1. Cardioembolic Stroke: Diagnosis and Management
Gregory W. Albers, MD
Professor of Neurology and Neurological Sciences
Director, Stanford Stroke Center

2. Cardioembolic Stroke: Diagnosis and Management
Diagnostic criteria for cardioembolism
Clinical and neuroimaging features
Aortic atheroma
Patent foramen ovale
Treatment of cardioembolic stroke

3. Diagnosis of Cardioembolic Stroke
“The presence of a potential cardioembolic source in the absence of cerebrovascular disease in a patient with a non-lacunar stroke”
Cerebral Embolism Task Force, 1989

4. Cardioembolic Sources
High Risk
Medium Risk
Low / Unclear Risk
Atrial fibrillation
Recent anterior MI
Mechanical valve
Rheumatic mitral
stenosis
Thrombus / tumor
Endocarditis
LV hypokinesia / aneurysm
Bioprostetic valve
Congestive failure
Cardiomyopathy
Myxomatous MVP
Patent foramen ovale
Atrial septal aneurysm
Spontaneous echo contrast

5. How Often are Lacunes Cardioembolic?
About 20% have potential cardiac sources
About % attributed to cardioembolism
Cardioembolic lacunes often large (>1.5 cm)

6. Clinical Features of Cardioembolic Stroke
Abrupt non-progressive onset
Decreased consciousness at onset
Embolism to other organs
Palpitations at onset
Pure Wernicke’s aphasia
Hemianopia without hemiparesis

7. Neuroimaging Features of Cardioembolic Stroke
Embolic occlusion on early angiography
Absent or minimal atherosclerosis
Involvement of posterior division of MCA
Multiple cortical infarcts
Delayed hemorrhagic transformation
Hyperdense MCA sign on CT

8. Multiple Acute Ischemic Lesions in Different Vascular Territories on DWI
Pettis
ADC

9. “Embolic Pattern” on DWI
Russell Johnson

25. PFO and Stroke
Patent foramen ovale occurs in about 20% of normal controls
Associated with stroke in case-control series: especially < 55 yrs, large PFO, atrial septal aneurysm
Prospective studies: low stroke recurrence and no association with size

26. Stroke Recurrence Following Cryptogenic Stroke in Young Patients
Group yr Stroke Risk
No atrial septal abnormality 4.2% ( )
(N = 304)
PFO alone (N = 216) % ( )
PFO and ASA (N = 51) 15.2 % ( )*
NEJM 2001;345:
*p =0.007 (compared with no atrial septal abnormality)
All patients received ASA 300 mg/day; ages years

27. Antithrombotic Therapy for PFO-Associated Stroke
The PICSS Sub-study of WARSS
Group Stroke or Death (2 yrs)
Warfarin (N = 97) %
Aspirin (N = 106) %
No increase in stroke rate with large PFOs; 51 patients with ASA +PFO had similar event rates and no differential response to warfarin vs. aspirin

28. Therapeutic Options for PFO-related Stroke
Low recurrence risk on aspirin
Warfarin not more effective than aspirin
Surgical Closure
Endovascular closure devices

29. Treatment
of Acute
Cardioembolic Stroke

30. Treatment of Acute Cardioembolic Stroke
Recent trial results
Risk factors for early stroke recurrence
Risk of hemorrhagic complications
Risk factors for sympotomatic ICH
Recommendations for therapy

31. Recent Trial Results Trial Recurrent Stroke (%)
IST (AF subgroup) Heparin 2.8
(N = 3169) No heparin 4.9
TOAST (cardioembolism) Danaparoid 0
(N = 266) Placebo 1.6
HAEST (all with AF) Dalteparin 8.5
(N = 449) Aspirin 7.5
TAIST* HD Tinzaparin 3.3
(N = 1484) LD Tinzaparin 4.7
Aspirin 3.1
*no benefit in cardioembolism subgroup

32. Treatment of Acute Cardioembolic Stroke
Risk of Early Stroke Recurrence
Multiple recent emboli
Mechanical heart valve
Atrial fibrillation + high risk features
Established intra-cardiac thrombus

33. Treatment of Acute Cardioembolic Stroke
Risk of Hemorrhagic Complications
Anticoagulation increases the risk of extracranial hemorrhage by about 2%
Spontaneous hemorrhagic transformation is common and usually asymptomatic
Anticoagulation increases the risk of symptomatic ICH by about 2%

34. Treatment of Acute Cardioembolic Stroke
Risk Factors for Symptomatic ICH
Infarct size
Timing of reperfusion ( hours)
Excesssive anticoagulation / tPA
Heparin bolus?
Severe hypertension?

35. Treatment of Acute Cardioembolic Stroke
Recommendations for Therapy
Aspirin for acute therapy (t-PA if eligible)
If low risk for early recurrence: begin warfarin (days to weeks)
If high risk of early recurrence: consider early anticoagulation if low risk for symptomatic hemorrhage

36. Cardioembolic Stroke: Diagnosis and Management
Diagnostic criteria for cardioembolism
Clinical and neuroimaging features
Aortic atheroma
Patent foramen ovale
Treatment of cardioembolic stroke