Background: Ischemic strokes (IS) occur in up to 35% of patients with infective endocarditis (IE). The use of tissue plasminogen activator (tPA) in IE is controversial because of high rates of spontaneous hemorrhagic transformation secondary to presence of pyogenic arteritis, micro abscesses, immune complex-mediated arteritis, and the concurrent presence of mycotic aneurysms with subsequent rupture. Endovascular treatment (EVT) appears to be an option for these patients when presenting with proximal artery occlusion.
Methods: A systematic search was conducted, using Pubmed, MeSH, Ovid and Embase databases, to investigate peer-reviewed studies of IE and IS (2011-to-March 2018).
Results: We present a case of a 49-year-old woman presenting as an acute IS for consideration of tPA while on treatment for Streptococcus mitis IE. She was not considered for tPA given the high likelihood that her stroke was secondary to a septic embolus. EVT option was considered but CTA only showed a filling deficit in distal M2 segment and due to clot position she was not deemed a candidate. We found 21 case reports EVT in the setting of IE and proximal clots with 15 having good outcomes (NIHSS ≤ 5).
Conclusion: We present a potential option in the treatment of IE-associated acute IS where tPA is not an option. From our literature review, it appears that EVT is a promising treatment option for IS patients in the setting of IE. However, one has to be conscious of the potential reporting bias associated with case reports and more robust prospective data in this setting is warranted.

Endovascular treatment for acute ischemic stroke of infective endocarditis: a case presentation and systematic review