Therapeutic Dilemmas in the Management of Stroke Among Patients With Infective Endocarditis (IE): A Literature Review

Infective endocarditis (IE) is an infection of the endocardial lining of the heart, with high morbidity and mortality. Neurological complications, mainly stroke, represent the most frequent and devastating extracardiac manifestations. Despite continued advancements in diagnostics and management, the optimal strategies and guidelines to prevent and treat IE-associated stroke remain controversial and scarce. We conducted a detailed narrative review of recent literature focusing on the epidemiology, risk factors, pathophysiology, diagnostic approaches, and therapeutic strategies for stroke in the context of IE. Evidence was drawn from multinational cohort studies, systematic reviews, guideline statements, and recent updates in imaging, surgical practices, and guidelines. Stroke leads to complications in approximately 15%-20% of IE cases, with regional variation linked to healthcare-associated infections, intravenous drug use, and rheumatic or congenital heart disease. Risk factors include Staphylococcus aureus infection, vegetation size >10 mm, hypertension, atrial fibrillation, and cerebral microbleeds. Advanced neuroimaging techniques (MRI, CTA, and MRA) aid in the early detection of ischemic and hemorrhagic events, while updated Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) criteria improve diagnostic accuracy. Antimicrobial therapy reduces embolic risk, but the role of anticoagulants and antiplatelet agents remains controversial. Intravenous thrombolysis is contraindicated due to high hemorrhagic risk, whereas mechanical thrombectomy appears safe and effective only in carefully selected patients. The timing of cardiac surgery requires multidisciplinary decision-making: early surgery may prevent embolism but is associated with increased perioperative neurological complications, particularly in hemorrhagic stroke. Mycotic aneurysms, though uncommon, call for early diagnosis and tailored endovascular or surgical management. IE-related stroke poses complex diagnostic and therapeutic challenges that require multidisciplinary care involving the integration of cardiology, neurology, infectious disease, and surgical expertise. Advances in imaging, early antimicrobial therapy, optimized surgical timing, and cautious use of reperfusion techniques are reshaping management. Ongoing research is needed to refine risk stratification and optimize individualized care.