The data for this review were identified from my files, recent guidelines, Cochrane reviews, and searches of Medline with the key words “cardioembolic stroke” and “guidelines, clinical practice and stroke” for the years 1998–2002. The 2001–02 issues of Stroke, Cerebrovascular Disease, and Neurology, were searched by hand. Papers published in English, French, Spanish, or Portuguese were included.
ReviewCardioembolic stroke: an update
Section snippets
At the site of effect
MRI can provide evidence for cardioembolism by showing lesions not visible on CT and can reveal cortical involvement in strokes that seem to be subcortical and multiple lesions in strokes that seem to be single lesions on CT. The sensitivity of MRI to haemorrhagic transformation is higher than that of CT. Diffusion-weighted imaging can also identify lacunar infarctions associated with embolic source. Diffusion-weighted imaging can show multiple regions of increased signal intensity in 16% of
Aortic-arch atheroma
Autopsy and transoesophageal-echocardiogram studies showed that protruding aortic atheroma (>4–5 mm) is 3–9 times more common in stroke patients than in healthy controls.39, 40 The relative risk of recurrence of stroke and other ischaemic events in stroke patients with plaques of atheroma in the aorta thicker than 4–5 mm ranges from 1·6 to 4·3.40, 41 Besides thickness over 4 mm, ulcerated, non-calcified plaques and those with mobile components are associated with an increased risk of stroke
Prevention of recurrent stroke: implementation of guidelines in practice
Risk factors for thromboembolism in atrial fibrillation are well identified and include previous embolism (including previous transient ischaemic attack or ischaemic stroke), age of more than 65 years, structural cardiac disease, rheumatic or other significant valvular heart disease, valvular artificial prosthesis, hypertension, heart failure and significant left ventricular systolic dysfunction, diabetes, and coronary disease (table 2).96, 97 Patients with fibrillation who are seen by
Alternatives to coumarinic oral anticoagulants
The FFAACS trial compared fluindone plus placebo with fluindone plus aspirin (100 mg/day) in high-risk patients with atrial fibrillation but was prematurely stopped because of low inclusion rate. The combination of aspirin with anticoagulant was associated with increased bleeding, but efficacy could not be measured owing to the small number of ischaemic events.119 The increased risk of haemorrhage from adding aspirin to fixed-dose low-intensity warfarin (international normalised ratio =1·2–1·5)
Acute antithrombotic treatment of cardioembolic stroke
The main rationale for early, acute antithrombotic treatment of cardioembolic stroke is the prevention of recurrent embolisation. However, there is still uncertainty over how long after a cardioembolic ischaemic stroke secondary prevention with anticoagulants should be started. Early stroke recurrence is higher in patients with cardioembolic stroke or atrial fibrillation than in other stroke subtypes or in patients in sinus rhythm.130, 131 The risk of early reembolisation was claimed to be as
Conclusion and future directions
During the past two decades, enormous progress has been made in the non-invasive diagnosis of cardioembolic disorders and in establishing evidence-based recommendations for the primary and secondary prevention of cardioembolic stroke (table 4). Although anticoagulants are the primary intervention for the prevention of cardioembolic stroke, they do not decrease death or dependency, change progression, or prevent early recurrence in acute stroke due to cardioembolism.
Because atrial fibrillation
Search strategy and selection criteria
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