Research Article| Volume 29, ISSUE 4, 104598, April 2020

Acute Ischemic Stroke Treatment in Infective Endocarditis: Systematic Review

  • Sofia Bettencourt
    Address correspondence to Sofia Bettencourt, Serviço de Neurologia, 6th floor, Hospital de Santa Maria, 1649-028 Lisboa, Portugal.
    Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
    Search for articles by this author
  • José M Ferro
    Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal

    Department of Neurosciences and Mental Health, Serviço de Neurologia, Hospital Santa Maria/Centro Hospitalar Lisboa Norte, Lisboa, Portugal
    Search for articles by this author


      Background: Ischemic stroke is a frequent neurologic complication of infective endocarditis. This systematic review aims to evaluate the efficacy and safety of thrombectomy in comparison to thrombolysis and to combined treatment in patients with infective endocarditis associated acute ischemic stroke. Methods: A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review included case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials, which reported the treatment of endocarditis-related acute ischemic stroke with mechanical thrombectomy, intravenous or intra-arterial thrombolysis in adult patients. Data sources: Scielo, b-on, Pubmed and Cochrane, from inception to April 2019. Reference lists were also checked. We compared the efficacy (independence, neurological improvement) and safety (intracranial bleeding, death) of acute ischemic stroke treatment with thrombolysis, thrombectomy and combined therapy. Results: Through systematic review 37 articles describing 52 patients met criteria. The risk of intracranial hemorrhage was 4.14 times higher in patients treated with intravenous thrombolysis (P = .001) and 4.67 times higher in patients treated with combined treatment (P = .01). There was trend for independence (P = .09) and neurological improvement (P = .07) in favor of thrombectomy, when comparing this group to the group treated with intravenous thrombolysis. Conclusions: With the limitation of the low quality of the available evidence, thrombectomy in infective endocarditis associated stroke appears to be safer than thrombolysis, or combined treatment. These results may be useful to guide clinical decisions, in selected patients.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Morris N.A.
        • Matiello M.
        • Lyons J.L.
        • et al.
        Neurologic complications in infective endocarditis: identification, management, and impact on cardiac surgery.
        Neurohospitalist. 2014; 4: 213-222
        • Sotero F.
        • Rosário M.
        • Fonseca A.
        • et al.
        Neurological complications of infective endocarditis.
        Curr Neurol Neurosci Rep. 2019; 19: 23
        • Sonneville R.
        • Mourvillier B.
        • Bouadma L.
        • et al.
        Management of neurological complications of infective endocarditis in ICU patients.
        Ann Intensive Care. 2011; 1: 10
        • Ferro J.
        • Fonseca A.
        Infective endocarditis.
        in: Biller José Ferro José M. Handbook of Clinical Neurology. 119. Elsevier, 2014: 75-91
        • Ringleb P.
        • Bousser M.
        • Ford J.
        • et al.
        Guidelines for management of ischaemic stroke and transient ischaemic attack 2008.
        Cerebrovasc Dis. 2008; 25: 457-507
        • Powers W.
        • Rabinstein A.
        • Ackerson T.
        • et al.
        Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2018; 49: e46-e110
        • Turc G.
        • Bhogal P.
        • Fischer U.
        • et al.
        European Stroke Organisation (ESO) –European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic Stroke.
        Eur Stroke J. 2019; 4: 6-12
        • Novya E.
        • Sonnevillae R.
        • Mazighib M.
        • et al.
        Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management.
        Médecine et maladies infectieuses. 2013; 43: 443-450
        • Asaithambi G.
        • Adil M.
        • Qureshi A.
        Thrombolysis for ischemic stroke associated with infective endocarditis results from the nationwide inpatient sample.
        Stroke. 2013; 44: 2917-2919
        • Liberati A.
        • Altman D.
        • Tetzlaff J.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Brownlee W.
        • Anderson N.
        • Barber P.
        Intravenous Thrombolysis is unsafe in stroke due to infective endocarditis.
        Intern Med J. 2013; 44 (195-7): 195-197
        • Sontineni S.
        • Mooss A.
        • Andukuri V.
        • et al.
