Potential Cardiac Source Of Embolism Research Articles

Occurrence of Simultaneous Left Ventricular Mural Thrombus and a Fresh Floating Thrombus in the Left Common Carotid Artery

Stroke is the third-leading cause of death in the United States after cardiovascular disease and cancer. It remains the leading cause of serious long-term disability in the United States. Mechanisms of ischemic stroke include embolism, decreased perfusion, and thrombosis. Cardio-embolism, defined as a source of embolus originating from the heart, may account for an estimated 20% of ischemic strokes. Intracavity thrombus from wall motion abnormalities, especially in the first 2 weeks after anterior myocardial infarction, has been described as a potential cardiac source of emboli. The finding of an LV apical thrombus detected by transthoracic echocardiography as a possible embolic source and the simultaneous discovery of a fresh floating thrombus in the left common carotid artery as detected by duplex ultrasonography are rare findings. We report a case of a 77-year-old man with both of these findings with signs and symptoms of a myocardial infarction with late presentation. Trans-thoracic echocardiography revealed an echo density consistent with mural thrombus that was located adjacent to the severely hypokinetic left ventricular apical wall. A carotid duplex revealed a totally occluded left common carotid artery with an echo density suggestive of thrombus. Atheromatous deposits in the extra-cranial carotid arteries may cause localized thrombosis. However, a free-floating thrombus in the carotid artery could be a result of a cardiac source of embolism. Cardioembolic syndromes typically presents as emergencies. Prompt diagnosis and urgent optimal medical and surgical treatments are warranted because these patients have an increased risk for distal embolization and vessel occlusion that lead to severe disability or death.

Stroke mechanism in patients with non‐valvular atrial fibrillation according to the CHADS2 and CHA2DS2‐VASc scores

The CHADS(2) and CHA(2) DS(2) -VASc scores are useful to stratify embolic risks in patients with non-valvular atrial fibrillation (NVAF) and to identify patients eligible for anticoagulation. Although the risk of stoke increases in patients with higher CHADS(2) or CHA(2) DS(2) -VASc scores, it is uncertain why the stroke rate increases in them. Concomitant potential cardiac sources of embolism (PCSE) may be more frequent in patients with higher CHADS(2) or CHA(2) DS(2) -VASc scores because stroke risks increase when concomitant PCSE is present in Atrial fibrillation (AF). On the other hand, atherothrombosis may be the cause when considering that most components of the CHADS(2) and CHA(2) DS(2) -VASc scores are risk factors for atherosclerosis. Amongst 5493 stroke patients who were prospectively registered with the stroke registry for 11years, 860 consecutive patients with NVAF were included for this study. We investigated the mechanisms of stroke according to the CHADS(2) /CHA(2) DS(2) -VASc score in stroke patients with NVAF. Amongst 860 patients, concomitant PCSE were found in 334 patients (38.8%). The number of PCSE increased as the CHADS(2) /CHA(2) DS(2) -VASc score increased (P<0.001). Of individual PCSE, akinetic left ventricular segment, hypokinetic left ventricular segment and myocardial infarction <4weeks were associated with the CHADS(2) /CHA(2) DS(2) -VASc score. The presence of possible atherothrombotic mechanism, in addition to AF, was suggested in 27.3%. The proportion of patients with concomitant presence of possible atherothrombosis was increased as the CHADS(2) /CHA(2) DS(2) -VASc score increased (P<0.001). Increased frequency of concomitant PCSE and that of the atherothrombotic mechanism may explain the high risk of stroke in patients with higher CHADS(2) /CHA(2) DS(2) -VASc score.

Determinants of Infarction Patterns in Cardioembolic Stroke

Background: Embolic infarctions from the heart are known to cause multiple scattered infarct lesions as well as single, large territorial infarctions. However, it remains unknown which factors contribute to these different infarction patterns in patients with potential cardiac sources of embolism (PCSE). Methods: We examined 388 ischemic stroke patients with a high-risk PCSE using diffusion-weighted imaging. Infarction patterns were categorized into a single large lesion, a single small lesion, confluent and additional lesions, or small scattered lesions. The relationships between infarction patterns and clinical and hematologic parameters were investigated. Results: Of the 388 patients, a single large lesion was detected in 139 (35.8%), a single small lesion in 29 (7.5%), confluent and additional lesions in 171 (44.1%), and small scattered lesions in 49 (12.7%). Prior use of antiplatelet agents and anticoagulant were associated with the pattern of small scattered lesions and a single small lesion, respectively. Additionally, higher white blood cell counts were associated with confluent and additional lesions. The type of high-risk PCSE was not related to a specific infarction pattern. Conclusions: These results suggest that platelet function and inflammatory processes may directly affect the thrombus formation in the cardiac chamber.

