGROUND: Infective endocarditis (IE) is more frequent in patients on chronic haemodialysis (CHD) than in the general population and vascular access is the more frequent identified port of its entry. According to experimental and clinical studies the vascular access may also interfere with the treatment of IE. To improve the treatment of IE in CHD, patients were temporarily switched to peritoneal dialysis (PD) after the removal of the vascular access. In this preliminary report the outcome of IE in those CHD patients switched to PD is compared with the outcome in IE patients who remained on CHD. METHODS: All cases of IE that occurred during a 5 year period were retrospectively analysed. The Duke criteria for IE were used for diagnosis. All patients underwent transoesophageal echocardiography. All patients were treated with the same schedule of antibiotic treatment. The vascular access of a patient was removed when it was judged to be the source of infection. RESULTS: Twenty-one patients were studied. Twelve patients had been temporarily switched to PD after the diagnosis of IE and nine patients had remained on CHD treatment. There were not statistically significant differences between the two groups with respect to demographic data, comorbid diseases and the frequency of Staphylococcus aureus as the causative germ. In-hospital mortality was 8.3% in patients switched to PD and 55.5% in patients maintained on HD (P: 0.03). CONCLUSIONS: The data presented here suggest that the high mortality of IE in CHD patients may also be associated with the vascular access necessary for HD. If these results are confirmed by prospective studies with higher numbers of patients, PD could turn out to have a place in the treatment of IE in CHD patients.     

Successful surgical treatment of intracranial mycotic aneurysm with brain abscess

Summary Report of a case of intracranial mycotic aneurysm accompanied by brain abscess, which occured as a complication of bacterial endocarditis. Excision of the aneurysm and total removal of the abscess produced a good result.     

Infective endocarditis with congenital heart disease

From 1988 to 2005, seven patients were operated at our hospital because of infectious endocarditis (IE) with congenital heart disease (CHD). Underlying CHD included ventricular septal defect (VSD) in 4 (2 previous operations with residual region), atrial septal defect (ASD) in 2 and bicuspid aortic stenosis (AS) in 1. No cases had preventive antibiotic prophylaxis for dental procedures. We could confirm bacteria origin from blood culture in all cases, but two patients had operations without gaining control of the infection. VSD or ASD closure and valve surgery were performed in four patients. One patient had a VSD closure, two patients had valve surgery. There were no operative or hospital deaths and there were no recurrences of IE during the study period. We successfully treated IE with CHD by enough debridement of the infective focus of IE, and valve surgery. It is important for patients with CHD to have preventive antibiotic prophylaxis for dental procedures.