Characterization and treatment of ischemic stroke in patients with infective endocarditis: a meta‐analysis

Background Ischemic stroke is a common and serious complication of infective bacterial endocarditis. This study aimed to characterize the frequency, clinical and pathological features, treatment strategies, and outcomes of patients with stroke due to infective endocarditis. Methods We systematically searched PubMed from database inception to October 2022 for studies reporting on stroke in patients with infective endocarditis and performed a meta-analysis. Results A total of 122 studies comprising 270,211 patients with infective endocarditis were included. Ischemic stroke occurred in 21% and hemorrhagic stroke in 5% of patients. Stroke was observed in 32% of patients with mitral valve endocarditis, 25% with aortic valve, and 11% with tricuspid valve endocarditis. Stroke was associated with significantly higher mortality (OR 2.35; 95%CI 1.74–3.16). Staphylococcus and Streptococcus species were most frequently associated with stroke (33% and 25%, respectively). The risk of stroke did not differ significantly between patients with and without pre-existing antithrombotic therapy (37% vs. 24%; OR 1.24, 95%CI 0.75–2.06). Successful reperfusion was achieved in 80% of patients undergoing mechanical thrombectomy, although mortality remained high at 49%. Conclusions Stroke is a common complication of infective bacterial endocarditis and has a substantial impact on patient outcomes. It occurs most frequently in patients with mitral valve endocarditis and in those with infections caused by staphylococcal pathogens. Stroke risk was not reduced in patients with pre-existing antithrombotic therapy, supporting discontinuation where no other indication exists. Mechanical thrombectomy in patients with endocarditis-related large vessel occlusion achieves high recanalization rates; however, overall clinical outcomes remain poor in this population.