Abstract
It is a necessary oversimplification to emphasize that treatment decisions about a disorder are based on knowledge of its cause. This is true in stroke as in other conditions. In applying this principle to cardioembolic stroke, one must deal with several difficult clinical problems. Does the patient have a cardiac disorder that may cause a stroke via embolic mechanisms, and so be treated in an attempt to prevent the first stroke? What are the risks of treatment compared to the potential benefits? Does the patient have a cardiac disorder that could have caused the stroke? Does the patient have noncardiac potential causes for his or her stroke? Is there any way to determine which of multiple possible stroke mechanisms actually caused the stroke? If a patient suffers a cardioembolic stroke, when should treatment to prevent a recurrence begin? One of these clinical questions arises in most patients with ischemic stroke.
Keywords
Atrial Fibrillation Infective Endocarditis Mitral Stenosis Mitral Valve Prolapse Computerize TomoPreview
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References
- 1.Easton JD, Sherman DG. Progress in cerebrovascular disease. Stroke. 1980;11:433–441.PubMedCrossRefGoogle Scholar
- 2.Foulkes MA, Wolf PA, Price TR, et al. The stroke data bank: design, methods, and baseline characteristics. Stroke. 1988;19:547–554.PubMedCrossRefGoogle Scholar
- 3.Garvin CF. Mural thrombi in the heart. Am Heart J. 1941;21:713–720.CrossRefGoogle Scholar
- 4.Vost A, Wolochow DA, Howell DA. Incidence of infarcts of the brain in heart disease. J Pathol Bacteriol. 1964;88:463–470.PubMedCrossRefGoogle Scholar
- 5.Adams RD, Vander Eecken HM. Vascular diseases of the brain Ann Rev Med. 1953;4:213–252.PubMedCrossRefGoogle Scholar
- 6.Ramirez-Lassepas M, Cipolle RJ, Bjork RJ, et al. Can embolic stroke be diagnosed on the basis of neurologic clinical criteria? Arch Neurol. 1987;44: 87–89.PubMedCrossRefGoogle Scholar
- 7.Bogousslaysky J, Hachinski VC, Boughner DR, et al. Cardiac and arterial lesions in carotid transient ischemic attacks. Arch Neurol. 1986;43:223–228.CrossRefGoogle Scholar
- 8.Bogousslaysky J, Van Melle FE, Regli F. The Lausanne stroke registry: analysis of 1,000 consecutive patients with first stroke. Stroke. 1988;19: 1083–1092.CrossRefGoogle Scholar
- 9.Bogousslaysky J, Van Melle G, Regli F. Middle cerebral artery pial territory infarcts: a study of the Lausanne stroke registry. Ann Neurol. 1989;555–560.Google Scholar
- 10.Okada Y, Yamaguchi T, Minematsu K, et al. Hemorrhagic transformation in cerebral embolism. Stroke. 1989;20:598–603.PubMedCrossRefGoogle Scholar
- 11.Pessin MS, Lathi ES, Cohen MB, et al. Clinical features and mechanism of occipital infarction. Ann Neurol. 1987;21:290–299.PubMedCrossRefGoogle Scholar
- 12.Fisher CM. The posterior cerebral artery syndrome. Can J Neurol Sci. 1986;13:232–239.PubMedGoogle Scholar
- 13.Ghika J, Bogousslavky J, Regli F. Small deep infarct: a study of embolic sources. Stroke. 1989;20:158. Abstract.Google Scholar
- 14.Mohr JP, Caplan LR, Melski JW, et al. The Harvard cooperative stroke registry: a prospective registry. Neurology. 1978;28:754–762.PubMedCrossRefGoogle Scholar
