Cardiogenic Embolism Research Articles

Pure midbrain infarction

To describe the clinical features, MRI findings, and the pathogenesis of the pure midbrain infarction. Forty patients with infarcts limited to the midbrain were studied. MRI and angiography (mostly MR angiography) were performed in all patients. Clinical manifestations included gait ataxia in 27 (68%) patients, dysarthria in 22 (55%), limb ataxia in 20 (50%), sensory symptoms in 17 (43%), third nerve palsy in 14 (35%), definitive limb weakness (< or =IV/V) in nine (23%), and internuclear ophthalmoplegia in five (13%). According to MRI findings, the lesions were categorized into four groups. The anteromedial group (n = 18) was characterized by oculomotor disturbances (89%), ataxia (89%, bilateral in 17%), and sensory changes (39%) usually restricted to the perioral and hand areas. Lesions restricted to the subcortical area (n = 10) were usually related to small vessel disease (SVD) (78%), whereas those involving the medial surface (n = 8) were caused by large vessel disease (LVD) (78%). The anterolateral group (n = 11) was characterized by ataxia (70%) and definitive hemiparesis (30%) usually caused by LVD (82%). The combined group (n = 6) had frequent oculomotor disturbances (83%), definitive hemiparesis (67%), and ataxia (50%) and was usually associated with LVD (67%). The lateral group (n = 2) was characterized by prominent sensory symptoms. The prognosis was generally good except for one patient with a bilateral lesion. Clinical-radiologic correlation study yields four distinct subgroups: anteromedial, anterolateral, combined, and lateral. Large vessel disease and small vessel disease are usual pathogenic mechanisms, whereas cardiogenic embolism is rare.

増加する心原性脳塞栓症，その予防と治療

増加する心原性脳塞栓症，その予防と治療

Stroke in Korea

Stroke is the second most important cause of death, followed by cancer, in Korea. There has been no evidence of decrease in stroke mortality until recently. Although intracerebral hemorrhage (ICH) outnumbered cerebral infarction (CI) before 1980, recent large hospital registry studies reported that the proportion of ICH is approximately 20%. As compared with the western population, small arterial disease is relatively common and cardiogenic embolism is uncommon. The middle cerebral artery is the most common site of atherosclerosis in patients with ischemic stroke. Hypertension is present in 60–70%, and diabetes mellitus in 25–30% among admitted stroke patients. Increased intake of fat or animal protein and increased incidence of diabetes mellitus appear to explain the decrease in ICH in our country. The stroke knowledge of the general population is deviated from scientific facts, possibly due to the strong influence of alternative medicine. Moreover, due to an increase in life expectancy and decrease in birth rate, the proportion of aged population increases rapidly. Therefore, stroke will remain as a major social burden in Korea. Nationwide efforts are required for risk factor reduction, stroke education and the proper care of stroke patients.

Le syndrome de la main étrangère par infarctus du corps calleux: À propos d’un cas

A 64-year-old man with alien hand syndrome presented with abnormal feelings in the left upper limb, associated with an intermanual conflict. There were no clinical signs of frontal or parietal apraxia. This syndrome was induced by an infarct localized in the right posterior area of the splenium, subsequent to a cardiogenic embolus. This observation enlightens the rising syndrome of callosal type alien syndrome due to a posterior callosal infarct.