Ulcerated Carotid Plaques with Ultrasonic Echolucency Are Causatively Associated with Thromboembolic Cerebrovascular Events

The presence of ulcerated carotid plaques is a risk factor for ischemic stroke, which is associated with thromboembolism. We evaluated the relationship between ulcerated carotid plaques and cerebrovascular events in patients with acute ischemic stroke or transient ischemic attack. We extracted 48 consecutive patients with ulcerated carotid plaques from a cohort of 1111 patients with acute ischemic stroke or transient ischemic attack. All patients were evaluated by carotid ultrasonography and diffusion-weighted magnetic resonance imaging. We defined thromboembolic events by excluding potential cardiac sources of embolism, stroke in posterior circulation, contralateral lesions, and single and small (<1.5 cm) subcortical lesions, and we considered the remaining patients with cortical lesions or multiple or large subcortical lesions as having experienced a thromboembolic cerebrovascular event. We compared ultrasonographic findings in the patients with and those without a thromboembolic cerebrovascular event. A relationship with thromboembolic events was suspected in 10 patients (21%) with ulcerated carotid plaques. The proportion of smokers was significantly higher in the group of patients with a thromboembolic event (90% vs 53%; P = .03). Logistic regression demonstrated a significant association between thromboembolic events and the presence of echolucent ulcerated plaques (odds ratio, 9.34, 95% confidence interval, 1.65-53.0), even though maximum intima-media thickness and other variables of ulcerated plaques (eg,depth of ulcers, thickness of the plaque, or the degree of stenosis) did not differ significantly between the 2 groups. Our findings indicate that although cerebrovascular events are closely associated with echolucent ulcerated carotid plaques, the prevalence of thromboembolism was not very high (∼20%) in our cohort of Japanese patients with ulcerated carotid plaques.

The Role of Echocardiography in the Management of Stroke

Echocardiography is increasingly being used as a screening test to identify sources of cardiogenic embolism in patients with ischemic stroke or transient ischaemic attack (TIA). However, no consensus exists presently on the utilization of this imaging facility in individuals with stroke. To evaluate the yield of transthoracic echocardiography in patients with ischaemic stroke with a view to providing guidance in its use in clinical management of stroke. One hundred and twenty-six consecutive stroke patients with 90 controls were recruited prospectively. Patients were examined echocardiographically for evidence of intramural thrombus, congenital defects, valvular heart disease, wall motion abnormalities and intra-cardiac masses using two-dimensional, m-Mode and Doppler facilities. Potential cardiac source of emboli (CSE) was identified in 23.0% of the stroke patients. Those who had CSE identified aged 53.0(20.8) years were younger (p=0.0001) than those who did not have CSE, 57.2 (13.5) years. Five (4.0%) patients had rheumatic valvular heart disease with demonstrable clots in the left atrium. On the other hand, four(3.2%) patients had RHD without thrombi seen. Two patients had biventricular thrombi. One of these patients had giant clots within the ventricles and multiple freely mobile thrombi in right ventricle without obvious cardiac structural defect. Young stroke or transient ischaemic attacks patients who have clinical signs suggesting the heart as the potential CSE should have low threshold for echocardiography. However, there is a need for rationalisation of request for echocardiography where such clinical signs are absent.