- 15.Biller J, Johnson MR, Adams HP, et al. Echocardiographic evaluation of young adults with nonhemorrhagic cerebral infarction. Stroke. 1986;17: 608–612.PubMedCrossRefGoogle Scholar
- 16.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.PubMedCrossRefGoogle Scholar
- 17.Fogelholm R, Melin J. Echocardiography in ischaemic cerebrovascular disease. Brit Med J. 1987;295:305–306.CrossRefGoogle Scholar
- 18.Gagliardi R, Benvenuti L, Frosini F, et al. Frequency of echocardiographic abnormalities in patients with ischemia of the carotid territory — a preliminary report. Stroke. 1985;16:118–120.PubMedCrossRefGoogle Scholar
- 19.Good DC, Frank S, Verhulst S, et al. Cardiac abnormalities in stroke patients with negative arteriograms. Stroke. 1986;17:6–11.PubMedCrossRefGoogle Scholar
- 20.Nishide M, Irino T, Gotoh M, et al. Cardiac abnormalities in ischemic cerebrovascular disease studied by two-dimensional echocardiography. Stroke. 1983;14:541–545.PubMedCrossRefGoogle Scholar
- 21.Rem JA, Hachinski VC, Boughner DR, et al. Value of cardiac monitoring and echocardiography in TIA and stroke patients. Stroke. 1985;16:950–956.PubMedCrossRefGoogle Scholar
- 22.Robbins JA, Sagar KB, French M, et al. Influence of echocardiography on management of patients with systemic emboli. Stroke. 1988;14:546–549.CrossRefGoogle Scholar
- 23.Todnem K, Vik-Mo H. Cerebral ischemic attacks as a complication of heart disease: the value of echocardiography. Acta Neurol Scand. 1986;74:323–327.PubMedCrossRefGoogle Scholar
- 24.Foster CJ, Sekiya T, Love HG, et al. Identification of intracardiac thrombus: comparison of computed tomography and cross-sectional echocardiography. Br J Radiol. 1987;60:327–331.PubMedCrossRefGoogle Scholar
- 25.Goldstein JA, Schiller NB, Lipton MJ, et al. Evaluation of left ventricular thrombi by contrast-enhanced computed tomography and two-dimensional echocardiography. Am J Cardiol. 1986;57:757–760.PubMedCrossRefGoogle Scholar
- 26.Helgason CM, Chomka EV, Rich S, et al. Ultrafast cardiac CT scanning in stroke. Stroke. 1987;18:283. Abstract.Google Scholar
- 27.Masuda Y, Morooka N, Yoshida H, et al. Noninvasive diagnosis of thrombus in the heart and large vessels-usefulness of two dimensional echocardiography and X-ray CT. Japanese Circ J. 1984;48: 83–89.CrossRefGoogle Scholar
- 28.Gomes AS, Lois JF, Child JS, et al. Cardiac tumors and thrombus: evaluation with MR imaging. AIR. 1987;149:895–899.Google Scholar
- 29.Aschenberg W, Schluter M, Kremer P, et al. Transesophageal two-dimensional echocardiography for detection of left atrial appendage thrombus. J Am Coll Card. 1986;7:163–166.CrossRefGoogle Scholar
- 30.Zenker G, Erbel R, Kramer G, et al. Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events. Stroke. 1988;19:345–348.PubMedCrossRefGoogle Scholar
- 31.Seward JB, Khandheria BK, Oh JK, et al. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo Clinic Proc. 1988;63:649–660.CrossRefGoogle Scholar
- 32.Kessler C, Henningsen H, Reuther R, et al. Identification of intracardiac thrombi in stroke patients with indium-111 platelet scintigraphy. Stroke. 1987;18: 63–67.PubMedCrossRefGoogle Scholar
- 33.Cerebral Embolism Task Force. Cardiogenic brain embolism: the second report of the cerebral embolism task force. Arch Neurol. 1989;46:727–743.CrossRefGoogle Scholar