        Effectiveness of thrombolytic therapy in acute embolic stroke due to infective endocarditis.
        Stroke Res Treat. 2010; 2010841797
        • Ong E.
        • Mechtouff L.
        • Bernard E.
        • et al.
        Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature.
        J Neurol. 2013; 260: 1339-1342
        • Junna M.
        • Lin C.
        • Espinosa R.
        • et al.
        Successful intravenous thrombolysis in ischemic stroke caused by infective endocarditis.
        Neurocrit Care. 2007; 6: 117-120
        • Fuentes Fernández I.
        • Morales Ortíz A.
        • Sanmartín Monzó J.
        • et al.
        Fatal outcome following thrombolysis for stroke secondary to infectious endocarditis.
        Neurología. 2016; 31: 421-423
        • Bhuva P.
        • Kuo S.
        • Hemphill J.
        • et al.
        Intracranial Hemorrhage Following Thrombolytic Use for Stroke Caused by Infective Endocarditis.
        Neurocrit Care. 2010; 12: 79-82
        • Walker K.
        • Sampson J.
        • Skalabrin E.
        • et al.
        Clinical characteristics and thrombolytic outcomes of infective endocarditis-associated stroke.
        Neurohospitalist. 2012; 2: 87-91
        • Jung J.
        • Park M.
        • Kwon D.
        • et al.
        Safety of intravenous thrombolysis in embolic stroke by infective endocarditis.
        Neurology Asia. 2013; 18: 209-211
        • Tversky S.
        • Libman R.
        • Schloss E.
        • et al.
        Catastrophic intracranial hemorrhages after IV tPA in a patient with insidious onset of fever and back pain.
        J Stroke Cerebrovasc Dis. 2016; 25: e69-e70
        • Vales M.
        • García-Pastor A.
        • Vázquez-Alén P.
        • et al.
        Intravenous thrombolysis in ischemic stroke caused by infective endocarditis: a dangerous combination.
        Revista de Neurología. 2016; 62: 426-428
        • Silva F.
        • Diaz G.
        • Rodríguez V.
        • et al.
        Neurological complications of infective endocarditis: controversies.
        Revista Colombiana de Cardiología. 2011; 18: 212-219
        • Ashkanani A.
        • Bitar Z.
        • Maadrani O.
        Acute stroke thrombolysis in infective endocarditis.
        SAGE Open Med Case Rep. 2018; 62050313X18807629
        • Glenn J.
        • Strecker-McGraw M.
        • McGraw I.
        • et al.
        Rupture of an occult intracranial mycotic aneurysm after intravenous thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke.
        J Emerg Med. 2017; 53: 717-721
        • Ren B.
        • Lasam G.
        A rare case of native mitral valve bacillus cereus endocarditis culminating into a cerebrovascular infarction.
        Cardiol Res. 2018; 9: 173-175
        • Miran M.
        • Roering L.
        • Maud A.
        • et al.
        Thrombolytic use in acute ischemic stroke patients with concurrent infective endocarditis: emphasis on history, physical exam, outcomes, and review of literature.
        J Neurol Transl Neurosci. 2017; 5: 1077
        • Li W.
        • Chen Y.
        • Wann S.
        Lactococcus garvieae endocarditis with initial presentation of acute cerebral infarction in a healthy immunocompetent man.
        Intern Med. 2008; 47: 1143-1146
        • Siccoli M.
        • Benninger D.
        • Schuknechtb B.
        • et al.
        Successful intra-arterial thrombolysis in basilar thrombosis secondary to infectious endocarditis.
        Cerebrovasc Dis. 2003; 16: 295-297
        • Dababneh H.
        • Hedna S.
        • Ford J.
        • et al.
        Endovascular intervention for acute stroke due to infective endocarditis.
        Neurosurg Focus. 2012; 32 (E1): 1-4
        • Kim J.
        • Jeon J.
        • Kim Y.
        • et al.
        Forced arterial suction thrombectomy of septic embolic middle cerebral artery occlusion due to infective endocarditis: an illustrative case and review of the literature.
        Neurointervention. 2014; 9: 101-105
        • Sukumaran S.
        • Jayadevan E.R.
        • Mandilya A.
        • et al.
        Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis.
        Neurol India. 2012; 60: 23
        • Kan P.
        • Webb S.
        • Siddiqui A.
        • et al.
        First reported use of retrievable stent technology for removal of a large septic embolus in the middle cerebral artery.
        World Neurosurg. 2012; 77: 591
        • Akkoyunlu Y.
        • Iraz M.
        • Kocaman G.
        • et al.
        Abiotrophia defectiva endocarditis presenting with hemiplegia.
        Jundishapur J Microbiol. 2013; 6: e8907
