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Impact of Brain MRI on the Diagnosis of Infective Endocarditis and Treatment Decisions: Systematic Review and Meta-Analysis.

Background: Despite increasing use of brain MRI in patients with suspected infective endocarditis, the clinical impact of brain MRI in this setting has not yet been systematically reviewed to our knowledge. Objective: To evaluate the frequency of findings on brain MRI in patients with suspected or confirmed infective endocarditis and to determine the impact of such findings on clinical decisions. Evidence Acquisition: A systematic search of PubMed, EMBASE, and Cochrane databases was performed from January 1, 1990 to December 31, 2020 for original research investigations of brain MRI in patients with suspected or confirmed infective endocarditis. Study quality was assessed using QUADAS-2. Study endpoints included the frequency of brain MRI findings, as well as the frequency of diagnostic modifications, therapeutic plan modifications, and valvular surgical plan modifications resulting from MRI findings. Frequencies were pooled using the inverse variance method. Subgroup analysis was performed. Evidence Synthesis: A total of 21 studies with 2133 patients were included. Study quality was considered overall moderate. In terms of brain MRI findings, the pooled frequency of acute ischemic lesions was 61.9% (95% CI, 50.7-71.9%); cerebral microbleeds 52.9% (95% CI, 41.6-63.9%); hemorrhagic lesions, 24.7% (95% CI, 15.1-37.9%); abscess or meningitis, 9.5% (95% CI, 5.6-15.6%); and intracranial mycotic aneurysm, 6.2% (95% CI, 4.0-9.4%). Subgroup analysis after excluding three studies in which neurologic findings served as the indication for all brain MRI examinations yielded similar frequencies of these findings. Six studies reported results regarding the impact of brain MRI findings on clinical decisions. The frequency of diagnostic modifications in two studies was 5.4% and 32.1%. The pooled frequency of therapeutic plan modification in six studies was 12.8% (95% CI, 6.5-23.7%) and of valvular surgical plan modification in five studies was 14.2% (95% CI, 8.2-23.4%). Conclusion: In patients with suspected or confirmed infective endocarditis, brain MRI examinations commonly show relevant abnormalities that impact diagnostic and therapeutic clinical decisions. Clinical Impact: The findings support a potential role for screening brain MRI in patients with suspected or confirmed infective endocarditis, regardless of the presence or absence of neurologic symptoms.