- 34.Aronow WS, Gutstein H, Fsieh FY. Risk factors for thromboembolic stroke in elderly patients with chronic atrial fibrillation. Am J Cardiol. 1989;63: 366–367.PubMedCrossRefGoogle Scholar
- 35.Flegel KM, Shipley MJ, Rose G. Risk of stroke in nonrheumatic atrial fibrillation. Lancet. 1987;1: 526–529.PubMedCrossRefGoogle Scholar
- 36.Tanaka H, Hayashi M, Date C, et al. Epidemiologic studies of stroke in Shibata, a Japanese provincial city: preliminary report on risk factors for cerebral infarction. Stroke. 1985;16:773–780.PubMedCrossRefGoogle Scholar
- 37.Onundarson PT, Thorgeirsson G, Jonmundsen E, et al. Chronic atrial fibrillation- epidemiologic features and 14 year follow-up: a case-control study. Eur Heart J. 1987;8:521–527.PubMedGoogle Scholar
- 38.Wolf PA, Dawber TR, Thomas HE, et al. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham Study. Neurology. 1978;28:973–977.PubMedCrossRefGoogle Scholar
- 39.Boysen G, Petersen P, Kastrup J, et al. Cerebral blood flow during chronic atrial fibrillation and after conversion to sinus rhythm. J Cerebral Blood Flow Metab. 1989;9(suppl 1):S365.Google Scholar
- 40.Kopecky SL, Gerah BJ, McGoon MD, et al. The natural history of lone atrial fibrillation. N Engl J Med. 1987;317:669–674.PubMedCrossRefGoogle Scholar
- 41.Close JB, Evans DW, Bailey SM. Persistent lone atrial fibrillation- its prognosis after clinical diagnosis. J R Coll Gen Practitioners. 1979;29:547–549.Google Scholar
- 42.Brand FN, Abbott RD, Kannel WB, et al. Characteristics and prognosis of lone atrial fibrillation. JAMA. 1985;254:3449–3453.PubMedCrossRefGoogle Scholar
- 43.Petersen P, Hansen JM. Stroke in thyrotoxicosis with atrial fibrillation. Stroke. 1988;19:15–18.PubMedCrossRefGoogle Scholar
- 44.Peterson P, Godtfredsen J, Boysen G, et al. Placebocontrolled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK Study. Lancet. 1989;1:175–179.CrossRefGoogle Scholar
- 45.The Stroke Prevention in Atrial Fibrillation Investigators. Preliminary report of the Stroke Prevention in Atrial Fibrillation Study. N Engl J Med. 1990; 322:863–868.Google Scholar
- 46.Johannessen KA, Nordrehaug JE, von der Lippe G, et al. Risk factors for embolization in patients with left ventricular thrombi and acute myocardial infarction. Br Heart J. 1988;60:104–110.PubMedCrossRefGoogle Scholar
- 47.Johannessen KA, Nordehaug JE, von der Lippe G. Left ventricular thrombosis and cerebrovascular accident in acute myocardial infarction. Br Heart J. 1984;51:553–556.PubMedCrossRefGoogle Scholar
- 48.Nordrehaug JE, Johannessen KA, von der Lippe G. Usefulness of high-dose anticoagulants in preventing left ventricular thrombus in acute myocardial infarction. Am J Cardiol. 1985;55:1491–1493.PubMedCrossRefGoogle Scholar
- 49.Aryan S, Boscha K. Prophylactic anticoagulation for left ventricular thrombi after acute myocardial infarction: a prospective randomized trial. Am Heart J. 1987;113:688–693.CrossRefGoogle Scholar
- 50.Domenicucci S, Bellotti P, Chiarella F, et al. Spontaneous morphologic changes in left ventricular thrombi: a prospective two-dimensional echocardiographic study. Circulation. 1987;75:737–743.PubMedCrossRefGoogle Scholar
- 51.Gueret P, Dubourg O, Ferrier A, et al. Effects of fulldose heparin on the development of left ventricular thrombosis in acute transmural myocardial infarction. J Am Coll Cardiol. 1986;8:419–426.PubMedCrossRefGoogle Scholar