Clinical and neuroradiological features of internal watershed infarction and the occlusive diseases of carotid artery system

Background: To describe the clinical and neuroradiological features of internal watershed (IWS) infarction and to analyze the relationship between IWS infarction and occlusive diseases of carotid artery system.Methods: We identified 27 IWS infarction patients with diffusion-weighted magnetic resonance imaging by commonly used templates within 10 days after the onset. Patients with potential cardiac sources of embolism were excluded. Occlusive diseases of carotid arteries were assessed by magnetic resonance angiography or digital subtraction angiography. Baseline characteristics, clinical course, prognosis, neuroradiological features and symptomatic arteries were analyzed.Results: Two patterns were identified: 14 patients had confluent IWS (C-IWS) infarction, and 13 patients had partial IWS (P-IWS) infarction. Twelve patients in C-IWS group and 10 patients in P-IWS group had severe stenosis (>70%) or occlusion in either the internal carotid artery (ICA) or middle cerebral artery (MCA). Occlusive diseases of ICA and non-lacunar syndrome were more prevalent in C-IWS group, while occlusive diseases of MCA and lacunar syndrome were more prevalent in P-IWS group. Concomitant small cortical lesions ipsilateral to IWS infarcts were more common in C-IWS group than in P-IWS group, and were significantly associated with ICA diseases. Clinical deterioration during the first seven days after admission and poor outcome assessed by the Modified Rankin Score 3 months after stroke were more prevalent in C-IWS group than in P-IWS group.Conclusions: There is a relatively definite relationship between IWS infarction and occlusive diseases of carotid arteries. The distribution of symptomatic arteries (ICA or MCA) in C-IWS group is significantly different from that in P-IWS group. Both hypoperfusion and microembolism are probable mechanisms. There may be some differences in their roles in pathogenesis of C-IWS and P-IWS infarction. Microembolism may contribute C-IWS infarction in addition to hypoperfusion, which is the major pathogenesis of P-IWS infarction.

Stroke severity in concomitant cardiac sources of embolism in patients with atrial fibrillation

Background Atrial fibrillation (AF), which is the most common etiology of cardioembolic stroke, may be accompanied by other cardiac sources of embolism. The heterogeneity and multiplicity of the cardiac sources of embolism may influence stroke severity via formation of thrombi with heterogenous compositions, ages, and sizes. We investigated among stroke patients with AF whether stroke severity is different between patients with concomitant potential cardiac sources of embolism and those without. Methods The subjects for this study were consecutive patients with cerebral infarction and AF who underwent transesophageal echocardiography during a 10-year period. The definitions and determination of high- and medium-risk potential cardiac sources of embolism were based on the Trial of Org 10172 in Acute Stroke Treatment classification. Initial stroke severity and infarct sizes were compared between patients with concomitant potential cardiac sources of embolism and those without. Results Of the 266 patients enrolled, 181 (68.0%) had one or more concomitant potential cardiac sources of embolism. Left atrial thrombus and spontaneous echo contrast were most common. Patients with concomitant potential cardiac sources of embolism had a higher median score on the initial National Institute of Health Stroke Scale (6 vs. 3, p = 0.005) and a larger infarction diameter (45.4 ± 31.3 mm vs. 35.5 ± 26.6 mm, p = 0.002) than those without. Occlusion of the symptomatic arteries was more frequently detected in patients with concomitant potential cardiac sources of embolism. Conclusions Stroke patients with AF frequently had concomitant potential cardiac sources of embolism, and strokes were more severe in them.

Carotid Plaque Inflammation Is Associated With Cerebral Microembolism in Patients With Recent Transient Ischemic Attack or Stroke

Cerebral infarcts distal to carotid stenoses are thought to be caused by emboli from inflamed, destabilized plaques. We hypothesized that microembolic signals (MES) on transcranial Doppler will be associated with carotid plaque inflammation on (18)F fluorodeoxyglucose positron-emission tomography (FDG PET) in recently symptomatic patients. Sixteen patients presenting with recent (47 ± 31 days) anterior circulation transient ischemic attack or minor stroke and 50% to 99% stenosis of the ipsilateral carotid bifurcation underwent FDG PET, high-resolution black-blood carotid MRI, and transcranial Doppler for detection of MES. Patients with potential cardiac sources of emboli or contralateral MES were excluded. Regions of interest defined on the coregistered MRI were used to measure FDG standardized uptake values (with Rousset partial volume correction) from the index and contralateral carotid plaques and artery. Ipsilateral MES were detected in 7 patients (MES+ group) and absent in 8 (MES- group). There was a significant difference in index-to-contralateral plaque standardized uptake value ratio between MES+ (median, 1.05; first to third quartile, 0.96 to 1.32) and MES- (median, 0.76; first to third quartile, 0.62 to 0.94) patients (P=0.005). The interval from symptom onset to PET and percent index carotid stenosis were not different between the 2 groups (P=0.68 and P=0.48, respectively). In this sample of recently symptomatic patients with carotid stenosis, an association was found between in vivo measures of plaque inflammation detected by FDG PET and the presence of transcranial Doppler MES. These findings strengthen the notion that embolic events distal to carotid stenoses are related to plaque inflammation, and FDG PET may be useful in the investigation of culprit carotid lesions.

Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC)

Embolism of cardiac origin accounts for around 15-30% of ischaemic strokes. Strokes due to cardioembolism are generally severe and early and long-term recurrence and mortality are high. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthone cerebrovascular occlusive disease. In this respect, echocardiography (both transthoracic and/or transoesophageal) serves as a cornerstone in the evaluation, diagnosis, and management of these patients. A clear understanding of the various types of cardiac conditions associated with cardioembolic stroke and their intrinsic risk is therefore very important. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism.

Risk Factors for Small Cortical Infarction on Diffusion-Weighted Magnetic Resonance Imaging in Patients With Acute Ischemic Stroke

Diffusion-weighted magnetic resonance imaging (MRI) is sensitive for detecting acute ischemic lesions. The present study evaluated risk factors associated with small cortical infarction (SCI) on diffusion-weighted MRI. We analyzed 123 patients with acute ischemic stroke retrospectively. We defined an SCI as a cortical lesions < 1.5 cm in diameter detected by diffusion-weighted MRI. Risk factors and comorbidities included hypertension, hypercholesterolemia, diabetes mellitus, cigarette smoking, potential cardiac sources of embolism, carotid disease, and coagulopathy. Carotid disease was defined as > 50% stenosis or occlusion in the internal carotid artery, detected by carotid ultrasonography. In addition, we analyzed plasma levels of coagulation and fibrinolysis markers. We also compared carotid disease, potential cardiac sources, and coagulopathy among localization of SCI. SCI was identified in 22.8% of patients with acute ischemic stroke. Carotid disease (odds ratio [OR] = 4.4; 95% confidence interval [CI] = 1.7-11.42; P = .002) and coagulopathy (OR = 6.8; 95% CI = 1.33-35.17; P = .02) were found to be independent risk factors for SCI. SCI with carotid disease was not associated with bilateral and multiple territorial lesions, whereas SCI with coagulopathy was associated with bilateral lesions. No borderzone lesions were found in SCI patients with cardiac sources. Our findings suggest that carotid disease and coagulopathy are independent risk factors for SCI. Localization of SCI varies depending on the underlying diseases.

Watershed Infarcts in Transient Ischemic Attack/Minor Stroke With ≥50% Carotid Stenosis

Watershed ischemia is a significant cause of stroke in severe carotid disease, but its pathophysiology is unsettled. Although hemodynamic compromise has long been regarded as the main mechanism-particularly with deep watershed infarction-there is some contradictory evidence from clinical and pathological studies for a role of microembolism, thought to result from plaque inflammation. However, no study so far has directly addressed these conflicting scenarios. In 16 consecutive patients with recent transient ischemic attack/minor stroke and ipsilateral 50% to 99% carotid stenosis, we prospectively obtained (1) plaque inflammation mapping with (18)F fluorodeoxyglucose positron emission tomography; (2) brain MRI and perfusion MR; and (3) transcranial Doppler detection of microembolic signals (MES). Patients were excluded if on dual antiplatelets or with a potential cardiac source of emboli or contralateral MES. We found the expected significant relationship between (1) degree of stenosis and severity of distal hemodynamic impairment in the watershed areas; and (2) degree of in vivo plaque inflammation and rate of MES/hr. Deep watershed infarcts were present in 8 patients and MES in 8 (3 with both). There was no systematic association between the presence of deep watershed infarcts and either hemodynamic impairment or MES, but deep watershed infarcts were present only when either hemodynamic impairment or MES was present (P=0.01). This pilot study supports the idea that in symptomatic carotid disease, deep watershed infarcts result either from hemodynamic impairment secondary to severe lumen stenosis or from microembolism secondary to plaque inflammation. There was no direct evidence that both mechanisms act in synergy.

