CARDIOEMBOLIC STROKE Debasis Das, MD, FACC Interventional Cardiologist CHI St. Vincent Heart Clinic Arkansas April 25, 2015

Ischemic Cerebral Infarct

Introduction Most severe form of ischemic stroke. Incidence is 25% of all stroke High (25%) in-hospital mortality Prone to early and long-term recurrence Many are preventable

Etiologies Atrial fibrillation or flutter Recent MI, LV aneurysm Mechanical prosthetic valves Dilated cardiomyopathy Rheumatic mitral valve stenosis PFO, ASD, VSD Endocarditis Cardiac tumors Calcific aortic valve stenosis Complex aortic arch atheroma Cardiac catheterization

Atrial Fibrillation

LAA thrombus

Thrombus in PFO

LV Aneurysm with Thrombus

Left Atrial Myxoma

Mitral valve vegetation

Aortic arch atheroma

Clinical Features Sudden onset to maximal deficit Decreased level of consciousness at onset Wernicke’s aphasia or global aphasia without hemiparesis A valsalva maneuver at the time of stroke onset Co-occurrence of cerebral and systemic emboli Simultaneous or sequential strokes in different vascular territories

Diagnosis Compatible clinical picture Recognition of emboligenic disease Exclusion of carotid and cerebral atherosclerosis

Tests Transthoracic echocardiogram Transesophageal echocardiogram CT scan of the heart Holter monitor, event recorder CT scan, MRI of the brain Carotid duplex ultrasound Transcranial Doppler

Prevention and Treatment Anticoagulation (Atrial fibrillation, mural thrombus, prosthetic valves) Left atrial appendage closure, ligation, resection Treatment of structural heart disease PFO, ASD, VSD closure

ASO

Amplatzer Septal Occluder

Amplatzer atrial appendage occluder (Image courtesy of BMJ Publishing Group Ltd and British Cardiovascular Society.)