Diagnose und Differenzialdiagnose der zerebralen Vaskulitis

Over a 5-year period, we investigated 77 consecutive patients (36 males, 41 females, mean age 40.9 years) referred to our hospital with the diagnosis of CNS vasculitis. Extensive workup including MRI, echocardiography, laboratory tests, angiography ( n=53), and biopsies at appropriate sites ( n=26) was performed based on individual history and symptoms. Prominent symptoms were stroke ( n=61), encephalopathy ( n=14), and headaches ( n=2). Vasculitis was finally diagnosed in 13 patients (17%) including isolated angiitis of the CNS ( n=3), giant cell arteritis ( n=4), and septic arteritis ( n=3). Thirty-two patients (42%) presented noninflammatory vasculopathies including moyamoya ( n=6), Sneddon's syndrome ( n=5), dissection ( n=4), CADASIL ( n=2), and collagen vascular disease ( n=9). Coagulopathy was found in 14 cases (18%) including antiphospholipid syndrome ( n=8) and APC resistance ( n=4). Other causes were cardiogenic embolism ( n=8), multiple sclerosis ( n=5), and migraine stroke ( n=3). Only a minority of patients referred for evaluation of suspected CNS vasculitis actually present with inflammatory vascular disease. Main differential diagnosis includes noninflammatory vasculopathies, coagulopathies, and cardiac disease. Since septic processes may be responsible for the symptoms, "blind" treatment with immunosuppressive agents should be strictly avoided.

減圧開頭術後の頭蓋形成術により神経症状の改善とリハビリテーションの促進を認めた一例

Decompressive craniectomy is occasionally performed for salvage in the acute phase of patients with increasing intracranial pressure. However, it causes various disorders in the chronic state, known as a “syndrome of the sinking skin flap” or “symptoms of the trephined” (ST). Atmospheric pressure on the brain, cerebral blood flow changes, or cerebrospinal fluid hydrodynamic changes have been postulated as possible reasons for these disorders, both of which can be improved by cranioplasty. We now report a case of facilitating rehabilitation, with improved ST, cognitive and motor functions, and activities of daily living (ADL) after cranioplasty. The patient was a 47-year-old man who underwent decompressive craniectomy for cerebral herniation following cardiogenic cerebral embolism. He suffered from persistent left hemiparesis, left spatial neglect and ST (headache and fatigability). His cognitive and motor functions had not been recovered through rehabilitation before the cranioplasty was performed. ST also prevented him from continuing rehabilitation. However, facilitating rehabilitation, with improved ST, cognitive and motor functions, and ADL was significantly shown after cranioplasty. These functional recoveries were postulated to correlate to an improved cerebral blood flow following cranioplasty, which was evaluated by 123I-IMP SPECT. The present case suggests that cranioplasty would be a significant therapeutic strategy for facilitating rehabilitation and improving functional recovery in patients following decompressive craniectomy.

Poster 201: Stroke rehabilitation in a patient with a cardiac pacemaker for chronic atrial fibrillation: a case report.

Setting: Inpatient stroke rehabilitation hospital. Patient: A 60-year-old man with an artificial pacemaker suffered from cardiogenic cerebral embolism. Case Description: The patient received a pacemaker (ventricular demand inhibited pacemaker with rate-adaptive mode) implantation for chronic bradycardic atrial fibrillation. The pacemaker relieved his congestive heart failure and episodes of Adams-Stokes syndrome. 5 years after the implantation, he suffered a hemorrhagic cerebral embolism, which led to severe disability. He had flaccid left hemiplegia and severe disuse syndrome after prolonged (>4mo) bedrest. He could not sit up and could tilt his head up for less than 2 minutes because of mortal orthostatic intolerance and hypotension and a lack of physiologic Bainbridge reflex. Low endurance of exercise with absolute chronotropic incompetence arrested the rehabilitation. By modulating programmable pacemaker function every 2 weeks, we started to rehabilitate the patient. The programmable function was an optimal or lower rate and a rate-adaptive pacing rate, which included upper sensor rate, activity threshold, reaction time, and recovery time, in response to physical motion and activity. Assessment/Results: Periodic programming of the pacemaker function allowed him to continue rehabilitation. Specifically, we enabled its ability to vary the pacing rate in response to increased physical activity in accordance with progressive rehabilitation programs. After 4 months of rehabilitation, he could sit in a wheelchair for >3 hours without significant orthostatic hypotension and he performed activities of daily living with mild assistance. Discussion: This case emphasizes the importance of examining the function of a previously implanted pacemaker. In accord with varying rehabilitation programs and gradual improvement in physical activities, periodic adjustment of a programmable pacemaker can lead to a better functional outcome. Conclusion: Rate-adaptive pacemaker mode benefited this stroke patient, who had severe orthostatic intolerance and chronotropic incompetence, that is, flaccid hemiplegia and bradycardic atrial fibrillation.

