Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis: Multidisciplinary Management to Determine Timing of Cardiac Surgery.

Infective endocarditis (IE) is a disease process associated with significant morbidity and mortality due to systemic embolization and metastatic infection. We present the case of a 65-year-old male with an extensive past medical history who presented with chest pain and dyspnea and was found to have Enterococcus faecalis aortic valve IE complicated by severe aortic regurgitation. His complex hospital course included non-ST-elevation myocardial infarction (NSTEMI) secondary to septic coronary embolization, as well as cerebrovascular embolization causing a left parieto-occipital infarct. The coronary embolization was favored to be septic in etiology given the presence of an aortic valve vegetation, concurrent Enterococcus faecalis bacteremia, and the absence of an alternative explanation for the acute distal coronary occlusion. Neurovascular evaluation and digital subtraction angiography confirmed a distal intracranial mycotic aneurysm causing hemorrhage. The complexity of this case necessitated extensive multidisciplinary collaboration among neurology, neurosurgery, cardiothoracic surgery, infectious disease, neurointerventional radiology, and other specialty services to find the source of infection and balance the risks of intracranial hemorrhage, ongoing infection, and urgent valve replacement. This case highlights how neurological complications can dictate the sequence and timing of cardiac surgery to achieve favorable outcomes in patients with complex disseminated Enterococcus faecalis IE.