Clinical and Radiologic Correlations of Small and Large Centrum Ovale Infarcts

Acute centrum ovale (CO) infarction confined to the territory of perforating long medullary arteries is rarely reported. This study was designed to investigate the full spectrum of clinical findings, topography, and pathogenesis of patients with acute CO infarct. A total of 64 patients with CO infarct were recorded. Risk factors such as age, hypertension, diabetes mellitus, hypercholesterolemia, smoking, and cardiopathy were recorded. The average age of the patients was 64.2 years. There were 46 patients (71.8%) in large-infarct group and 18 patients (28.1%) in small-infarct group. The most frequent risk factor was hypertension (89.1%). Other risk factors included smoking (39%), diabetes mellitus (29.7%), hyperlipidemia (28.1%), transient ischemic attack (15%), carotid stenosis (9%), atrial fibrillation (21%), other potential cardiac source of embolism (39%), and myocardial infarct (4%). The main clinical feature was faciobrachiocrural paralysis associated dysarthria (51.6%). Other clinical characteristics were facial, upper and lower extremity paralysis with sensorial deficits and/or dysarthria (26.6%), hemiparesis including face (12.5%), and either facial and upper or upper and lower extremity paralysis with hemisensorial deficit (9.4%). The baseline Barthel index was found to be less than 50 in 22 patients (34.4%) and greater than 50 in 42 patients (65.6%) for the entire group whereas 72% of patients were independent at discharge. In this article, risk factors, clinical spectrum, and features of CO infarcts were correlated in a large patient group. The majority of CO infarcts were large and had a poorer outcome compared to previous reports.

Transoesophageal echocardiography in patients with acute stroke with sinus rhythm and no cardiac disease history

BackgroundTransoesophageal echocardiography (TOE) is the gold standard for detecting potential cardiac sources of embolism (PCSE). However, the role of TOE in patients with ischaemic stroke with normal sinus rhythm (NSR)...

Abstract 5505: The Impact of Selectively Performed Echocardiography in Patients With Acute Ischemic Stroke or Transient Ischemic Attack

Background: The updated ACC/AHA/ASE guideline in 2003 recommended that echocardiography be performed selectively in patients with acute ischemic stroke or TIA. We aimed to evaluate the diagnostic yield and therapeutic impact of transthoracic echocardiography (TTE) with such an approach. Methods: A total of 984 consecutive patients with acute ischemic stroke or TIA were included in the study. Clinical data were systemically reviewed, including the reports of ECG, brain MRI/CT and carotid duplex ultrasound (CDUS). TTE data were retrospectively analyzed. Results: TTE tests were performed in 624 (63.4%) patients (mean age 70.9±14.1 years, 47.4% of men). Atrial fibrillation (AF) was present in 116 (18.6%) patients. An overall potential cardiac source of embolism (PCSE) was found in 155 (24.8%). Atrial septal abnormality (PFO± septal aneurysm) and LV dysfunction (EF ≤ 30%± wall motion abnormality/LV aneurysm) were the most frequent PCSE in younger (&lt; 45 years) and older (≥ 45 years) patients, respectively. The overall diagnostic yield of TTE was comparable in both groups (35.5% vs 26.8%, P = 0.303). Significant carotid stenosis was found in 27 (7.5%) patients in the older group by CDUS, but none in the younger patients. After excluding patients with AF and significant carotid stenosis, who have independent indication for anticoagulation or intervention, the therapeutic impact of TTE was more significant in younger patients (27.6% vs 11.5%, P = 0.019). Numbers needed to test (NNT) for detection of a PCSE was 4 in younger patients and 9 in older patients, the latter being more than 2-fold of the former. Conclusion: Selectively performed TTE in patients with ischemic stroke or TIA can provide important information on PCSE. The diagnostic yield and therapeutic impact are much higher in younger patients. Table. Potential cardiac source of embolism

Influence of transoesophageal echocardiography on therapy and prognosis in young patients with TIA or ischaemic stroke

