Brain vs Heart: Prioritizing Treatment in Left-Side Infective Endocarditis With Neurologic Complications

A paradigmatic case is presented of subarachnoid hemorrhage as the initial sign of bacterial endocarditis on a mechanical cardiac prosthesis, in the absence of symptoms and echocardiographic evidence of infective endocarditis and vegetation. The presentation emphasizes the need to pursue a diagnostic workup for bacterial endocarditis whenever a patient with a mechanical prosthesis presents to the emergency department with focal neurologic signs. In addition, it highlights the potential use of second-level diagnostic tools to assess the extent of abscess presence and lesion extension to other cardiac structures for proper surgical planning. Finally, the presented case confirms that cardiopulmonary bypass surgery is not contraindicated and should not be delayed, even in the presence of extensive endocardial lesions with concurrent subarachnoid hemorrhage.