Published Online
on June 22, 2006

A more recent version of this article appeared on August 1, 2006

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Submitted on February 1, 2006
Revised on March 28, 2006
Accepted on April 21, 2006

Neurological Outcome of Septic Cardioembolic Stroke After Infective Endocarditis

Elfriede Ruttmann MD^*; Johann Willeit MD; Hanno Ulmer PhD; Orest Chevtchik MD; Daniel Höfer MD; Werner Poewe MD; Günther Laufer MD; and Ludwig C. Müller MD

From the Departments of Cardiac Surgery (E.R., O.C., D.H., G.L., L.C.M.), Neurology (J.W., W.P.), and Medical Statistics, Informatics, and Health Economy (H.U.), Innsbruck Medical University, Innsbruck, Austria.

^* To whom correspondence should be addressed. E-mail: elfriede.ruttmann{at}uibk.ac.at.

Background and Purpose--The aim of this study was to evaluate mortality and neurological outcomes of cardioembolic cerebral stroke in infective endocarditis (IE) patients requiring cardiac surgery.

Methods--A consecutive series of 214 patients undergoing cardiac surgery for IE was followed up for 20 years. In 65 patients (mean age, 52 years), IE was complicated by computed tomography- or magnetic resonance imaging-verified stroke (n=61) or transient ischemic attack (n=4). Perioperative (30-day) and long-term mortality was assessed with regression models adjusting for age. Complete neurological recovery of IE survivors was defined by a modified Rankin score of 1 and a Barthel index of 20 points.

Results--Fifty of 61 stroke patients (81.9%) survived surgery. In comparison with nonstroke patients, the age-adjusted perioperative mortality risk was 1.70-fold (95% CI, 0.73 to 3.96, P=0.22) higher and long-term mortality risk was 1.23-fold (95% CI, 0.72 to 2.11, P=0.45) higher in stroke patients. Patients with complicated stroke (meningitis, hemorrhage, or brain abscess) showed a higher perioperative mortality rate (38.9% vs 8.5%, P=0.007) but no higher neurological complication rate than patients with uncomplicated ischemic stroke. Complete neurological recovery was achieved in 35 IE survivors (70%, 95% CI, 55% to 82%). However, in the case of middle cerebral artery stroke, recovery was only 50% and was significantly lower compared with non--middle cerebral artery stroke (P=0.012).

Conclusion--Uncomplicated IE-related stroke showed a favorable prognosis with regard to both long-term survival and neurological recovery. The formidable risk of secondary cerebral hemorrhage due to cardiac surgery seems to be much lower than previously thought.

Key words: infective endocarditis • neurologic rehabilitation • septic embolism • stroke

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