Review Article

Cardioembolic Stroke: An Update

Authors: Roger E. Kelley, MD, Alireza Minagar, MD

Abstract

Cardioembolic stroke accounts for approximately 15% of all strokes and is thought to be one of the more preventable types of strokes. Features that have been reported to support cardioembolism as a mechanism for ischemic stroke have included documented cardiac source of embolism, maximal neurologic deficit at onset, multiple cerebrovascular territories involved, enhanced tendency toward hemorrhagic transformation, enhanced risk of syncope or seizure associated with presentation, and lower likelihood of premonitory transient ischemic attacks. Features that tend to make cardioembolic stroke less likely include significant cerebral atherosclerosis, stepwise progression of the neurologic deficit within a finite period of time, vascular distribution such as entire internal carotid artery territory with combined middle cerebral artery and anterior cerebral artery involvement or watershed distribution, and premonitory transient ischemic attacks. A number of cardiac conditions can promote thromboembolism, and there is risk stratification reflective of the specific condition or coexistent conditions. Anticoagulant therapy generally has been found to be the most effective means of preventing cardiogenic brain embolism, but the intensity of anticoagulation needs to be optimized to reflect the risk-to-benefit ratio for the particular patient.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

  1. Cerebral Embolism Study Group. Cardiogenic brain embolism: The second report of the Cerebral Embolism Task Force. Arch Neurol 1989; 46: 727–743.Cerebral Embolism Study Group.
  2. Caplan LR, Hier DB, D'Cruz I. Cerebral embolism in the Michael Reese Stroke Registry. Stroke 1983; 14: 530–536.
  3. Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: The German Stroke Data Bank. Stroke 2001; 32: 2559–2566.
  4. Laupacis A, Albers G, Dalen J, Dunn M, Feinberg W, Jacobson A. Antithrombotic therapy in atrial fibrillation. Chest 1995; 108( 4 Suppl): 352S–359S.
  5. Kopecky SL, Gersh BJ, McGoon MD, Whisnant JP, Holmes DR Jr, Ilstrup DM, et al. The natural history of lone atrial fibrillation: A population-based study over three decades. N Engl J Med 1987; 317: 669–674.
  6. Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: The Framingham study. Neurology 1978; 28: 973–977.
  7. Stern S, Altkorn D, Levinson W. Anticoagulation for chronic atrial fibrillation. JAMA 2000; 283: 2901–2903.
  8. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: A major contributor to stroke in the elderly—The Framingham Study. Arch Intern Med 1987; 147: 1561–1564.
  9. Halperin JL, Hart RG. Atrial fibrillation and stroke: New ideas, persisting dilemmas. Stroke 1988; 19: 937–941.
  10. Hart RG, Halperin JL. Atrial fibrillation and stroke: Concepts and controversies. Stroke 2001; 32: 803–808.
  11. Miller VT, Pearce LA, Feinberg WM, Rothrock JF, Anderson DC, Hart RG. Differential effect of aspirin versus warfarin on clinical stroke types in patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation Investigators. Neurology 1996; 46: 238–240.
  12. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: Stroke prevention in patients with nonvalvular atrial fibrillation—Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1998; 51: 671–673.
  13. Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996; 348: 633–638.
  14. Hart RG, Coull BM, Hart D. Early recurrent embolism associated with nonvalvular atrial fibrillation: A retrospective study. Stroke 1983; 14: 688–693.
  15. Sage JI, Van Uitert RL. Risk of recurrent stroke in patients with atrial fibrillation and non-valvular heart disease. Stroke 1983; 14: 537–540.
  16. Wolf PA, Kannel WB, McGee DL, Meeks SL, Bharucha NE, McNamara PM. Duration of atrial fibrillation and imminence of stroke: The Framingham Study. Stroke 1983; 14: 664–667.
  17. Loh E, Sutton MS, Wun CC, Rouleau JL, Flaker GC, Gottlieb SS, et al. Ventricular dysfunction and the risk of stroke after myocardial infarction. N Engl J Med 1997; 336: 251–257.
  18. Cerebral Embolism Task Force. Cardiogenic brain embolism. Arch Neurol 1986; 43: 71–84.
  19. Maggioni AP, Franzosi MG, Santoro E, White H, Van de Werf F, Tognoni G. The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment: Gruppo Italiano per lo Studio della Sopravivenza nell'Infarto Miocardico II (GISSI-2) and The International Study Group. N Engl J Med 1992; 327: 1–6.
  20. Pullicino PM, Halperin JL, Thompson JL. Stroke in patients with heart failure and reduced left ventricular ejection fraction. Neurology 2000; 54: 288–294.
