How do you approach evaluating the hemorrhage risk of restarting anticoagulation in a patient with ischemic stroke and infective endocarditis without access to DSA?

This is a really excellent question. First of all, if the patient has infective endocarditis, they really should undergo appropriate antibiotic treatment prior to initiating anticoagulation. I have seen several patients have significant (and in some cases fatal) hemorrhages because anticoagulation was started without an appropriate workup.

If, however, the patient is hemodynamically unstable or meets surgical criteria for valve repair/replacement and anticoagulation is absolutely needed procedurally prior to completion of antibiotic therapy, or there is another significant medical issue that requires emergent anticoagulation, then I typically do get a DSA angiogram to rule out any mycotic aneurysms, which would elevate the risk of hemorrhag...

Antithrombotic treatment decisions in bacterial endocarditis are frequently challenging given the high-risk nature of the condition for both thromboembolic and hemorrhagic complications, heterogeneous patient population, and relative paucity of data.

I understand the question to be specific to a situation where all diagnostic modalities, including brain MRI and CTA of the head, are available except for a conventional angiogram. So at its core, the question is regarding the risk of initiating anticoagulation when (1) the CTA of the head did not show a mycotic aneurysm, (2) in principle, anticoagulation is thought appropriate, but (3) there is a lack of definite exclusion of a mycotic aneurysm by DSA. And maybe, there is (4) a patient deemed a...