        • Ladner T.
        • Davis B.
        • He L.
        • et al.
        Complex decision-making in stroke: preoperative mechanical thrombectomy of septic embolus for emergency cardiac valve surgery.
        J NeuroIntervent Surg. 2015; 7: e41
        • Sveinsson O.
        • Herrman L.
        • Holmin S.
        Intra-arterial mechanical thrombectomy: an effective treatment for ischemic stroke caused by endocarditis.
        Case Reports in Neurology. 2016; 8: 229-233
        • Scharf E.L.
        • Chakraborty T.
        • Rabinstein A.
        • et al.
        Endovascular management of cerebral septic embolism: three recent cases and review of the literature.
        J NeuroIntervent Surg. 2017; 9: 463-465
        • Nishino W.
        • Tajima Y.
        • Inoue T.
        • et al.
        Severe vasospasm of the middle cerebral artery after mechanical thrombectomy due to infective endocarditis: an autopsy case.
        J Stroke Cerebrovasc Dis. 2017; : 30281
        • Liang J.
        • Bishu K.
        • Anavekar N.
        Infective endocarditis complicated by acute ischemic stroke from septic embolus: successful solitaire FR Thrombectomy.
        Cardiol Res. 2012; 3: 277-280
        • Ambrosioni J.
        • Urra X.
        • Hernández-Meneses M.
        • et al.
        Mechanical thrombectomy for acute ischemic stroke secondary to infective endocarditis.
        Clin Infect Dis. 2018; 66: 1286-1289
        • Hernández-Fernández F.
        • Rojas-Bartolomé L.
        • García-García J.
        • et al.
        Histopathological and bacteriological analysis of thrombus material extracted during mechanical thrombectomy in acute stroke patients.
        Cardiovasc Intervent Radiol. 2017; 40: 1851-1860
        • Elodie O.
        • Labeyrie P.E.
        • Aubry M.
        • et al.
        Whipple's endocarditis diagnosed by thrombus analysis retrieved by successful mechanical thrombectomy.
        J Neurol Sci. 2019; 400: 42-43
        • Toeg H.
        • Al-Atassi T.
        • Kalidindi N.
        • et al.
        Endovascular treatment for cerebral septic embolic stroke.
        J Stroke Cerebrovasc Dis. 2014; 23: e375-e377
        • Bain M.
        • Hussain M.
        • Gonugunta V.
        • et al.
        Successful recanalization of a septic embolus with a balloon mounted stent after failed mechanical thrombectomy.
        J Neuroimaging. 2011; 21: 170-172
        • Kang G.
        • Yang T.
        • Choi J.
        • et al.
        Effectiveness of mechanical embolectomy for septic embolus in the cerebral artery complicated with infective endocarditis.
        J Korean Med Sci. 2013; 28: 1244-1247
        • Bolognese M.
        • Hessling A.
        • Muller M.
        Successful thrombectomy in endocarditis-related stroke: case report and review of the literature.
        Interv Neuroradiol. 2018; 24: 529-532
        • Bhaskar S.
        • Cordato D.
        • Cappelen-Smith C.
        • et al.
        Clarion call for histopathological clot analysis in “cryptogenic” ischemic stroke: implications for diagnosis and treatment.
        Ann Clin Transl Neurology. 2017; 4: 926-930
        • Sgrecciaa A.
        • Caritàb G.
        • Coskunc O.
        • et al.
        Acute ischemic stroke treated with mechanical thrombectomy and fungal endocarditis: A case report and systematic reviewof the literature.
        J Neuroradiol. 2019;
        • Distefano M.
        • Calandrelli R.
        • Arena V.
        • et al.
        A Puzzling Case of Cryptogenic Stroke.
        J Stroke Cerebrovasc Dis. 2019; 28: e33-e35
        • Goyal M.
        • Menon B.K.
        • van Zwam W.H.
        • et al.
        Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials.
        Lancet. 2016; 387: 1723-1731

      Linked Article

      • Safety and Efficacy of Thrombolysis and Mechanical Thrombectomy in Infective Endocarditis
        Journal of Stroke and Cerebrovascular DiseasesVol. 29Issue 6
        • Preview
          We read with much interest the article “Acute Ischemic Stroke Treatment in Infective Endocarditis: Systemic Review” by Bettencourt et al, published in your esteemed journal. Authors have reviewed 37 articles including 52 patients. Sixteen of whom received IV thrombolysis, 22 received mechanical thrombectomy, 11 received combined treatment. The authors stated that the quality of the articles were low. And have concluded that the risk of intracerebral hemorrhage was 4 times higher in the group treated with IV thrombolysis comparing to the group treated with thrombectomy.
        • Full-Text
        • PDF