Objective. To determine the influence of transoesophageal echocardiography (TEE) on therapy and prognosis in patients with cryptogenic transient ischaemic attack (TIA) or ischaemic stroke under the age of 50 years.Methods and results. We evaluated all patients aged 50 and under who were referred to our university hospital for cryptogenic TIA or ischaemic stroke during the period 1 January 1996 to 31 December 2004. All patients underwent both transthoracic echocardiography (TTE) and TEE. Patients with known pre-existent heart disease, such as atrial fibrillation, were excluded. Eighty-three patients with TIA (22) and ischaemic stroke (61) were enrolled. Mean age was 39+/-8 years (range 18 to 50). In 30% of the patients TEE detected one or more potential cardioembolic source, compared with 10% for TTE (p=0.003). Standard treatment (aspirin 38 mg daily) was changed in 7% of the patients due to the TEE findings. Complete followup was obtained in 93% with an average of 5+/-3 years. Twelve recurrences occurred; two out of six patients (33%) with therapy change and ten out of 71 (14%) of the patients without therapy change had a recurrent TIA or ischaemic Stroke.Conclusion. In patients with cryptogenic TIA or ischaemic stroke, TEE is superior to TTE in the detection of a potential cardiac source of embolism. However, findings obtained by TEE only influence the already initiated treatment in a small percentage of patients. The recurrence rate both in the group with and without therapy change is high. (Neth Heart J 2009;17:373-7.).

Cardiac Computed Tomographic Angiography for Detection of Cardiac Sources of Embolism in Stroke Patients

We assessed the diagnostic performance of 2-phase 64-slice cardiac computed tomographic angiography (CCTA) for the detection of a cardiac source of embolism in stroke patients using transesophageal echocardiography (TEE) as the reference standard. We selected 137 patients who had experienced a recent episode of stroke and had undergone both 2-phase 64-slice CCTA and TEE within a period of 5 days. A potential cardiac source of embolism detected at both CCTA and TEE was recorded, and echocardiographic findings were categorized into high- and medium-risk sources based on the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. Of 137 patients, 100 abnormal findings in 91 patients were found on TEE, and 46 patients had no abnormal finding on TEE. The overall sensitivity, specificity, positive predictive value, and negative predictive value of the 64-slice CCTA for detecting cardiac sources of embolism were 89% (95% CI, 82%, 95%), 100% (95% CI, 90%, 100%), 100% (95% CI, 95%, 100%), and 81% (95% CI, 70%, 92%), respectively. TEE detected a total of 47 high-risk sources of embolism, whereas CT detected 44 lesions. For medium-risk sources of cardiac embolic stroke, TEE detected a total of 53 abnormal findings, whereas CT detected 44 abnormal findings. Of 53 lesions, there were 8 false-negative results on CT (5 patent foramen ovale and 3 atrial septal aneurysm). Two-phase 64-slice CCTA is a noninvasive and useful modality for detecting high-risk cardiac sources of embolism in stroke patients.

Ischemic stroke of the cortical “hand knob” area: stroke mechanisms and prognosis

Cortical ischemic stroke affecting the precentral "hand knob" area is a rare but well known stroke entity. To date, little is known about the underlying stroke mechanisms and the prognosis. Twenty-nine patients admitted to our service between 2003 and 2007 were included in the study on the basis of an acute ischemic infarct of the cortical "hand knob" area confirmed by diffusion-weighted magnetic resonance imaging with contralateral hand paresis. For all patients clinical, epidemiological as well as imaging data at the time point of admission were analysed retrospectively and follow-up data on all patients was obtained. The majority (n = 21/72%) had an isolated infarct of the cortical "hand knob" area. In 23 (79%) patients it was a first ever stroke. Ten patients (34%) had ipsilateral extracranial stenosis of the internal carotid artery (ICA), whereas potential cardiac embolic sources were less frequent (n = 4/14%). No patient exhibited ipsilateral MCA stenosis. All but two patients (93%) had marked atherosclerotic alterations of the ICA. Hypertension was the most prevalent vascular risk factor (n = 23/79%). At follow-up (mean 25.0 months, range 0.4-47.4 months) no patient had died and only one (3%) experienced a recurrent stroke. The majority of patients (79%) reported improvement of hand paresis, 17 (59%) were asymptomatic (modified Rankin score = 0). Only one patient was significantly disabled due to a recurrent stroke. In conclusion, ischemic infarcts affecting the cortical "hand knob" area are frequently associated with atherosclerotic changes of the carotid artery, suggesting an arterio-arterial thrombembolic stroke mechanism. It mostly reflects first ever ischemic stroke, and follow-up data suggest a rather benign course.

