Professional Documents
Culture Documents
http://emedicine.medscape.com/article/1160370-overview#aw2aab6b2
Overview Cardioembolic Stroke
The heart was established as an important source for the development of
emboli when Gowers, in 1875, described a case of left middle cerebral artery
and retinal artery emboli. Cardiogenic embolism accounts for approximately
20% of ischemic strokes each year. New diagnostic techniques (transesophageal
echocardiography, cardiac magnetic resonance imaging) have allowed clinicians
to better characterize well-established sources of embolism and to discover
other potential etiologies of cardioembolic stroke (see the following image).
Onset of symptoms after a Valsalva-provoking activity (enhancing rightto-left shunting in patients with a patent foramen ovale [PFO])
Concomitant diseases (eg, systemic lupus erythematosus and LibmanSacks endocarditis, neoplasia, marantic endocarditis)
Risk
Low
1.9
Low
2.8
Moderate
High
5.9
>3
Very high
>8.5
Antithrombotic Therapy
Class of
Recommendation
(lone AF)
no therapy
no risk factors*
Age 60-74 y, no risk factors*
mellitus or CAD
2.0-3.0)
2.0-3.0)
(mitral stenosis)
Prosthetic heart valves
Previous thromboembolism
Persistent atrial thrombus on
I
IIA
Tee
Source: ACC/AHA/ESC 2006 Guidelines for the management of patients with
atrial fibrillation.[11]
AF = atrial fibrillation; CAD = coronary artery disease; EF = ejection fraction;
INR = international normalized ratio; LV = left ventricle; TEE = transesophageal
echocardiography.
*
Risk factors for thromboembolism include heart failure (HF), (LV) ejection
determine its size, any associated atrial septal aneurysm, and the amount of
shunting.
Although case-control studies have documented a higher frequency of PFO in
young adults with cryptogenic ischemic stroke, it is present by chance
association in at least 50% of cases in patients with stroke. The rate of stroke
recurrence is 1-2% per year. Larger size, spontaneous right-to-left shunting,
and associated atrial septal aneurysm are postulated to identify subgroups at
high risk for recurrence.
PFO is not associated with increased risk of subsequent stroke or death among
medically treated patients with cryptogenic stroke. However, in a study, both
PFO and septal aneurysm (ASA) possibly increase the risk of subsequent stroke
(but not death) in medically treated patients younger than 55 years. [13]
Mono et al identified several concurrent etiologies for recurrent cerebrovascular
events in PFO patients, including large artery disease, small artery disease,
cardioembolism, cerebral vasculitis, thrombophilic disorder, and
antiphospholipid-antibody syndrome.[14]
In patients with a cryptogenic stroke and an atrial septal abnormality, evidence
is insufficient to determine whether warfarin or aspirin is superior in
preventing recurrent stroke or death, but minor bleeding is more frequent with
warfarin. Evidence evaluating the efficacy of surgical or endovascular closure is
insufficient.[13] Clinical trials are ongoing to compare endovascular closure
versus medical therapy. If a patient is not a participant in a clinical PFO
closure trial, the American Academy of Neurology recommendations are to
initiate medical therapy and consider closure only if there are repeated
recurrent clinical events on maximal medical therapy.[13]
Elucidation of the role of other therapeutic approaches such as surgical closure
(eg, transthoracic, percutaneous) awaits the results of clinical trials and better
characterization of the natural history. At present, PFO should not be
considered the cause of stroke until other etiologies have been thoroughly
excluded.