We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Images in Neurology |

Multiple Septic Brain Emboli in Infectious Endocarditis

Jonathan Tisdell, MD; Thomas W. Smith, MD; Susanne Muehlschlegel, MD, MPH
Arch Neurol. 2012;69(9):1206-1207. doi:10.1001/archneurol.2011.3563.
Text Size: A A A
Published online


A 34-year-old woman with known intravenous drug use presented with fever, somnolence, dysarthria, ataxia, and a generalized papulopustular rash. Cerebrospinal fluid and blood cultures were positive for methicillin-resistant Staphylococcus aureus. Cardiac ultrasonography showed mitral valve vegetations consistent with infective endocarditis. The patient rapidly became comatose and required mechanical ventilation. Brain magnetic resonance imaging showed numerous bilateral embolic lesions in the infratentorial and supratentorial compartments on fluid-attenuated inversion recovery sequences (Figure 1A and B, arrowheads), of which many contained microbleeds (gradient echo sequences, Figure 1C and D, arrowheads). A larger hemorrhagic lesion with space-occupying effect was seen in the left parietal lobe and was possibly due to the rupture of a mycotic aneurysm. The patient was not medically stable enough to undergo a cerebral angiogram to prove our suspicion. Despite aggressive neurointensive care and maximal osmotherapy, our patient's brain edema progressed and resulted in uncal herniation and midbrain compression. The family withdrew care according to the patient's wishes. An autopsy confirmed multiple acute and subacute infarcts, with microabscesses and hemorrhage in the bilateral hemispheres, brainstem, and cerebellum. Localized meningitis, as well as meningeal vessels containing infectious brain emboli, was seen on microscopy (Figure 2).

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview


Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Magnetic resonance images. A and B, Fluid-attenuated inversion recovery magnetic resonance images depicting numerous infectious emboli (arrowheads). C and D, Gradient echo magnetic resonance images depicting the hemorrhagic components of these emboli (arrowheads), as well as 1 large intracerebral hemorrhage, presumably due to rupture of a mycotic aneurysm (* in parts A and C).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Cortical brain microscopy shows a thrombosed meningeal vessel with infectious embolus (arrow) and adjacent meningitis (arrowheads) (original magnification ×10).




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

1 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles