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Effect of Early Cerebral Magnetic Resonance Imaging on Clinical Decisions in Infective Endocarditis: A Prospective Study

Xavier Duval, MD, PhD; Bernard Iung, MD; Isabelle Klein, MD, PhD; Eric Brochet, MD; Gabriel Thabut, MD, PhD; Florence Arnoult, MD; Laurent Lepage, MD; Jean-Pierre Laissy, MD, PhD; Michel Wolff, MD; Catherine Leport, MD, PhD, IMAGE (Resonance Magnetic Imaging at the Acute Phase of Endocarditis) Study Group
[+] Article and Author Information

For members of the IMAGE Study Group, see the Appendix.


From Paris 7 University Medical School, AP-HP Bichat University Hospital, and INSERM CIC 007, Paris, France.


Grant Support: By a research grant from the French Ministry of Health. The Département de la Recherche Clinique et du Développement, Assistance Publique-Hôpitaux de Paris, sponsored the study (PHRC AOM 04076). IRB authorization number, 0511114 (Comité de Protection des Personnes Paris-Ile de France 1).

Acknowledgment: The authors thank Pr. Philippe Ravaud for active support during the conception phase, the members of the independent committee for their valuable advice, and the patients for active participation in the study.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2408.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Duval (xavier.duval@bch.aphp.fr). Data set: Not available.

Requests for Single Reprints: Xavier Duval, MD, PhD, Centre d'Investigation Clinique, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75877 Paris Cedex 18, France; e-mail, xavier.duval@bch.aphp.fr.

Current Author Addresses: Dr. Duval: Centre d'Investigation Clinique, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Drs. Iung and Brochet: Service de cardiologie, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Drs. Klein and Laissy: Service de radiologie, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Dr. Thabut: Département d'épidémiologie, biostatistique, et recherche clinique, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Dr. Arnoult: Service des explorations fonctionnelles, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Dr. Lepage: Service de chirurgie cardiaque, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Dr. Wolff: Service de réanimation infectieuse, Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, 75748 Paris Cedex, France.

Dr. Leport: Université de médicine Paris 7, 16 rue Henri Huchard, 75748 Paris Cedex, France.

Author Contributions: Conception and design: X. Duval, B. Iung, E. Brochet, G. Thabut, J.-P. Laissy, M. Wolff, C. Leport.

Analysis and interpretation of the data: X. Duval, B. Iung, I. Klein, G. Thabut, J.-P. Laissy, M. Wolff, C. Leport.

Drafting of the article: X. Duval, B. Iung.

Critical revision of the article for important intellectual content: X. Duval, B. Iung, I. Klein, E. Brochet, G. Thabut, F. Arnoult, L. Lepage, J.-P. Laissy, M. Wolff, C. Leport.

Final approval of the article: X. Duval, B. Iung, M. Wolff.

Provision of study materials or patients: X. Duval, M. Wolff.

Statistical expertise: G. Thabut.

Obtaining of funding: X. Duval.

Administrative, technical, or logistic support: X. Duval, G. Thabut.

Collection and assembly of data: X. Duval, B. Iung, I. Klein, E. Brochet, F. Arnoult, L. Lepage, J.-P. Laissy, M. Wolff.


Ann Intern Med. 2010;152(8):497-504. doi:10.7326/0003-4819-152-8-201004200-00006
Text Size: A A A

Background: Neurologic complications of endocarditis can influence diagnosis, therapeutic plans, and prognosis.

Objective: To describe how early cerebral magnetic resonance imaging (MRI) affects the diagnosis and management of endocarditis in hospitalized adults.

Design: Single-center prospective study between June 2005 and October 2008. (ClinicalTrials.gov registration number: NCT00144885)

Setting: Tertiary care university hospital in France.

Patients: 130 patients with endocarditis.

Intervention: Cerebral MRI with angiography performed up to 7 days after admission and before any surgical intervention.

Measurements: 2 experts jointly established the endocarditis diagnostic classification (according to Duke-modified criteria) and therapeutic plans just before and after MRI and then compared them.

Results: Endocarditis was initially classified as definite in 77 patients and possible in 50 and was excluded in 3. Sixteen patients (12%) had acute neurologic symptoms. Cerebral lesions were detected by MRI in 106 patients (82% [95% CI, 75% to 89%]), including ischemic lesions in 68, microhemorrhages in 74, and silent aneurysms in 10. Solely on the basis of MRI results and excluding microhemorrhages, diagnostic classification of 17 of 53 (32%) cases of nondefinite endocarditis was upgraded to either definite (14 patients) or possible (3 patients). Endocarditis therapeutic plans were modified for 24 (18%) of the 130 patients, including surgical plan modifications for 18 (14%). Overall, early MRI led to modifications of diagnosis or therapeutic plan in 36 patients (28% [CI, 20% to 36%]).

Limitation: Investigators did not assess whether the MRI-related changes in diagnosis and therapeutic plans improved patient outcomes or led to unnecessary procedures and increased costs.

Conclusion: Cerebral lesions were identified by MRI in many patients with endocarditis but no neurologic symptoms. The MRI findings affected both diagnostic classifications and clinical management plans.

Primary Funding Source: French Ministry of Health.

Figures

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Figure 1.
Study flow diagram.

IE = infective endocarditis; MRI = magnetic resonance imaging; S. sanguinis = Streptococcus sanguinis.

* Numbers in parentheses include microhemorrhages as vascular phenomena in the Duke modified classification.

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Figure 2.
Infarcts and microhemorrhages.

Disseminated acute small cerebellar (A) and hemispheric (B) infarcts with cortical and subcortical localizations (curved arrows) appear as hyperintensities on diffusion-weighted magnetic resonance imaging. In the same patient, T2* gradient-recalled imaging sequences show microhemorrhages of varying size (C [straight and curved arrows]) and a subarachnoidal cortical hemorrhage (D [arrow]).

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Figure 3.
Ischemic stroke and microinfarct.

Diffusion-weighted magnetic resonance imaging shows acute hyperintense ischemic stroke in right cerebral frontal anterior territory (arrow) and a subcortical microinfarct on left hemisphere (arrow).

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Figure 4.
Microhemorrhages and mycotic aneurysm.

T2* cerebral magnetic resonance imaging shows corticomeningeal small black dots related to microhemorrhages (A). At the corresponding site of a left frontal microhemorrhage (white arrow), axial and sagittal magnetic resonance angiography views (B and C) suggest the presence of a fusiform mycotic aneurysm; arterial origin was confirmed by using cerebral angiography (D).

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