Brain-first strategy for infective endocarditis with infectious intracranial aneurysm: Coil embolization followed by endoscopic mitral valve repair.

Infective endocarditis (IE) complicated by infectious intracranial aneurysms (IIAs) presents a therapeutic dilemma, as cardiopulmonary bypass (CPB) with systemic heparinization may trigger aneurysm rupture, whereas delaying surgery carries the risks of the disease worsening. A 38-year-old man presented with active IE caused by Streptococcus agalactiae with severe mitral regurgitation and a symptomatic 5-mm infectious intracranial aneurysm located in the distal left posterior cerebral artery. Urgent cardiac surgery was required but the aneurysm carried a substantial risk of rupture during CPB, endovascular coil embolization was performed first. Five days later, endoscopic minimally invasive mitral valve repair with an autologous pericardial patch was performed without complications. The patient was discharged after four weeks of antibiotic therapy. At six months postoperatively, the patient remains asymptomatic without recurrent infection or valve dysfunction. A staged strategy consisting of preoperative endovascular treatment followed by minimally invasive valve surgery may represent a safe and effective approach for patients with IE complicated by infectious intracranial aneurysms, allowing cardiac surgery while minimizing the risk of intracranial hemorrhage.