Intracerebral and Subarachnoid Hemorrhage as a Result of Infective Endocarditis : A Case Report

Infective endocarditis (IE) may have devastating and life-threatening neurological complications. The incidence of intracranial hemorrhage (e.g. subdural hematoma, subarachnoid hemorrhage (SAH), and intracerebral hemorrhage(ICH)) is rare. A 39 years old male, came to emergency unit with heart failure clinical features, accompanied with fever for 2 weeks, and apical systolic murmur found in the physical examination. In the second day of admission, the patient experienced a sudden decrease of conciousness, weakness of the right limbs, and slurred speech. CT scan examination showed left parietal lobe ICH with volume ± 20 cc, and SAH in left parietal lobe, basal systern, to pontine systern. Echocardiography revealed AML flail with severe mitral regurgitation and vegetation in AML. Empirical parenteral antibiotics ceftriaxone and gentamicin were given. In the following day, the conciousness was increasing. Later, the blood culture examination showed growing of Staphylococcus saprophyticus.Intracranial hemorrhage may cause worsening in patient’s condition, and require withdrawal in anticoagulant therapy. Cardiac surgery should be delayed.Despite of its uncommon incidence, physician should be aware of the neurological complication of IE to recognize and do the prompt treatment of the disease.


CASE PRESENTATION
A 39 years old male came to emergency department with shortness of breath especially after walking in a distance and also when lying down sleeping one week before admission.He often woke up at night because of the shortness of breath and more comfortable in sitting position.In the second day of admission, patient had fever with 39 o C body temperature.
blood cell increased (17.300 / µl).ECG examination showed anteroseptal ia however the CKMB was within normal limit.Paracetamol 500 mg tid, bide dinitrate 5 mg tid and clopidogrel 75 mg once a day were planned to be , when suddenly the patient had decrease of conciousness with Glasgow Coma

DISCUSSION
We reported a case of male patient, 39 years old with IE presented with he failure (HF) manifestation accompanied by fever.In the second day of admission, t Neurological complications in IE, stroke in particular, are associated with higher mortality and morbidity. 1,310] SAH in IE is uncommon and only described in case reports.ICMA is classically associated with SAH, however non-aneurysmal spontaneous SAH could happen in a rare cases. 9,11American Heart Association (AHA) recommends computed tomogaphic angiography (CTA) and magnetic resonance angiography (MRA) to examine the patient with neurological symptoms to detect cerebral aneurysm. 12ICH in IE also can be the result of arterial injury, such as septic arteritis that usually occurs during uncontrolled infection. 13 this case, a very rare ICH and SAH were happened at the same time in the left parietal lobe area.However, further studies to know what caused the bleeding could not be done due to the limitation of the resources.
The general principle of successful treatment of IE relies on microbial eradication by anti-microbial drugs.Surgery contributes by removing infected material and draining abscesses. 4Early diagnosis and administration of appropriate antibiotics are also important in preventing neurological complication. 14

Figure 1 .
Figure 1.Thorax x ray examination showed bilateral pleural effusion and slight cardiomegaly

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5 and slurred speech.There were right facial palsy, and right lateralization.ontrast head CT scan revealed ICH at left parietal lobe with perifocal edema g midline shift 0.6 cm to the right, and SAH in left parietal, basal cystern, until e cystern.The patient was moved to high care unit.Neurologist consultant sted intravenous piracetam 3 gram injection tid, nimodipine 60 mg oral qid, and izole injection tid.Clopidogrel administration was delayed and intravenous xon 1 gram bid was given.

Figure 2 .
Figure 2. ICH and SAH in left parietal lobe shown in CT scan examination

Figure 2 .Figure 3 .
Figure 2. ICH and SAH in left parietal lobe shown in CT scan examination 1,2It ranges from ischemic stroke or TIA,