Stroke Characteristics, Management, and Outcomes in Patients with Non-bacterial Thrombotic Endocarditis: A Systematic Review
Ahmed Aljabali1, Hallie Taylor-wedge2, Todd Laffaye4, Majd Al-Ahmad5, Ayham Harahsheh6, Mohammad Alamoush7, Khaled Dweik2, Mayowa Osundiji3, Amir Mbonde8, Cumara O'Carroll9, Bart Demaerschalk9, Ehab Harahsheh10
1Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan., 2Neurology, 3Clinical genomics, Mayo Clinic Arizona, 4Mayo Clinic Alix School of Medicine, 5Internal Medicine, University of Missouri Columbia, 6Internal Medicine, Islamic Hospital, 7Faculty of Medicine, University of Jordan, 8Medical College of Georgia, 9Mayo Clinic, 10Neurology, University of Arizona
Objective:
This systematic review summarizes stroke presentation, imaging features, management, and outcomes in patients with NBTE-related stroke.
Background:
Stroke is a frequent manifestation of non-bacterial thrombotic endocarditis (NBTE), yet current knowledge largely stems from case reports and small case series
Design/Methods:
We searched PubMed, MEDLINE, Web of Science and PsycINFO databases through August 2025 for studies reporting individual cases or case series of NBTE-related stroke. Extracted data included demographics, vascular risk factors, stroke presentation, imaging features, NBTE etiology, treatment (unfractionated heparin/low molecular weight heparin (UFH/LMWH), warfarin, direct oral anticoagulants (DAOCs), and/or valvular surgeries), and treatment outcomes. Multivariate regression was used to identify predictors of recurrent stroke and mortality.
Results:
We included 163 patients from 149 studies (median age 56 [IQR:46-64], 60% females). Right (26%) and left (25%) hemispheric stroke syndromes predominated clinical presentation, and multi-territory ischemic infarcts (>2 territories) in 66%. Conventional vascular risk factors were infrequent (1%-23%), whereas deep vein thrombosis (58%) and systemic embolism (40%) frequently preceded or coincided with stroke onset. Malignancy (73%) and autoimmune diseases (21%) were the main NBTE etiologies. Anticoagulation was initiated in 69% and 21% underwent valvular surgery. Over a median follow-up of 1.5 months, stroke recurred in 45% and death in 47% of patients. Malignancy (OR 34.5, P<0.001) and metastases (OR 5.5, P<0.001) significantly increased mortality risk, while UFH/LMWH (OR 0.3, P=0.006), VKA (OR 0.1, P<0.001) and autoimmune etiology (OR 0.2, P=0.029) were associated with decreased mortality. Malignancy (OR 6.8, P=0.009) and DOAC use (OR 8.4, P=0.013) were linked to recurrent stroke in this patient population.
Conclusions:
NBTE should be considered in stroke patients lacking conventional risk factors, particularly those with underlying malignancy or autoimmune disease. Malignancy and DOAC use may increase the risk of recurrent strokes in this patient population.
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