Endothelial and platelet activation in acute ischemic stroke and its etiological subtypes.

Activation of endothelial cells and platelets is an important mediator of atherothrombosis. Markers of endothelial cell and platelet activation such as soluble adhesion molecules can be measured in plasma. We hypothesized that patients with acute ischemic stroke would have increased blood concentrations of soluble E-selectin and von Willebrand factor (vWF), primarily reflecting activation of endothelial cells, and increased concentrations of soluble P-selectin and platelet-derived microvesicles (PDM), primarily reflecting activation of platelets, compared with healthy controls. We also hypothesized that these markers would be differentially elevated in ischemic stroke caused by large- and small-artery atherothrombosis compared with cardiogenic embolism. We conducted a case-control study of 200 hospital-referred cases of first-ever ischemic stroke and 205 randomly selected community controls stratified by age, sex, and postal code. Using established criteria, we classified cases of stroke by etiological subtype in a blinded fashion. The prevalence of vascular risk factors and blood concentrations of E-selectin, P-selectin, vWF antigen, and PDM were determined in stroke cases within 7 days and at 3 to 6 months after stroke and in controls. Mean blood concentrations of soluble E-selectin, P-selectin, and PDM within 7 days of stroke onset were all significantly higher in cases compared with controls. At 3 to 6 months after stroke, the mean blood concentrations of E-selectin and P-selectin fell significantly below that of controls, and PDM concentrations remained elevated. There was a strong, graded, and independent (of age, sex, and vascular risk factors) association between increasing blood concentrations of E-selectin during the acute phase and all etiological subtypes of ischemic stroke, particularly ischemic stroke caused by large-artery atherothrombosis. There was also a significant, graded, and independent association between increasing blood concentrations of vWF during the acute phase and ischemic stroke caused by large-artery atherothrombosis. We have demonstrated significant associations between acute elevation of blood markers of endothelial cell and platelet activation and ischemic stroke and between acute elevation of blood markers of endothelial cell activation and ischemic stroke caused by large-artery atherothrombosis. Persistent elevated blood concentrations of PDM may be a marker of increased risk of ischemic stroke.

Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients.

Although there have been attempts to make clinical-MRI correlation in patients with lateral medullary infarction (LMI), studies with a large number of patients are unavailable. In this study, clinical features, MRI findings and angiogram results of 130 acute, consecutive patients with pure LMI were studied and correlated. MRI-identified lesions were classified rostro-caudally as rostral, middle and caudal, and horizontally as typical, ventral, large, lateral and dorsal. The distribution of horizontal subtypes was significantly different (P <0.001) among three rostro-caudal lesions in that rostral lesions tend to be ventral types and caudal lesions are lateral types. Patients with rostrally located lesions had dysphagia, facial paresis (P < 0.01, each) and dysarthria (P < 0.05) significantly more often, and severe gait ataxia and headache (P < 0.05, each) less often than those with caudal lesions. The frequencies of dysphagia (P < 0.01), dysarthria (P < 0.01) and bilateral trigeminal sensory pattern (P < 0.05) were significantly different among horizontal subtypes in that these symptoms were frequent in patients with "large type" as compared with those with lateral type lesions. Angiograms performed in 123 patients showed vertebral artery (VA) disease in 67% and posterior inferior cerebellar artery (PICA) disease in 10%. The presumed pathogenetic mechanisms included large vessel infarction in 50%, arterial dissection in 15%, small vessel infarction in 13% and cardiac embolism in 5%. Dissection occurred more often in patients with caudal (versus rostral) lesions (P < 0.01), whereas dorsal type infarcts (versus other types) were related more often to cardiogenic embolism and normal angiogram findings (P < 0.05, each). Patients with isolated PICA disease (versus those with VA disease) more often had cardiogenic embolism (P < 0.05) and less often had dissection (P < 0.01). It is concluded that rostro-caudal and horizontal classification of MRI helps us to understand the clinical and, partly, the aetiopathogenetic aspect of the heterogeneous LMI syndrome.

