Cardiogenic subarachnoid bleed: A case report

Background: Ruptured mycotic aneurysms account for approximately 5% of the neurologic complications of infective endocarditis. Rarely, a ruptured mycotic aneurysm can be the first manifestation of infective endocarditis and is associated with an 80% mortality rate. A case of subarachnoid haemorrhage (SAH) with infective endocarditis undergoing successful multidisciplinary management is reported. Case Summary: A 41-year-old male presented with sudden onset vomiting, followed by loss of consciousness. Soon after admission, patient developed severe respiratory distress and bilateral coarse crepitations on auscultation. Electrocardiogram showed sinus tachycardia with features of left ventricular hypertrophy. He was immediately intubated and put on mechanical ventilation. Urgent chest X-ray showed features of pulmonary oedema and was administered diuretics. Computed tomography (CT) scan showed SAH and intraventricular hemorrhage. Simultaneous CT angio demonstrated left posterior cerebral artery aneurysm [Figure 1]. Echocardiography revealed severe aortic regurgitation along with vegetation on the aortic cusps [Figure 2]. Diagnosis of infective endocarditis was made provisionally and started on appropriate antibiotics after sending blood for culture. Once stabilised, he was taken up for definitive treatment. Cerebral angiogram revealed a mycotic aneurysm of posterior cerebral artery which was embolised. He improved over the next few days and was discharged being neurologically intact. One month after discharge, he underwent aortic valve replacement and thus attained complete recovery. Conclusion: The overall prevalence of haemorrhage in central nervous system involvement of infective endocarditis is 3–7%. However, SAH or subdural haematoma is rare. The incidence of clinically diagnosed intracranial mycotic aneurysms in patients with infective endocarditis is approximately 2%. When aneurysms form, the most likely mechanism is bacterially induced weakening. Our case report depicts successful management of a rare but fatal disorder through interdisciplinary collaboration.

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No conflict of interest has been declared by the author(s).