A 59-year-old woman visited a local hospital for fever and was diagnosed as having infective endocarditis (IE) on the basis of blood cultures and transthoracic echocardiography. Based on clinical episodes of subarachnoid hemorrhage after admission, it was judged that she was not a good candidate for urgent open heart surgery, and it was decided to treat her with conservative medical therapy for the acute phase. We explored the optimum timing for surgery by employing gadolinium (Gd) contrast medium-enhanced magnetic resonance imaging (MRI) T2* weighted image (black dots) due to her high risk of perioperative cerebral hemorrhage. After the disappearance of the contrast media enhancement effect around the black dots, open heart surgery was performed successfully on the 103rd hospitalization day. The patient was discharged 22 days after the surgery with no clinical complications. This case suggests that disappearance of the contrast media enhancement effect around the black dots may be a useful marker for optimal timing of surgery to minimize the risk of perioperative cerebral hemorrhage in patients with IE. Learning Objective. The MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE. 1. Introduction Infective endocarditis (IE) is a serious disease characterized by refractory heart failure combined with sepsis. Intracranial bleeding is an important potential complication which can be influenced by the timing of open heart surgery [1]. Here we report a case of IE complicated with a brain mycotic aneurysm that was checked regularly by brain magnetic resonance imaging (MRI) with gadolinium (Gd) enhancement to explore optimal timing for open chest surgery. As a result, after disappearance of Gd-enhanced T2* weighted image (black dots), the patient underwent successful valve replacement without perioperative symptomatic complications. We discuss the possible usefulness of Gd-enhanced brain MRI to minimize perioperative hemorrhagic complications based on existing knowledge in the literature. 2. Case Report A 59-year-old woman had an intermittent fever from the end of October to the end of November 2012 when she consulted a local hospital and Streptococcus viridans was detected by blood culture. Transthoracic echocardiography (TTE) revealed the presence of vegetations on the aortic and mitral valves with regurgitation. On the basis of the Duke criteria, she was diagnosed with definite infective endocarditis (IE), and intravenous antibiotic treatment
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