LONG-TERM EFFECTS OF STROKE

LONG‐TERM EFFECTS OF STROKE Edited by Julien Bogousslavsky 2002. Monticello, NY: Marcel Dekker, Inc. Price $175. pp. 344. ISBN 0–8247–0624–2 A serious shortcoming in current neurological practice is the post‐acute care we are able to provide to patients with stroke. Whereas tremendous research has recently changed the ways in which neurologists view acute ischaemic stroke, with a number of thrombolytic and neuroprotective approaches now available and others under investigation, little attention is paid to patients following maximal acute care. Progress in the intensive care of such patients in specialised critical care neurology units has also improved outcomes, as has good aetiological diagnosis (e.g. cardiogenic embolism, carotid stenosis) and secondary prevention. However, after discharge from the intensive care unit and the inpatient neurology ward, with maximal acute treatment and perhaps secondary prevention tailored to a specific aetiological diagnosis, patients are sent off to the care of physiatrists and therapists for various re‐educational programs that are not motivated by the goals of brain recovery or purposeful neural remodelling. Furthermore, practising neurologists pay little attention to patients at this stage of stroke recovery, despite the fact that these patients have a serious neurological illness (they have the same illness as before, just as do patients with amyotrophic lateral sclerosis or Alzheimer’s disease or Parkinson’s disease), and the fact that they have marked neurological signs and symptoms. A particular irony of improved acute stroke care is the increased survival of patients with such problems. In advanced countries, stroke is the primary cause of disability in adults. A recent book, targeted at clinical neurologists, aims to reduce this knowledge gap regarding the long‐term effects of stroke. This book, edited by the well‐known stroke neurologist Julien Bogousslavsky of Lausanne, contains twelve chapters focusing on various aspects of assessment and prognosis of stroke sequelae, including several chapters …

Cardioembolic stroke: an update.

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, step-wise 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.

C-reactive protein in ischemic stroke and its etiologic subtypes

The possible role of C-reactive protein (CRP) in the etiology and prognosis of ischemic stroke remains to be clearly defined. The purpose of this study was to determine whether CRP levels are elevated in patients with stroke, whether they remain persistently elevated, and whether CRP levels are higher in patients with etiologic subtypes of stroke caused by large or small artery disease (“atherogenic hypothesis”) or whether they may be higher in patients with more extensive cerebral infarction caused by large artery or cardiogenic embolism (“inflammatory hypothesis”). We conducted a case-control study of 199 hospital cases with a first-ever ischemic stroke and 202 randomly selected community controls. Cases of stroke were classified by etiologic subtype and the prevalence of conventional vascular risk factors and CRP levels were determined in cases and controls. Blood levels of CRP measured within 7 days of acute stroke were significantly higher in cases compared with controls (8.50 vs. 2.18 mg/L, P <.0001) and remained elevated in stroke survivors at 3 to 6 months of follow-up (3.35 vs. 2.18 mg/L, P =.003) although levels were significantly lower compared with the first 7 days (3.35 vs. 8.50 mg/L, P <.001-.003). Compared with the lowest quartile of CRP, the upper 3 quartiles were associated with an adjusted odds ratio (OR) of ischemic stroke of 1.9 (95% CI: 1.0-3.8) for the second quartile, 5.8 (95% CI: 2.9-11.4) for the third quartile, and 16.9 (95% CI: 7.9-36.1) for the fourth quartile (P for trend <.0001). Comparing the upper with the lower quartile, the strongest association was with etiologic stroke subtypes caused by large artery disease (OR 52.5; 95% CI: 13.4-205) and embolism from the heart (OR 56.1; 95% CI: 11.3-278), with a much weaker association with small artery disease (OR 2.4; 95% CI: 0.8-6.0). The mean Oxford Handicap Scale score was lowest in small artery, intermediate in large artery and highest in cardioembolic stroke (2.8 vs. 3.1 vs. 3.6, respectively; P =.001) while the mean Barthel Index was highest in small artery, intermediate in large artery, and lowest in cardioembolic stroke (13.5 vs. 11.5 vs. 8.6, respectively; P =.002). Furthermore, there was a significant correlation between CRP levels during the first 7 days and stroke severity, as measured by the Oxford Handicap Scale score (P =.03) and Barthel index (P =.001). We conclude that there is a strong, independent relationship between elevated blood levels of CRP and ischemic stroke, particularly because of more severe strokes caused by large artery disease and embolism from the heart, which remains evident over the long term. These results are consistent with the inflammatory marker hypothesis of CRP as a marker of the extent of ischemic cerebral injury and its complications. Copyright © 2003 by National Stroke Association.

