Cardioembolic stroke: clinical features, specific cardiac disorders and prognosis

Abstract

This article provides the reader with an overview and up-date of clinical features, specific cardiac disorders and prognosis of cardioembolic stroke. Cardioembolic stroke accounts for 14-30% of ischemic strokes and, in general, is a severe condition; patients with cardioembolic infarction are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of cardioembolic infarction, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The more common high risk cardioembolic conditions are atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy, and mitral rheumatic stenosis. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhyhtmia can be detected by Holter monitoring. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. In our experience, in-hospital mortality in patients with early embolic recurrence (within the first 7 days) was 77%. Patients with alcohol abuse, hypertension, valvular heart disease, nausea and vomiting, and previous cerebral infarction are at increased risk of early recurrent systemic embolization. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent.

Keywords: Cardioembolic stroke; atrial fibrillation; cardiac source of emboli; outcome.; recurrent embolization.

Fig. (1)

Histopathological specimen showing a hemorrhagic cerebral infarction of a cardioembolic origin with signs of ventricular displacement and brain herniation in the territory of the middle cerebral artery.

Fig. (2)

Hemorrhagic cardioembolic infarction in a patient with a spectacular shrinking deficit syndrome visualized in the brain MRI study (spin-echo hyperintensity T1-weighted image).

Fig. (3)

Transthoracic echocardiography shows a left ventricular aneurysm (VI) in a patient with history of acute myocardial infarction.

Fig. (4)

Transthoracic echocardiography reveals a thrombus in the left atrium (T) in a patient with double rheumatic mitral valve lesion and atrial fibrillation.

Fig. (5)

Right lobar hemorrhage (A) secondary to rupture of a mycotic aneurysm in the course of an infective bacterial endocarditis; transthoracic echocardiography (B) shows an abscess in the posterolateral aortic root (a) between the aortic valve leaflets and the mitral valve.