Predicting Stroke in Patients with Infective Endocarditis: A Systematic Review and Meta-Analysis of Risk Factors

Background: Neurological complications in patients with infective endocarditis (IE), such as ischemic and hemorrhagic stroke, are well-described; However, predicting which patients are most likely to experience stroke remains uncertain. Aims: We conducted a systematic review and meta-analysis to identify the factors associated with risk of stroke in patients hospitalized with IE. Methods: A systematic search of Ovid MEDLINE, EMBASE, and Web of Science up to June 27th, 2024 was conducted. Articles evaluating risk of acute ischemic stroke (AIS) or intracranial hemorrhage (ICH) in patients with IE were included. Meta-analysis of odds ratios was feasible for only some predictive factors due to study heterogeneity. Cochrane’s Risk of Bias in Non-Randomized Studies of Exposure tool was used for risk-of-bias assessment. Summary of Review: Of 3538 studies identified, 35 were included: 9 prospective and 26 retrospective cohort. Staphylococcus aureus infection (odds ratio, 3.05; 95% CI, 1.96-4.73, I2 = 77.2%; 9 studies), and 1 mm increment in vegetation size (odds ratio, 1.26; 95% CI, 1.02-1.55, I2 = 90.1%; 3 studies) were associated with a higher risk of AIS, after adjusting for other covariates. High intensity signals on transcranial Doppler, and comorbidities such as hypertension, atrial fibrillation, and hyperlipidemia were also found to be associated with a higher risk of AIS. The risk of ICH was increased by thrombocytopenia, mycotic aneurysms, prior ICH or AIS, and cerebral microbleeds. Conclusions: Our study has identified factors which are associated with increased stroke risk in IE, and may help physicians predict risk. While echocardiographic and neuroimaging findings may be particularly informative, underlying comorbidities and various laboratory values may also contribute to predicting IE-associated strokes.