Ischaemic Cerebrovascular Events in HIV Infection

Several case reports and series described ischaemic cerebrovascular events in HIV infection. However, the exact prevalence and the clinical features of these events are unknown. We performed a cohort study on 772 consecutive HIV infected patients and evaluated the rate of transient ischaemic attacks (TIA) and of completed stroke. A total prevalence of 1.9% for TIA (0.8%) and stroke (1.2%) was calculated resulting in an annual incidence rate of 216 per 100,000. The prevalence was highest in the later stages of the infection. Stroke patients had a poorer immunological state than the TIA and the cohort patients. Probable (n = 3) and possible (n = 2) vasculitis and cardiogenic embolism (n = 2) could be detected as aetiology, the remaining patients had a cryptogenic event. Our data suggest that ischaemic cerebrovascular events are more common in HIV infected patients than in the general population and that a part of these events might be caused by HIV associated vasculitis or vasculopathy.

Antithrombotic Therapy for Ischemic Stroke

Ischemic stroke is among the principal causes of death and disability in the elderly. Although control of blood pressure, decreased cigarette smoking, and modified dietary habits are among important reasons for stroke decline, the use of antithrombotic therapy, rigorously prescribed. Several antiplatelet agents are approved to reduce the risk of recurrent stroke. Aspirin is the best-studied and most widely used antiplatelet agent for stroke prevention; it provides approximately 15% to 25% relatively risk reduction for secondary prevention of stroke or the major vascular death. Combining 2 antiplatelet agents with different mechanism of action was demonstrated to provide a substantial increase in efficacy in several studies. Anticoagulation should be considered first with potential cardiac sources of embolism. Heparin reduces development of erythrocyte-fibrin thrombi that form in regions of vascular stasis especially within the heart, in severely stenosed arteries sometimes engrafted on white thrombi, in acute arterial occlusion. Heparin should not be indiscriminately given to all acute brain ischemia patients, but may contribute to treatment of large artery occlusion and severe stenosis, cardiogenic embolism with a high acute recurrence risk, and dural sinus and cerebral venous thromobosis.

