| Summary: | Background The United States is experiencing a rapidly increasing rate of opioid drug abuse. Intravenous drug use (IVDU)‐related endocarditis can lead to significant neurological complications with high morbidity and mortality. When patient care necessitates anticoagulation, the standards for radiographic screening and the risk for intracranial hemorrhage are not clearly elucidated. Methods We conducted a retrospective cohort study involving patients treated for infective endocarditis at a single institution from 2014 to 2018. Patients were grouped based in history of IVDU and their demographics and clinical predictors for intracranial hemorrhage were analyzed. Results A total of 351 patients met inclusion criteria for this study, of whom 170 patients (48%) had a history of IVDU‐associated endocarditis. IVDU was associated with an increased prevalence of intracranial hemorrhage (25.9% versus 13.9%; P=0.005), including intraparenchymal hemorrhage (12.4% versus 5.1%; P=0.012), subarachnoid hemorrhage (17.6 versus 4.4%; P=0.001), and cerebral microbleeds (14.1% versus 7.2%; P=0.022). IVDU was also associated with an increased incidence of infectious intracranial aneurysm (10.6% versus 1.8%; P=0.001) and brain abscesses (4.7% versus 1.1%; P=0.025). Multivariate analysis showed that the presence of intracranial septic emboli (odds ratio [OR], 18.47 [8.4–40.250]; P=0.001) and infectious intracranial aneurysm (OR, 12.38 [3.24–47.28]; P=0.001) as significant predictive factors for intracranial hemorrhage after presenting with endocarditis. Conclusion The opioid epidemic has increased the incidence of infective endocarditis and resultant neurovascular complications. IVDU‐associated endocarditis is associated with increased hemorrhagic stroke and more frequent neurodiagnostic imaging.
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