- 52.Visser CA, Kan G, Meltzer RS, et al. Long-term follow-up of left ventricular thrombus after acute myocardial infarction. Chest. 1984;86:532–536.PubMedCrossRefGoogle Scholar
- 53.Keating EC, Gross SA, Schlamowitz RA, et al. Mural thrombi in myocardial infarction. Prospective evaluation by two-dimensional echocardiography. Am J Med. 1983;74:989–995.PubMedCrossRefGoogle Scholar
- 54.Asinger RW, Mikell FL, Elsperger J, et al. Incidence of left ventricular thrombosis after acute transmural myocardial infarction. N Engl J Med. 1981;305: 297–302.PubMedCrossRefGoogle Scholar
- 55.Friedman MJ, Carlson K, Marcus FI, et al. Clinical correlations in patients with acute myocardial infarction and left ventricular thrombus detected by two-dimensional echocardiography. Am J Med. 1982;72:894–898.PubMedCrossRefGoogle Scholar
- 56.Bhatnagar SK, Hudak A, Al Yusuf AR. Left ventricular thrombosis, wall motion abnormalities, and blood viscosity changes after first transmural anterior myocardial infarction. Chest. 1985;88:40–44.PubMedCrossRefGoogle Scholar
- 57.Visser CA, Kan G, Meltzer RS, et al. Echocardiography to evaluate postinfarction left ventricular thrombi. Clin Cardiol. 1986;3:62.Google Scholar
- 58.Spirito P, Bellotti P, Chiarella F, et al. Prognostic significance and natural history of left ventricular thrombi in patients with acute anterior myocardial infarction: a two-dimensional echocardiographic study. Circulation. 1985;72:774–778.PubMedCrossRefGoogle Scholar
- 59.Visser CA, Kan G, Meltzer RS, et al. Embolic potential of left ventricular thrombus after myocardial infarction: a two-dimensional echocardiographic study of 119 patients. J Am Coll Card. 1985;5: 1276–1280.CrossRefGoogle Scholar
- 60.Tramarin R, Pozzoli M, Febo O, et al. Two-dimensional echocardiographic assessment of anticoagulant therapy in left ventricular thrombosis early after acute myocardial infarction. European Heart J. 1986;7:482–492.Google Scholar
- 61.Chesebro JH, Ezekowitz MD, Badimon L, et al. Intracardiac thrombi and systemic thromboembolism: Detection, incidence and treatment. Ann Rev Med. 1985;36:579–605.PubMedCrossRefGoogle Scholar
- 62.Turpie AGG, Robinson JG, Doyle DJ, et al. Comparison of high-dose with low-dose subcutaneous heparin to prevent left ventricular mural thrombosis in patients with acute transmural anterior myocardial infarction. N Engl J Med. 1989;320: 352–357.PubMedCrossRefGoogle Scholar
- 63.Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction. Long-term follow-up with serial echocardiography. Ann Int Med. 1984;100:789–794.PubMedCrossRefGoogle Scholar
- 64.Tobin R, Slutsky RA, Higgins CB. Serial echocardiograms in patients with congestive cardiomyopathies: lack of evidence for thrombus formation. Clin Cardiol. 1984;7:99–101.PubMedGoogle Scholar
- 65.Gottdiener JS, Gay JA, VanVoorhees L, et al. Frequency and embolic potential of left ventricular thrombus in dilated cardiomyopathy: assessment by two-dimensional echocardiography. Am J Cardiol. 1983;52:1281–1285.PubMedCrossRefGoogle Scholar
- 66.Fuster V, Gersh BJ, Giuliani ER, et al. The natural history of idiopathic dilated cardiomyopathy. Am J Cardiol. 1981;47:525–531.PubMedCrossRefGoogle Scholar