院内診療情報データベースとしての脳卒中データベースの構築と活用

The Japanese Standard Stroke Registry Study (JSSRS) group (chief investigator: S. Kobayashi) developed new software for its acute stroke database. In our institute, this software was applied within a medical records database system that functioned in a local area network (LAN). From January 1, 2000, to January 31, 2002, 2,068 stroke patients were registered in the JSSRS database, and 1,731 patients' data were confirmed. About 70 patients were registered monthly, and cumulative cases with unconfirmed data were not increased but changed up to a mean 75 cases per month. The third section (medical record manager) should control continuous registration of stroke patients and confirmation of input data. The JSSRS database was useful for confirming classification of disease, patients' history, and clinical course for other forms in the medical records database. According to the confirmed stroke database, clinical categories of acute brain infarction were classified into cardiogenic embolism in 28.0%, atherothrombotic stroke in 27.4%, and lacunar stroke in 35.3%. Time from stroke onset to admission was within 3 hours in 36%, and within 6 hours in 48%. Accuracy of the stroke database could improve after the introduction of JSSRS database software. An acute stroke databank based on the JSSRS database could be valuable for establishing evidenced based medicine (EBM) for stroke management and planning of new strategy for acute stroke. In addition, input data for the JSSRS database is useful for confirming and establishing a medical records database.

Association between Atrial Septal Aneurysm and Patent Foramen ovale in Young Patients with Recent Stroke and Normal Carotid Arteries

Background: Atrial septal aneurysm (ASA) has been considered a potential source of cardiogenic embolism for many years. The ASA Multicenter Italian (ASA-MI) Study evaluated the prevalence and characteristics of ASA in patients with stroke and normal carotid arteries compared with control patients without stroke. The purpose of the present study was to evaluate the frequency of ASA and the association with patent foramen ovale (PFO) in the subgroup of younger patients (aged less than 55 years) included in the ASA-MI Study. Methods: The ASA-MI Study included 606 patients, enrolled between November 1990 and December 1996: 245 patients with a previous cerebral embolic attack and normal carotid study and a control group of 316 patients. They all underwent transthoracic and transesophageal echocardiography. The subgroup of younger patients aged less than 55 years included 90 patients (61 men and 29 women of mean age 49 ± 5 years) (group AY). This group was evaluated and compared with an age- and sex-matched control population (61 men; of mean age 48 ± 6 years) (group BY). Results: The prevalence of ASA was 48.8% (95% confidence interval 40–61) in group AY and 22.2% in the group BY (95% confidence interval 18–33) (χ² = 5.968; p = 0.01). Morphological features were similar in the 2 groups of patients. ASA involved the entire septum in 52% of patients of group AY, and in 47.2% of group BY. The prevalence of PFO was 58.8% (95% confidence interval 43–62) in group AY and 28.8% in group BY (95% confidence interval 17–35) (χ² = 5.811; p = 0.01). A strong association was found between ASA and PFO. Of the 90 younger patients with stroke, 39 of 44 (88.6%) with ASA also had PFO, compared with 14 of 46 (30.4%) without ASA (χ² = 7.370; p = 0.007). Conclusion: We found that ASA and PFO were independent predictive factors for stroke in younger patients with stroke and normal carotid arteries and that the association between ASA and PFO bore an increased odds risk.

Massive cerebral infarctions in main cerebral arteries.

This study was designed to investigate the outcomes in patients with massive cerebral infarction, and to determine the risk factors associated with worse outcomes in the patients with massive cerebral infarction. Twenty-seven patients with acute massive cerebral infarction were hospitalized in our institution. These 10 men and 17 women had an average age of 77.8 years (range, 42 to 97 years). Some patients had multiple infarctions. Thirteen patients had infarctions of the middle cerebral artery, 12 patients had internal carotid artery infarctions, 6 patients had anterior cerebral artery infarctions, and 3 patients had vertebro-basilar artery infarctions. The causes of the main cerebral arterial infarctions were cardiac embolism in 22 patients, atherothrombosis in 4 patients, and unknown in one patient. Fifteen (55%) of the 27 patients died from transtentorial herniation caused by massive cerebral infarction or from general complications. Of the 12 patients (45%) who survived, 8 patients were moderately disabled, 1 patient was severely disabled, and 3 patients existed in a vegetative state. Worse outcomes were more frequent in younger patients with internal carotid artery infarctions related to cardiogenic embolism.

Hypertension and clusters of risk factors in different stroke subtypes (an analysis of Hungarian patients via Budapest Stroke Data Bank).

