Neurologic complications of infective endocarditis in children

Abstract

Objectives: To define the frequency and characteristics of acute neurologic complications in children hospitalised with infective endocarditis and to identify risk factors for neurologic complications.

Study design: Retrospective cohort study of children aged 0-18 years hospitalised at a tertiary children's hospital from 1 January, 2008 to 31 December, 2017 with infective endocarditis.

Results: Sixty-eight children met Duke criteria for infective endocarditis (43 definite and 25 possible). Twenty-three (34%) had identified neurologic complications, including intracranial haemorrhage (25%, 17/68) and ischaemic stroke (25%, 17/68). Neurologic symptoms began a median of 4.5 days after infective endocarditis symptom onset (interquartile range 1, 25 days), though five children were asymptomatic and diagnosed on screening neuroimaging only. Overall, only 56% (38/68) underwent neuroimaging during acute hospitalisation, so additional asymptomatic neurologic complications may have been missed. Children with identified neurologic complications compared to those without were older (48 versus 22% ≥ 13 years old, p = 0.031), more often had definite rather than possible infective endocarditis (96 versus 47%, p < 0.001), mobile vegetations >10mm (30 versus 11%, p = 0.048), and vegetations with the potential for systemic embolisation (65 versus 29%, p = 0.004). Six children died (9%), all of whom had neurologic complications.

Conclusions: Neurologic complications of infective endocarditis were common (34%) and associated with mortality. The true frequency of neurologic complications was likely higher because asymptomatic cases may have been missed without screening neuroimaging. Moving forward, we advocate that all children with infective endocarditis have neurologic consultation, examination, and screening neuroimaging. Additional prospective studies are needed to determine whether early identification of neurologic abnormalities may direct management and ultimately reduce neurologic morbidity and overall mortality.

Keywords: CHD; Infective endocarditis; infectious intracranial aneurysm; intracranial haemorrhage; neuroimaging; stroke.

Figure 1.

Summary of infectious endocarditis cohort.

Figure 2.

Trans-esophageal echocardiogram demonstrates erosion of the mitral to aortic fibrous continuity in a child with infective endocarditis (left). A vegetation on the posterior leaflet of the mitral valve seen on trans-thoracic echocardiogram in a different child with IE (right).

Figure 3.

Kaplan-Meier survival curve with 95% confidence interval showing neurologic complication-free survival. Vertical tick marks indicate censor time for children without identified neurologic complications.

Figure 4.

Infectious intracranial aneurysm in an infant with hypoplastic left heart syndrome and infective endocarditis with left middle cerebral artery stroke. Top panels show T2 axial (left) and coronal (right) MRIs with right middle cerebral artery infectious intracranial aneurysm. Bottom panels demonstrate the infectious intracranial aneurysm on conventional angiogram before (left) and after (right) coiling.

Figure 5.

Previously healthy adolescent with structurally normal heart with infective endocarditis and small infectious intracranial aneurysm. T2 MRI (left) with edema surrounding infectious intracranial aneurysm. Time of flight MRA (middle) demonstrates small infectious intracranial aneurysm. T1 multiplanar reformation post-gadolinium image (right) demonstrates contrast enhancement.

Figure 6.

Adolescent with DiGeorge Syndrome and repaired truncus arteriosus with St. Jude’s valve in the mitral position and infective endocarditis. The head CT demonstrated multiple septic emboli with hemorrhagic transformation (small right frontal lesion demonstrated on this slice) (left panel). Head CT 48 hours later with massive hemorrhage before (middle panel) and after (right panel) craniectomy. CTA was not performed, but the large hemorrhage was presumed to be due to a ruptured infectious intracranial aneurysm.