Significance of the T2*-weighted gradient echo brain imaging in patients with infective endocarditis

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Abstract

Background

Although aneurysm formation accompanying parenchymal hemorrhage is one of devastating complications in the central nerves system (CNS), imaging studies of the brain are not routinely warranted in patients with infective endocarditis (IE). To assess the clinical importance for detecting silent lesions in the central nervous system, we investigated hypointense signal spots detected on the brain T2*-weighted MR imaging in patients with IE.

Methods and results

Eleven patients with IE were retrospectively reviewed. Seven patients (63.6%) showed hypointense signal spots on T2*-weighted MR images. The number of hypointense signal spots increased within only a few weeks in five patients.

Conclusion

The brain T2*-weighted MR imaging in patients with IE may have a potential role to detect CNS lesions with clinical significance of potentially high risk of intracranial hemorrhage. T2*-weighted hypointense signal spots may be specific to brain involvement, and be quite useful in monitoring CNS lesions associated with IE, even if they are asymptomatic.

Section snippets

Patients and methods

We retrospectively reviewed consecutive cases of IE treated at the Nagasaki University Hospital from June 2006 to July 2007. All patients were diagnosed as having IE according to the modified Duke criteria. This study included only patients in whom the brain T2*-weighted MR imaging was performed. The initial and follow-up imaging in all patients were undertaken with the 1.5-T scanner (Signa CV/i; GE Healthcare, Milwaukee, WI) with a standard head coil. T2*-weighted MR imaging used a gradient

Results

Clinical characteristics and MRI findings of all patients are shown in Table 1. The most common initial symptoms were fever in four (35.5%), and lumbago in three patients. Others had shoulder pain, general fatigue, emotional change, and hemiparesis. The most common predisposing conditions for IE included mitral or aortic valvular incompetence in eight, and a dental procedure in two, and prosthetic heart valve in one patient. The intervals between the clinical manifestation and the diagnosis of

Patient 1

A 23-year-old woman, who had a history of cardiac surgery for the ventricular septal defect, suffered headache and general fatigue after a dental treatment. She was admitted to a local hospital, and diagnosed as IE. She was transferred to our institute, and underwent the aortic valve replacement. After the procedure, computed tomography (CT) of the brain revealed a parenchymal hematoma in the left frontal lobe (Fig. 1A). Both CT angiography (CTA) and cerebral angiography (CAG) demonstrated an

Discussion

Intracranial IAs are less common (2–4% of endocarditis cases) but they produce potentially devastating neurological complications such as intracerebral or subarachnoid hemorrhage [9], [10], [11]. Since IAs can be clinically silent and some of them could resolve by antibiotic therapy, actual incidence of IAs is considered to be higher than the ones reported in the literatures [12]. IAs may result from septic embolism of vegetations to the arterial vasa vasorum or the intraluminal space, and

Conclusion

The brain T2*-weighted MR imaging in patients with IE may have a potential role to detect minor abnormalities related to IE, with clinical significance of high risk of intracranial hemorrhage. T2*-weighted hypointense signal spots might be specific to brain involvements of IE, and be helpful in diagnosing and monitoring CNS lesions in patients with IE.

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      Ischemic stroke was the most common finding in 72%, followed by MH in 34%, ICH in 17%, and SAH in 12%. Previous studies have reported rates of IS ranging from 37% to 83% and rates of MH between 57% and 94%.1,15,23-25 The higher rate of MH in other studies may be attributable to the fact that hemosiderin-sensitive MRI sequences were not routinely used in the earlier years of our study time frame.

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