Our aim was to determine the frequency of hypertension in the Hungarian stroke population, and to compare it with the data of other stroke registries. We attempted to find characteristic cluster-like associations between hypertension and another nine risk factors in different stroke subtypes and to ascertain the role of hypertension in leukoaraiosis, in early mortality, in stroke recurrence and in the case fatality rate up to 10 years. Risk factor profile of 500 unselected acute stroke cases of the Budapest Stroke Data Bank were analysed. We compared data of hypertensive stroke patients to those of unaffected ones. LIFEREG procedure of the SAS software package, cluster analysis, logistic regression, Pearson's correlation coefficient and Student's t-test were used as statistical methods. Hypertension was documented in 75% of the patients. The largest clusters were formed by the following groups: atherosclerotic stroke, hypertension with ischaemic heart disease; lacunar stroke and haemorrhage, hypertension with elevated serum cholesterol, cardiogenic embolism, ischaemic heart disease with atrial fibrillation. The case fatality rate was significantly higher in the group of hypertensive patients with ischaemic heart disease relative to those without it during the 10 years follow-up period. In the leukoaraiosis-group, systolic blood pressure was significantly higher than in the non-leukoaraiosis group. The rate of hypertension was higher than in other stroke registries. Hypertension appears to be the most frequent risk factor in stroke patients but case fatality rate is determined by presence or absence of ischaemic heart disease.

Patent Foramen Ovale and Recurrent Stroke

Clinical management of patients with acute stroke and the approach used for secondary prevention depends upon clarification of pathogenesis. Although most strokes are a consequence of cerebrovascular disease, ≈15% to 20% of ischemic (nonhemorrhagic) strokes have been attributed to cardiogenic embolism.1 In practice, determination of the stroke mechanism is fraught with uncertainty, particularly when the possibility of thromboembolism emanating from atherosclerotic lesions in the aorta or cervical arteries is considered. When cardiogenic embolism is suspected, cardiac ultrasound is the principal method used to identify the potential source. The finding of left atrial enlargement has been shown to bear a significant relationship to the risk of stroke in a multivariate analysis of population-based data from the Framingham Heart Study2. The most frequent confounding variable is atrial fibrillation, occurring in >2 million patients in North America and in over half of all patients with cardiogenic embolism. Criteria for selection of patients with acute ischemic stroke for transesophageal echocardiography (TEE) to search for a potential cardiac source of embolism are controversial, particularly because cardiogenic embolism is often an uncertain diagnosis that is inferred merely on the basis of the finding of potential cardiac source. Even after extensive investigation, ≈40% of ischemic stroke patients have no clearly identifiable pathogenesis (cryptogenic stroke).3 In one study, 62% of patients younger than 60 years of age without an obvious source of cerebral infarction and 23% of those with arterial lesions had potential sources of cardiogenic embolism identified by TEE ( P =0.0007 for the difference).4 See p 2625 Among the cardiac anomalies detected by TEE that have been implicated as risk factors for stroke are patent foramen ovale (PFO) and atrial septal aneurysm (ASA).5,6⇓ The foramen ovale, a remnant of the fetal circulation, remains patent through adulthood in ≈1 in 4 …

HEART–BRAIN RELATIONSHIP: ATRIAL FIBRILLATION AND STROKE

In Western countries, stroke is the second cause of death and the first cause of disability. Cardiogenic embolism is the most frequent cause of recurrent strokes. Nonvalvular atrial fibrillation (NVAF) is the most common source of cardiogenic embolism, with a stroke recurrence rate of about 10% per year. Randomised trials have shown that anticoagulation and aspirin are safe in patients with NVAF, leading to 70% and 22% risk reduction of strokes, respectively. Many potential candidates to anticoagulation fail to receive the appropriate treatment for primary and secondary prevention. More efforts should be spent to increase the number of treated subjects, in order to achieve effective prevention on stroke.