Service de Réanimation Médicale et des Maladies Infectieuses, EA 3964, Université Paris 7-Denis Diderot, Hôpital Bichat-Claude Bernard, 46, rue Henri-Huchard, 75877 Paris Cedex 18, EA 3964, University Paris 7, France.
Ann Intensive Care. 2011 Apr 20;1(1):10. doi: 10.1186/2110-5820-1-10.
Patients with infective endocarditis (IE) are generally referred to the intensive care unit (ICU) for one or more organ dysfunctions caused by complications of IE. Neurologic events are frequent causes of ICU admission in patients with IE. They can arise through various mechanisms consisting of stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Occlusion of cerebral arteries, with stroke or transient ischemic attack, accounts for 40% to 50% of the central nervous system complications of IE. CT scan is the most easily feasible neuroimaging in critically unstable patients. However, magnetic resonance imaging is more sensitive and when performed should follow a standardized protocol. In patients with ischemic stroke who are already receiving oral anticoagulant therapy, this treatment should be replaced by unfractionated heparin for at least 2 weeks with a close monitoring of coagulation tests. Mounting evidence shows that, for both complicated left-sided native valve endocarditis and Staphylococcus aureus prosthetic valve endocarditis, valve replacement combined with medical therapy is associated with a better outcome than medical treatment alone. In a recent series, approximately 50% of patients underwent valve replacement during the acute phase of IE before completion of antibiotic treatment. After a neurological event, most patients have at least one indication for cardiac surgery. Recent data from literature suggest that after a stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Neurologic complications of IE contribute to a severe prognosis in ICU patients. However, patients with only silent or transient stroke had a better prognosis than patients with symptomatic events. In addition, more than neurologic event per se, a better predictor of mortality is neurologic dysfunction, which is associated with location and extension of brain damage. Patients with severe neurological impairment and those with brain hemorrhage have the worse outcome.
患有感染性心内膜炎（IE）的患者通常因 IE 并发症导致一个或多个器官功能障碍而被转至重症监护病房（ICU）。IE 患者的 ICU 入院的常见原因是神经系统事件。这些事件可能通过多种机制引起，包括中风或短暂性脑缺血发作、脑出血、真菌性动脉瘤、脑膜炎、脑脓肿或脑病。大多数并发症在 IE 病程早期发生，是原发性或人工瓣膜左心异常的标志。脑动脉闭塞，伴中风或短暂性脑缺血发作，占 IE 中枢神经系统并发症的 40%至 50%。CT 扫描是在危重不稳定患者中最容易进行的神经影像学检查。然而，磁共振成像更敏感，当进行时，应遵循标准化方案。对于已经接受口服抗凝治疗的缺血性中风患者，应至少用未分级肝素替代治疗 2 周，并密切监测凝血试验。越来越多的证据表明，对于复杂的原发性瓣膜心内膜炎和金黄色葡萄球菌人工瓣膜心内膜炎，瓣膜置换联合药物治疗比单纯药物治疗的预后更好。在最近的一系列研究中，约 50%的患者在抗生素治疗完成之前的 IE 急性阶段进行了瓣膜置换。在发生神经系统事件后，大多数患者至少有一个心脏手术的指征。最近的文献数据表明，对于心力衰竭、感染未得到控制、脓肿或持续存在高栓塞风险的患者，在未昏迷或无严重缺陷的情况下，手术后应立即进行心脏手术，而不应延迟手术。IE 的神经系统并发症导致 ICU 患者预后严重。然而，只有无症状或短暂性中风的患者比有症状性事件的患者预后更好。此外，与神经事件本身相比，死亡率的更好预测因素是神经功能障碍，其与脑损伤的位置和程度有关。严重神经功能障碍和脑出血的患者预后最差。
