Endocarditis and cerebral aneurysm: the advantage of two-stage surgery

The therapeutic dilemma of infective endocarditis with intracranial aneurysm

The management of infective endocarditis (IE) complicated by an intracranial infectious aneurysm (IIA) places the clinician in a major therapeutic dilemma. The use of cardiopulmonary bypass (CPB) and the systemic heparinisation inherent in cardiac surgery expose the patient to a critical risk of aneurysmal rupture and intracranial haemorrhage. Conversely, delaying cardiac intervention to secure the aneurysm increases the risks of rapid deterioration of the infectious and valvular status.

This case study documents the therapeutic strategy applied to a 38-year-old patient suffering from active infective endocarditis caused by Streptococcus agalactiae, associated with severe mitral regurgitation and a 5 mm symptomatic intracranial aneurysm at the level of the distal left posterior cerebral artery. The objective is to evaluate the feasibility and safety of a sequential approach: emergency endovascular coil embolisation, followed by minimally invasive mitral valve repair using an autologous pericardial patch.

The authors test here the hypothesis that this combined strategy allows for the necessary cardiac surgery while drastically minimising the risk of cerebral haemorrhage associated with heparinisation. This work details the clinical results of this protocol, with a six-month postoperative follow-up showing no infectious recurrence or valvular dysfunction.

Clinical case methodology

This case report details a multidisciplinary therapeutic approach in a 38-year-old patient suffering from active infective endocarditis (IE) caused by Streptococcus agalactiae, complicated by an intracranial infectious aneurysm (IIA).

The therapeutic protocol was structured according to a sequential strategy aimed at securing cardiac surgical management, as the latter requires cardiopulmonary bypass (CPB) and systemic heparinisation with a high risk of aneurysmal rupture:

• Step 1 (Neuro-intervention): Given the presence of a 5 mm symptomatic aneurysm located on the distal left posterior cerebral artery, coil embolisation was performed as a first-line treatment.
• Step 2 (Cardiac surgery): Five days after the endovascular procedure, the patient underwent minimally invasive endoscopic mitral valve repair. The technique involved the use of an autologous pericardial patch.

Postoperative follow-up included four weeks of intravenous antibiotic therapy. The evaluation of the efficacy of this combined strategy was carried out through clinical follow-up and imaging six months after the intervention.

Clinical results and management

The reported case concerns a 38-year-old patient presenting with active infective endocarditis due to Streptococcus agalactiae, associated with severe mitral regurgitation. Imaging assessment revealed a 5 mm symptomatic intracranial infectious aneurysm, located at the level of the distal left posterior cerebral artery.

The strategy adopted consisted of a rigorous sequential approach:

• Step 1: Endovascular coil embolisation of the cerebral aneurysm to neutralise the haemorrhagic risk associated with the systemic heparinisation required for CPB.
• Step 2: Performance, five days after embolisation, of a minimally invasive endoscopic mitral valve repair with an autologous pericardial patch.

The cardiac intervention took place without intraoperative complication. The patient received targeted antibiotic therapy for four weeks before discharge. At six months of postoperative follow-up, the patient remains asymptomatic, with no sign of infectious recurrence or valvular dysfunction.

Surgical management of infective endocarditis associated with intracranial aneurysms

The treatment of patients presenting with infective endocarditis (IE) complicated by an infectious intracranial aneurysm (IIA) places the surgeon in a therapeutic dilemma. The need for cardiopulmonary bypass (CPB) and systemic heparinization during cardiac surgery exposes the patient to a critical risk of hemorrhagic aneurysmal rupture, while any surgical delay worsens the prognosis of the IE.

This case report concerns a 38-year-old patient with Streptococcus agalactiae IE, complicated by severe mitral regurgitation and a 5 mm symptomatic IIA on the left posterior cerebral artery. The chosen approach consisted of a sequenced strategy: endovascular coil embolization of the aneurysm, followed, five days later, by minimally invasive mitral valve repair using an autologous pericardial patch. This sequence secured the cerebral vascular bed before exposure to CPB, avoiding any hemorrhagic complication.

Limitations and perspectives
Although this case demonstrates the feasibility of a combined management, it is a single observation. The lack of comparison with a conservative approach or different surgical timings limits the generalization of the results, despite a favorable outcome at six months with no infectious recurrence or valve dysfunction.

This "brain-first protection" strategy seems to offer a robust alternative to classic dilemmas, by isolating the neurological risk before major cardiovascular intervention.

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