- 67.Wolf PA, Sila CA. Cerebral ischemia with mitral valve prolapse. Am Heart J. 1987;113:1308–1315.PubMedCrossRefGoogle Scholar
- 68.Jackson AC. Neurologic disorders associated with mitral valve prolapse. Can J Neurol Sci. 1986;13: 15–20.PubMedGoogle Scholar
- 69.Devereux RB, Hawkins I, Kramer-Fox R, et al. Complications of mitral valve prolapse. Am J Med. 1986;81:751–758.PubMedCrossRefGoogle Scholar
- 70.Baddour LM, Bisno AL. Infective endocarditis complicating mitral valve prolapse: Epidemiologic, clinical and microbiologic aspects. Reviews of Infect Dis. 1986;8:117–136.CrossRefGoogle Scholar
- 71.Stein PD, Kantrowitz A. Antithrombotic therapy in mechanical and biological prosthetic heart valves and saphenous vein bypass grafts. Chest. 1988; (suppl)95:107S–117S.Google Scholar
- 72.Levine HJ, Pauker SG, Salzman EW. Antithrombotic therapy in valvular heart disease. Chest. 1989; (suppl)95:98S–106S.PubMedGoogle Scholar
- 73.Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988;318:1148–1152.PubMedCrossRefGoogle Scholar
- 74.Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59:17–20.PubMedCrossRefGoogle Scholar
- 75.Webster MWI, Smith HJ, Sharpe DN, et al. Patent foramen ovale in young stroke patients. Lancet. 1988;2:11–12.PubMedCrossRefGoogle Scholar
- 76.Lynch JJ, Schuchard GH, Gross CM, et al. Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography. Am J Cardiol. 1984;53:1478–1480.PubMedCrossRefGoogle Scholar
- 77.Salgado AV, Furlan AJ, Keys TF, et al. Neurological complications of native and prosthetic valve endocarditis: a 12 year experience. Neurology. 1989;39: 173–178.PubMedCrossRefGoogle Scholar
- 78.Hart RG, Kagen-Hallet K, Joerns SE. Mechanisms of intracranial hemorrhage in infective endocarditis. Stroke. 1987;18:1048–1056.PubMedCrossRefGoogle Scholar
- 79.Salgado AV, Furlan AJ, Keys TF. Mycotic aneurysm, subarachnoid hemorrhage and indications for cerebral angiography in infective endocarditis. Stroke. 1987;18:1057–1060.PubMedCrossRefGoogle Scholar
- 80.Ott BR, Zamini A, Kleefield J, et al. The clinical spectrum of hemorrhagic infarction. Stroke. 1986; 17:630–637.PubMedCrossRefGoogle Scholar
- 81.Horning CR, Dorndorf W, Agnoli AL. Hemorrhagic cerebral infarction — a prospective study. Stroke. 1986;17:179–185.CrossRefGoogle Scholar
- 82.Lodder J, Krijne-Kubat B, Broekman J. Cerebral hemorrhagic infarction at autopsy: cardiac embolic cause and the relationship to the cause of death. Stroke. 1986;17:626–629.PubMedCrossRefGoogle Scholar
- 83.Hart RG, Easton JD. Hemorrhagic infarcts. Stroke. 1986;17:586–589.PubMedCrossRefGoogle Scholar
- 84.Cerebral Embolism Study Group. Cardioembolic stroke, immediate anticoagulation and brain hemorrhage. Arch Int Med. 1987;147:636–640.CrossRefGoogle Scholar
- 85.Sato Y, Mizoguchi K, Sato Y, et al. Anticoagulant and thrombolytic therapy for cerebral embolism of cardiac origin. Kurume Med J. 1986;33: 89–95.PubMedCrossRefGoogle Scholar
- 86.Gorsselink EL, Lodder J, van der Lugt PJM. Risk of early anticoagulation in patients with small deep infarcts possibly caused by cardiogenic emboli. Clin Neurol Neurosurg. 1987;89:157–159.PubMedCrossRefGoogle Scholar
- 87.Krijne-Kubat B, Lodder J, van der Lugt PJM. Hemorrhagic infarction on CT in cardioembolic stroke. Clin Neurol Neurosurg. 1987;89:103–105.PubMedCrossRefGoogle Scholar