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Increased microbleeds after infective endocarditis in a patient with valvular replacement

A 35-year-old women with mechanical mitral valve replacement presented with fever followed by loss of consciousness. Brain magnetic resonance imaging showed left middle cerebral artery infarction with multiple microbleeds (Fig. 1a). Transesophageal echocardiography showed vegetation and blood culture was positive for Staphylococcus capitis. A parenteral antibiotic therapy was immediately started, and appropriate anticoagulation with warfarin was carried out (time in therapeutic range 68.9%). One year later, she experienced left hemiparesis, and the follow-up magnetic resonance imaging showed another right middle cerebral artery infarction with increased microbleeds during a relatively short period (Fig. 1b, arrows). In the case of a cerebral infarction as a result of septic emboli, there is a chance of septic erosion of the arterial wall caused by the embolus to increase microbleeds. As long-term anticoagulation increases the risk of intracerebral hemorrhage in patients with multiple microbleeds, it might be necessary to follow up magnetic resonance imaging including gradient echo imaging within short periods, especially in