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

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

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

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

How Often are Lacunes Cardioembolic? About 20% have potential cardiac sources About 5 - 10% attributed to cardioembolism Cardioembolic lacunes often large (>1.5 cm)

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

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

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

“Embolic Pattern” on DWI Russell Johnson

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

Stroke Recurrence Following Cryptogenic Stroke in Young Patients Group 4 yr Stroke Risk No atrial septal abnormality 4.2% (1.8 - 6.6) (N = 304) PFO alone (N = 216) 2.3% (0.3 - 4.3) PFO and ASA (N = 51) 15.2 % (1.8 - 28.6)* NEJM 2001;345:740-746 *p =0.007 (compared with no atrial septal abnormality) All patients received ASA 300 mg/day; ages 18 - 55 years

Antithrombotic Therapy for PFO-Associated Stroke The PICSS Sub-study of WARSS Group Stroke or Death (2 yrs) Warfarin (N = 97) 16.5% Aspirin (N = 106) 13.2% 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

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

Treatment of Acute Cardioembolic Stroke

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

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

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

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%

Treatment of Acute Cardioembolic Stroke Risk Factors for Symptomatic ICH Infarct size Timing of reperfusion (12 - 48 hours) Excesssive anticoagulation / tPA Heparin bolus? Severe hypertension?

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

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