Other studies6 8 suggest that the risk of neurologi- cal deterioration during cardiac surgery after a stroke is lower than previously assumed, particularly in patients with silent cerebrovascular emboli. The first study to evaluate the timing of surgery after stroke in IE that included a risk adjustment for differences in patient characteristics comprised 198 patients.273 Fifty-eight patients who underwent surgery within 1 week of stroke were compared with 140 patients who underwent surgery 8 days after stroke. Hospital mortality was numerically but not significantly higher in the early surgery group (22.4% versus 12%). After adjustment for other risk factors such as age, paravalvular abscess, and heart failure, the risk of hos- pital mortality remained nonsignificantly higher in the early surgery group (odds ratio, 2.308; 95% confidence interval, 0.942 5.652). Differences in 1-year mortality were less pro- nounced, with an adjusted hazard ratio of 1.138 (95% con- fidence interval, 0.802 1.650). In-hospital mortality in the early surgery group was comparable to that of the medically treated patients. After hemorrhagic stroke, the risk of exacerbation by sur- gery is prohibitively high in the first month but can extend beyond 1 month in some patients, possibly because of the presence of undetected mycotic aneurysms (MAs). In a mul- ticenter study of patients with hemorrhagic stroke, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event compared with later surgery (75% versus These data support the following recommendations: Valve surgery may be performed in IE patients with stroke or sub- clinical cerebral emboli without delay if intracranial hemor- rhage has been excluded by imaging studies and neurological damage is not severe (ie, coma). In patients with major isch- emic stroke or intracranial hemorrhage, it is reasonable to delay valve surgery for at least 4 weeks. Recommendations 1. 