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embolic stroke

Also see ischemic stroke. Etiology: - embolus from cardiac source (20%) a) patent foramen ovale [3,4] - cryptogenic stroke, all ages, epecially < 55-60 b) atrial septal aneurysm in 28-40% of ischemic strokes in patients < 55 years of age c) patent foramen ovale & atrial septal aneurysm frequently occur together d) multiple cardiac emboli are suggested by 2 or more areas of ischemic infarction e) myocardial infarction [2] resulting in LV systolic dysfunction f) atrial fibrillation [2] - 25% of patients with cryptogenic embolic stroke have paroxysmal atrial fibrillation [1,5]; 12-16% [6] - perioperative atrial fibrillation associated with increased risk of embolic stroke (RR=1.3) [8] Pathology: - patients with cardioembolic stroke found to have oral microbiota dysbiosis & associated elevated plasma inflammatory cytokines [17] - plasma IL6, IL8, IL1-beta, TNF-alpha & sCD40L correlate with Peptostreptococcus, Staphylococcus, Selenomonas, Megasphaera & other bacteria [17] Special laboratory: - prolonged outpatient cardiac rhythm monitoring for atrial fibrillation indicated [1,6] - 30-day event-triggered recorder more sensitive than 24 hour HOLTER* - 6 months of monitoring with an insertable cardiac monitor [6] - 10 day HOLTER monitoring 3 times within 6 months [11] * it is not clear how or why the events were triggered Radiology: - also see ischemic stroke - CT angiography after thrombolysis for ischemic stroke identifies patients eligible for embolectomy - transcranial doppler ultrasonography - echocardiogram - transthoracic echocardiogram with agitated saline in younger patients - transesophageal echocardiogram not routinely indicated - can detect aortic arch thrombi: thrombi > 3 mm are suspect - identifies atrial septal defect in young adults with stroke - cardiac computed tomography - results similar to transesophageal echocardiogram [9] - ECG-gated cardiac CT at the time of initial brain imaging identifies cardiac thrombus more frequently than echocardiogram (7.1 vs 0.6%) [16] - identifies source in 6.3% of patients with otherwise cryptogenic stroke [16] Complications: - secondary hemorrhage may occur - microbleeds increase risk of recurrent stroke, ischemic stroke, intracerebral hemorrhage & mortality in embolic stroke of uncertain source, but do not influence effect of rivaroxaban [15] Management: - patients* may be able to detect rhythm irregularity by monitoring their own pulse post embolic stroke [7] - heparin followed by warfarin - do NOT use - neither rivaroxaban nor dabigtran is superior to aspirin for prevention of recurrent embolic stroke of undetermined origin & are associated with a higher risk of bleeding [1,12,14] - former recommendations - use asprin for 4-14 days, then switch to anticoagulation - direct oral anticoagulants appear safe to use within 7 days of ischemic stroke [10], within 4 days [21] - see ischemic stroke - patients eligibible for thrombolysis for ischemic stroke [1] - follow with CT angiography [1] - patients with embolic stroke of unknown source with high risk for atrial fibrillation* may benefit from anticoagulation [13] - see atrial fibrillation - patients with atrial fibrillation who experience embolic stroke may start/restart direct oral antigoagulant within 48 hours after a mild or moderate stroke or on day 6-7 after a severe stroke [18] - strategy minimizes hemorrhagic transformation of ischemic stroke [18] - continuing with same direct anticoagulant associated with lowest risk for recurrent stroke [19] * premature atrial contractions, left atrial enlargement, congestive heart failure, coronary artery disease, age > 75 years, hypertension, valvular heart disease Notes: - video [20]

