In cases when there is a high clinical suspi- cion of ICMAs and a negative initial screening with 1 of these modalities, then conventional angiography is reasonable to per- form. Cerebral MRI may be considered in all patients with left- sided IE who have no CNS signs or symptoms. MRI findings may assist in subsequent medical and surgical management.322 Recommendations 1. Cerebrospinal imaging should be performed to detect ICMA or CNS bleeding in all patients with IE or contiguous spread of infection who develop severe, localized headache, neurological deficits, or meningeal signs (Class I; Level of Evidence B). 2. Cerebrovascular imaging may be considered in all patients with left-sided IE who have no CNS signs or symptoms (Class IIb; Level of Evidence C). 3. CT angiography, magnetic resonance angiography, or digital subtraction angiography is reasonable as an initial imaging test for detection of ICMA (Class IIa, Level of Evidence B). 4. Conventional angiography for detection of sus- pected ICMA is reasonable in patients with negative CT angiography, magnetic resonance angiography, or digital subtraction angiography (Class IIa; Level of Evidence B). Extracranial MAs Intrathoracic or intra-abdominal MAs often are asymptomatic until leakage or rupture occurs. Presumably, most extracranial MAs will rupture if not excised. The appearance of a tender, pulsatile mass in a patient with IE suggests an extracranial MA. Hematemesis, hematobilia, and jaundice suggest rupture of a hepatic artery MA; arterial hypertension and hematuria sug- gest rupture of a renal MA; and massive bloody diarrhea sug- gests the rupture of an extracranial MA into the small or large bowel. Either CT scanning or multislice CT angiography with 3D reconstruction is indicated for initial imaging. TEE is useful in identifying MAs of the sinus of Valsalva and thoracic aorta. Recommendations 1. 