  21. Kannel WB, Wolf PA, Verter J. Manifestations of coronary artery disease predisposing to stroke: The Framingham Study. JAMA 1983; 250: 2942–2946.
  22. Dries DL, Rosenberg YD, Waclawiw MA, Domanski MJ. Ejection fraction and risk of thromboembolic events in patients with systolic dysfunction and sinus rhythm: Evidence for gender differences in the studies of left ventricular dysfunction trials. J Am Coll Cardiol 1997; 29: 1074–1080.
  23. Sacco RL, Shi T, Zamanillo MC, Kargman DE. Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: The Northern Manhattan Stroke Study. Neurology 1994; 44: 626–634.
  24. Sauer CM. Recurrent embolic stroke and cocaine-related cardiomyopathy. Stroke 1991; 22: 1203–1205.
  25. Kelley RE, Pina I, Lee SC. Cerebral ischemia and mitral valve prolapse: Case-control study of associated factors. Stroke 1988; 19: 443–446.
  26. Jackson AC, Boughner DR, Barnett HJ. Mitral valve prolapse and cerebral ischemic events in young patients. Neurology 1984; 34: 784–787.
  27. Gilon D, Buonanno FS, Joffe MM, Leavitt M, Marshall JE, Kistler JP, et al. Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med 1999; 341: 8–13.
  28. Furlan AJ, Craciun AR, Salcedo EE, Mellino M. Risk of stroke in patients with mitral annulus calcification. Stroke 1984; 15: 801–803.
  29. Russell JW, Biller J, Hajduczok ZD, Jones MP, Kerber RE, Adams HP Jr. Ischemic cerebrovascular complications and risk factors in idiopathic hypertrophic subaortic stenosis. Stroke 1991; 22: 1143–1147.
  30. Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med 2001; 345: 1318–1330.
  31. Kanter MC, Hart RG. Neurologic complications of infective endocarditis. Neurology 1991; 41: 1015–1020.
  32. Fairfax AJ, Lambert CD, Leatham A. Systemic embolism in chronic sinoatrial disorder. N Engl J Med 1976; 295: 190–192.
  33. Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318: 1148–1152.
  34. Petty GW, Khandheria BK, Chu CP, Sicks JD, Whisnant JP. Patent foramen ovale in patients with cerebral infarction: A transesophageal echocardiographic study. Arch Neurol 1997; 54: 819–822.
  35. Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992; 117: 461–465.
  36. Ranoux D, Cohen A, Cabanes L, Amarenco P, Bousser MG, Mas JL. Patent foramen ovale: Is stroke due to paradoxical embolism? Stroke 1993; 24: 31–34.
  37. Cabanes L, Mas JL, Cohen A, Amarenco P, Cabanes PA, Oubary P, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age: A study using transesophageal echocardiography. Stroke 1993; 24: 1865–1873.
  38. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: A meta-analysis of case-control studies. Neurology 2000; 55: 1172–1179.
  39. Ramirez-Lassepas M, Cipolle RJ, Bjork RJ, Kowitz J, Snyder BD, Weber JC, et al. Can embolic stroke be diagnosed on the basis of neurologic clinical criteria? Arch Neurol 1987; 44: 87–89.
  40. Kittner SJ, Sharkness CM, Price TR, Plotnick GD, Dambrosia JM, Wolf PA, et al. Infarcts with a cardiac source of embolism in the NINCDS Stroke Data Bank: Historical features. Neurology 1990; 40: 281–284.
  41. Kittner SJ, Sharkness CM, Sloan MA, Price TR, Dambrosia JM, Tuhrim S, et al. Infarcts with a cardiac source of embolism in the NINDS Stroke Data Bank: Neurologic examination. Neurology 1992; 42: 299–302.
  42. Mohr JP, Barnett HJM. Classification of ischemic stroke, in Barnett HJM, Stein BM, Mohr JP, Yatsu FM (eds): Stroke: Pathophysiology, Diagnosis & Management. New York, Churchill Livingstone, 1986, pp 281–291.
  43. Minematsu K, Yamaguchi T, Omae T. “Spectacular shrinking deficit”: Rapid recovery from a major hemispheric syndrome by migration of an embolus. Neurology 1992; 42: 157–162.
  44. Weisberg LA. Nonseptic cardiogenic cerebral embolic stroke: Clinical-CT correlations. Neurology 1985; 35: 896–899.
  45. Van Horn G, Hawes A. Global aphasia without hemiparesis: A sign of embolic encephalopathy. Neurology 1982; 32: 403–406.
  46. Weiller C, Ringelstein EB, Reiche W, Thron A, Buell U. The large striatocapsular infarct: A clinical and pathophysiological entity. Arch Neurol 1990; 47: 1085–1091.
  47. Ghika J, Bogousslavsky J, Regli F. Infarcts in the territory of the deep perforators from the carotid system. Neurology 1989; 39: 507–512.
  48. Bogousslavsky J, Van Melle G, Regli F. Middle cerebral artery pial territory infarcts: A study of the Lausanne Stroke Registry. Ann Neurol 1989; 25: 555–560.
  49. Bogousslavsky J, Regli F. Anterior cerebral artery territory infarction in the Lausanne Stroke Registry: Clinical and etiologic patterns. Arch Neurol 1990; 47: 144–150.
  50. Bassetti C, Bogousslavsky J, Barth A, Regli F. Isolated infarcts of the pons. Neurology 1996; 46: 165–175.
