儿童感染性心内膜炎的神经并发症。
Neurologic complications of infective endocarditis in children.
机构信息
Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
出版信息
Cardiol Young. 2023 Mar;33(3):463-472. doi: 10.1017/S1047951122001159. Epub 2022 May 12.
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.
目的
确定住院治疗感染性心内膜炎儿童中急性神经系统并发症的频率和特征，并确定神经系统并发症的危险因素。
研究设计
对 2008 年 1 月 1 日至 2017 年 12 月 31 日在一家三级儿童医院住院的 0-18 岁儿童感染性心内膜炎患者进行回顾性队列研究。
结果
68 例儿童符合杜克感染性心内膜炎标准（43 例明确诊断，25 例可能诊断）。23 例（34%）出现了神经系统并发症，包括颅内出血（25%，17/68）和缺血性脑卒中（25%，17/68）。神经系统症状出现在感染性心内膜炎症状出现后的中位数时间为 4.5 天（四分位距 1，25 天），尽管有 5 例患儿无症状，仅通过筛查性神经影像学检查诊断。总体而言，只有 56%（38/68）在急性住院期间接受了神经影像学检查，因此可能错过了其他无症状的神经系统并发症。与无神经系统并发症的患儿相比，有神经系统并发症的患儿年龄更大（48%≥13 岁 vs. 22%，p=0.031），更常患有明确而非可能的感染性心内膜炎（96% vs. 47%，p<0.001），活动性赘生物>10mm（30% vs. 11%，p=0.048）和具有全身栓塞风险的赘生物（65% vs. 29%，p=0.004）。6 例患儿死亡（9%），均有神经系统并发症。
结论
感染性心内膜炎的神经系统并发症较为常见（34%），且与死亡率相关。由于未进行筛查性神经影像学检查，可能遗漏了无症状病例，因此神经系统并发症的真实发生率可能更高。今后，我们建议所有感染性心内膜炎患儿均应进行神经科会诊、检查和筛查性神经影像学检查。需要进一步前瞻性研究以确定早期识别神经系统异常是否可以指导治疗，从而降低神经系统发病率和总体死亡率。
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