Related

cardiac conditions associated with embolic stroke

Specific

cryptogenic stroke; embolic stroke of undetermined source

General

ischemic stroke

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021
  2. Journal Watch 22(10):77, 2002 Lichtman et al Risk and predictors of stroke after myocardial infarction among the elderly: results from the Cooperative Cardiovascular Project. Circulation 105:1082, 2002 PMID: 11877359
  3. Petty GW, Khandheria BK, Meissner I, Whisnant JP, Rocca WA, Christianson TJ, Sicks JD, O'Fallon WM, McClelland RL, Wiebers DO. Population-based study of the relationship between patent foramen ovale and cerebrovascular ischemic events. Mayo Clin Proc. 2006 May;81(5):602-8. PMID: 16706256 - Petty GW, Khandheria BK, Meissner I, Whisnant JP, Rocca WA, Sicks JD, Christianson TJ, O'Fallon WM, McClelland RL, Wiebers DO. Population-based study of the relationship between atherosclerotic aortic debris and cerebrovascular ischemic events. Mayo Clin Proc. 2006 May;81(5):609-14. PMID: 16706257
  4. Handke M et al, Patient foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007, 357:2262 PMID: 18046029
  5. Tayal AH, Tian M, Kelly KM Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology. 2008 Nov 18;71(21):1696-701 PMID: 18815386
  6. Gladstone DJ et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014 Jun 26; 370:2467 PMID: 24963566 http://www.nejm.org/doi/full/10.1056/NEJMoa1311376 - Sanna T et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014 Jun 26; 370:2478. PMID: 24963567 http://www.nejm.org/doi/full/10.1056/NEJMoa1313600 - Kamel H. Heart-rhythm monitoring for evaluation of cryptogenic stroke. N Engl J Med. 2014; 370:2532-2533 PMID: 24963573
  7. Kallmunzer B et al Peripheral pulse measurement after ischemic stroke. A feasibility study. Neurology. July 23, 2014 PMID: 25056581 http://www.neurology.org/content/early/2014/07/23/WNL.0000000000000690
  8. Gialdini G et al Perioperative Atrial Fibrillation and the Long-term Risk of Ischemic Stroke. JAMA. 2014;312(6):616-622. PMID: 25117130 http://jama.jamanetwork.com/article.aspx?articleid=1895248 - Nuotio I et al Time to Cardioversion for Acute Atrial Fibrillation and Thromboembolic Complications. JAMA. 2014;312(6):647-649. PMID: 25117135 http://jama.jamanetwork.com/article.aspx?articleid=1895235
  9. Lee K et al. Predictors of recurrent stroke in patients with ischemic stroke: Comparison study between transesophageal echocardiography and cardiac CT. Radiology 2015 Aug; 276:381 PMID: 25692312
  10. Seiffge DJ et al. Early start of DOAC after ischemic stroke: Risk of intracranial hemorrhage and recurrent events. Neurology 2016 Sep 30 PMID: 27694266
  11. Wachter R, Groschel K, Gelbrich G et al. Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): An open-label randomised controlled trial. Lancet Neurol 2017 Apr; 16:282. PMID: 28187920 http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(17)30002-9/abstract
  12. Hart RG, Sharma M, Mundl H et al Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med 2018; 378:2191-2201 PMID: 29766772 https://www.nejm.org/doi/10.1056/NEJMoa1802686
  13. Healey JS, Gladstone DJ, Swaminathan B et al. Recurrent stroke with rivaroxaban compared with aspirin according to predictors of atrial fibrillation: Secondary analysis of the NAVIGATE ESUS randomized clinical trial. JAMA Neurol 2019 Apr 8; PMID: 30958508 https://jamanetwork.com/journals/jamaneurology/fullarticle/2729692
  14. Diener HC, Sacco RL, Easton JD et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med 2019 May 16; 380:1906-1917 PMID: 31091372 https://www.nejm.org/doi/10.1056/NEJMoa1813959https://www.medscape.com/viewarticle/986902
  15. Shoamanesh A, Hart RG, Connolly SJ et al Microbleeds and the Effect of Anticoagulation in Patients With Embolic Stroke of Undetermined SourceAn Exploratory Analysis of the NAVIGATE ESUS Randomized Clinical Trial. JAMA Neurol. 2021;78(1):11-20 PMID: 33074284 PMCID: PMC7573796 Free PMC article https://jamanetwork.com/journals/jamaneurology/fullarticle/2771829 - Puy L, Cordonnier C. Cerebral Microbleeds and Antithrombotic Treatments - Stop Worrying About Bleeding. JAMA Neurol. 2021;78(1):9-10 PMID: 33074292 https://jamanetwork.com/journals/jamaneurology/fullarticle/2771826
  16. Rinkel LA et al. Diagnostic yield of ECG-gated cardiac CT in the acute phase of ischemic stroke vs transthoracic echocardiography. Neurology 2022 Aug 2; [e-pub]. PMID: 35918169 https://n.neurology.org/content/early/2022/08/01/WNL.0000000000200995
  17. Ghanjanasak T Poor Oral Hygiene After Stroke Can Alter Inflammation Risk. Medscape. January 12, 2023 - Jing XZ, Xie X, Gao J et al Oral microbiota dysbiosis and increased inflammatory cytokines with different stroke subtypes. J Neuroinflammation. Jan 5, 2023 (preprint) https://www.researchsquare.com/article/rs-2398453/v1
  18. Fischer U et al. Early versus later anticoagulation for stroke with atrial fibrillation. N Engl J Med 2023 May 24; [e-pub]. PMID: 37222476 https://www.nejm.org/doi/10.1056/NEJMoa2303048
  19. Bonaventure Ip YM et al. Association of alternative anticoagulation strategies and outcomes in patients with ischemic stroke while taking a direct oral anticoagulant. Neurology 2023 May 24; [e-pub]. PMID: 37225430 https://n.neurology.org/content/early/2023/05/24/WNL.0000000000207422
  20. Johansen MC Cardioembolic Stroke VuMedi Jan 18, 2024 https://www.vumedi.com/video/cardioembolic-stroke/
  21. Werring D et al. Optimal timing of anticoagulation after acute ischaemic stroke with atrial fibrillation (OPTIMAS): A multicentre, blinded-endpoint, phase 4, randomised controlled trial. Lancet 2024 Nov 2; 404:1731 PMID: 39491870 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02197-4/fulltext