  51. Amarenco P, Roullet E, Goujon C, Cheron F, Hauw JJ, Bousser MG. Infarction in the anterior rostral cerebellum (the territory of the lateral branch of the superior cerebellar artery). Neurology 1991; 41: 253–258.
  52. Lhermitte F, Gautier JC, Derouesne C. Nature of occlusions of the middle cerebral artery. Neurology 1970; 20: 82–88.
  53. Kieffer SA, Alter M, Resch JA, Amplatz K. Serial angiographic evaluation of cerebrovascular disease. Acta Radiol Diagn (Stockh) 1969; 9: 352–360.
  54. Babikian VL, Feldmann E, Wechsler LR, Newell DW, Gomez CR, Bogdahn U, et al. Transcranial Doppler ultrasonography: Year 2000 update. J Neuroimaging 2000; 10: 101–115.
  55. Sliwka U, Georgiadis D. Clinical correlations of Doppler microembolic signals in patients with prosthetic cardiac valves: Analysis of 580 cases. Stroke 1998; 29: 140–143.
  56. Tegeler CH, Downes TR. Cardiac imaging in stroke. Stroke 1991; 22: 1206–1211.
  57. Bitar SR, Kichura GM, Labovitz AJ. Cardiac sources of emboli: The role of transesophageal echocardiography. Resid Staff Physician 1998; 44: 53–64.
  58. Cujec B, Polasek P, Voll C, Shuaib A. Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients. Stroke 1991; 22: 727–733.
  59. Pop G, Sutherland GR, Koudstaal PJ, Sit TW, de Jong G, Roelandt JR. Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks. Stroke 1990; 21: 560–565.
  60. Albers GW, Comess KA, DeRook FA, Bracci P, Atwood JE, Bolger A, et al. Transesophageal echocardiographic findings in stroke subtypes. Stroke 1994; 25: 23–28.
  61. Chimowitz MI, DeGeorgia MA, Poole RM, Hepner A, Armstrong WM. Left atrial spontaneous echo contrast is highly associated with previous stroke in patients with atrial fibrillation or mitral stenosis. Stroke 1993; 24: 1015–1019.
  62. Mounier-Vehier F, Leys D, Rondepierre P, Godefroy O, Pruvo JP. Silent infarcts in patients with ischemic stroke are related to age and size of the left atrium. Stroke 1993; 24: 1347–1351.
  63. Jonas S, Klein I, Dimant J. Importance of Holter monitoring in patients with periodic cerebral symptoms. Ann Neurol 1977; 1: 470–474.
  64. Come PC, Riley MF, Bivas NK. Roles of echocardiography and arrhythmia monitoring in the evaluation of patients with suspected systemic embolism. Ann Neurol 1983; 13: 527–531.
  65. Anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis (ASPECT) Research Group. Effect of long-term oral anticoagulant treatment on mortality and cardiovascular morbidity after myocardial infarction. Lancet 1994; 343: 499–503.
  66. Smith P, Arnesen H, Holme I. The effect of warfarin on mortality and reinfarction after myocardial infarction. N Engl J Med 1990; 323: 147–152.
  67. Azar AJ, Koudstaal PJ, Wintzen AR, van Bergen PF, Jonker JJ, Deckers JW. Risk of stroke during long-term anticoagulant therapy in patients after myocardial infarction. Ann Neurol 1996; 39: 301–307.
  68. Yamaguchi T, Minematsu K, Moriyasu H, Yasaka M, Miyashita K, Naritomi H, et al.; Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study Group. Optimal intensity of warfarin therapy for secondary prevention of stroke in patients with nonvalvular atrial fibrillation: A multicenter, prospective, randomized trial. Stroke 2000; 31: 817–821.
  69. Stamou SC, Hill PC, Sample GA, Snider E, Pfister AJ, Lowery RC, et al. Prevention of atrial fibrillation after cardiac surgery: The significance of postoperative oral amiodarone. Chest 2001; 120: 1936–1941.
  70. Antiplatelet Trialists’ Collaboration. Collaborative overview of randomised trials of antiplatelet therapy: Part I—Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308: 81–106.Antiplatelet Trialists’ Collaboration.
  71. Cannegieter SC, Rosendaal FR, Wintzen AR, van der Meer FJ, Vandenbroucke JP, Briet E. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med 1995; 333: 11–17.
  72. Turpie AG, Gent M, Laupacis A, Latour Y, Gunstensen J, Basile F, et al. A comparis on of aspirin with placebo in patients treated with warfarin after heart-valve replacement. N Engl J Med 1993; 329: 524–529.
  73. Mohr JP, Thompson JL, Lazar RM, Levin B, Sacco RL, Furie KL, et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345: 1444–1451.
  74. Devuyst G, Bogousslavsky J, Ruchat P, Jeanrenaud X, Despland PA, Regli F, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: A prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996; 47: 1162–1166.
  75. Wahl A, Meier B, Haxel B, Nedeltchev K, Arnold M, Eicher E, et al. Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism. Neurology 2001; 57: 1330–1332.
  76. Hart RG, Boop BS, Anderson DC. Oral anticoagulants and intracranial hemorrhage: Facts and hypotheses. Stroke 1995; 26: 1471–1477.