Specific cardiological evaluation after focal cerebral ischemia.

Purpose of this study was to define a subgroup of TIA/stroke patients who should be examined by transthoracal and transesophageal echocardiography or Holter-electrocardiography to identify those with cardiogenic brain embolism reliably; 300 consecutive patients with acute focal brain ischemia underwent a standardized diagnostic protocol for the evaluation of the etiology including, clinical examination by a cardiologist and routine electrocardiography, Holter-electrocardiography, transthoracal and transesophageal echocardiography. 188 patients had a potential cardiac source of embolism. In particular echocardiography was diagnostic in 163 patients, and Holter-electrocardiography 10; 159 of these 188 patients (84.6%) had competitive etiologies, predominantly large vessel atherosclerosis. In 136 patients cardiogenic brain embolism was assumed as quite definite or possible. To identify these patients reliably, transthoracal and transesophageal echocardiography would have been necessary in 89% of the entire group of patients (all with clinically cardiological abnormalities, pathological routine ECG, without vascular risk factors, or no atherosclerosis in duplex sonography), and Holter-electrocardiography in 54%.

Transoesophageal echocardiographic findings in patients with ischemic lacunar and nonlacunar stroke

The aim of this study was to compare risk factors and concomitant potential cardioembolic sources detected by transthoracic (TTE) and transoesophageal echocardiography (TEE) in patients with lacunar and nonlacunar infarcts. Clinical data of 139 patients with a first episode of ischemic stroke who underwent both TTE and TEE were analysed. Patients were divided into two groups, lacunar (LACI = 36), and nonlacunar infarcts (NLACI = 103); then the latter group was divided into two subgroups, anterior (ACI = 76) and posterior circulation infarct (POCI = 27). Presence of hypertension and diabetes mellitus were not significantly different between LACI and NLACI groups. The rate of potential cardioembolic risk factors detected by echocardiography was similar in the NLACI groups. At least one potential cardiac source of embolism was identified in 44% ( n = 16) of LACI, 52.6% ( n = 40) of ACI and 55.5% ( n = 15) of POCI patients. Atrial fibrillation was significantly frequent in the ACI group. No significant differences were found between all groups regarding age, sex, hyperlipidemia, and smoking. Our findings demonstrate that hypertension and diabetes mellitus are equally important in the pathogenesis of both LACI and NLACI groups and there is a need for careful cardiac evaluation in cases even with lacunar infarct.

Early Spontaneous Recanalization Following Acute Carotid Occlusion

Occlusion of the internal carotid artery (ICA) and stroke may be the consequence of either local thrombosis due to atherosclerosis or massive embolism. Up to date, there are only few reports of subsequent recanalization. We report 12/76 cases of acute ICA occlusion leading to ischemic stroke, in which early recanalization was identified. Ultrasound and stroke MRI findings, therapeutic options, and outcome are described. 10/12 patients showed an- or hypoechogenic morphology of occlusion. While in 7/12 cases complete recanalization was seen, in 5/12 patients partial recanalization with filiform flow (4) or residual high-grade stenosis (1) was detected. 10/12 patients had territorial or subcortical infarction, while two showed small cortical lesions only. In 7/12 cases, a potential cardiac source of embolism was found. Five patients received tPA; four patients underwent early carotid endarterectomy of the partially recanalized ICA within 48 hours. In the 10-day follow-up examination 10/12 patients showed clinical improvement as measured by the NIHSS. Spontaneous recanalization after occlusion of the ICA may occur and might be more frequent than hitherto assumed. Echogenicity analysis and serial examinations of symptomatic ICA occlusion is useful for identifying a patient subgroup that might benefit from further therapy.