Updates on Prevention of Cardioembolic Strokes / 대한뇌졸중학회지

Cardiac embolism continues to be a leading etiology of ischemic strokes worldwide. Although pathologies that result in cardioembolism have not changed over the past decade, there have been significant advances in the treatment and stroke prevention methods for these conditions. Atrial fibrillation remains the prototypical cause of cardioembolic strokes. The availability of new long-term monitoring devices for atrial fibrillation detection such as insertable cardiac monitors has allowed accurate detection of this leading cause of cardioembolism. The non-vitamin K antagonist oral anticoagulants have improved our ability to prevent strokes for many patients with non-valvular atrial fibrillation (NVAF). Advances in left atrial appendage closure and the U.S. Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device for stroke prevention in NVAF patients who have an appropriate rationale for a nonpharmacological alternative, have revolutionized the field and provided a viable option for patients at higher hemorrhagic risk. The role of patent foramen ovale closure for secondary prevention in selected patients experiencing cryptogenic ischemic strokes at a relatively young age has become clearer thanks to the very recent publication of long-term outcomes from three major studies. Advances in the management of infective endocarditis, heart failure, valvular diseases, and coronary artery disease have significantly changed the management of such patients, but have also revealed new concerns related to assessment of ischemic versus hemorrhagic risk in the setting of antithrombotic use. The current review article aims to discuss these advances especially as they pertain to the stroke neurology practice.

Characteristics of large artery atherosclerosis and cardioembolism acute ischemic stroke: A comparative study / 第二军医大学学报

Objective To investigate the difference in infarction characteristics between large artery atherosclerosis and cardioembolism acute ischemic stroke (AIS). Methods A retrospective study was done on 99 AIS patients, who were admitted to Emergency Room of our hospital and underwent multi-modal computed tomography (CT) after admission and before treatment. Forty-six of 99 AIS patients had large artery atherosclerosis and 53 had cardioembolism. The NIHSS score and GCS score on admission, infraction core and ischemic penumbra volumes and the volume difference, and vascular occlusion rates of posterior circulation and large artery were compared between the two groups. Results Compared with the cardioembolism group, the NHISS score was significantly lower and the GCS score was significantly higher in the large artery atherosclerosis group (9.5 [2.0, 16.0] vs 15.0 [6.0, 24.0], Z=2.31, P0.05). The large artery occlusion rate and posterior circulation occlusion rate were both significantly different between the large artery atherosclerosis and cardioembolism groups (30.43% [14/46] vs 50.94% [27/53] and 36.96% [17/46] vs 9.43% [5/53]; χ2=11.82 and 6.77, both P<0.001). Conclusion The clinical symptoms, cerebral changes and intracranial large artery changes are different in AIS patients with large artery atherosclerosis and cardioembolism. Etiology evaluation based on clinical features and multi-modal CT examination can help to accurately assess the ischemic state of AIS patients.

Endovascular treatment of acute ischemic stroke by large artery atherosclerosis and cardioembolism middle cerebral artery M1 segment occlusion: A single center retrospective study / 第二军医大学学报

Objective To investigate the clinical characteristics of the patients with acute ischemic stroke (AIS) caused by large artery atherosclerosis (LAA) or cardioembolism (CE) middle cerebral artery M1 segment occlusion, and to explore the difference of endovascular treatment. Methods The patients with AIS caused by M1 segment occlusion, who received endovascular treatment between Sep. 2014 and Feb. 2018 in our hospital, were recruited and assigned to LAA group and CE group. Clinical characteristics, treatment strategy, postoperative hemorrhage rate and prognosis were analyzed. Results Totally 134 patients were included, and 48 patients were in the LAA group and 86 patients were in the CE group. There were significant differences in the gender and age between the LAA and CE groups (male/female 39/9 vs 40/46, χ2＝ 15.363; average age [62.65±9.76] years vs [69.66±12.43] years, t＝－3.371; both P0.05). Compared with the CE group, the proportion of the patients with hypertension was significantly higher, and the National Institutes of Health stroke scale score on admission was significantly lower in the LAA group (70.8% [34/48] vs 51.2% [44/86], χ2＝4.900, P＝0.027; 13 [7, 16] vs 16 [13, 21], Z＝－3.603, P0.001). The proportion of the patients with angioplasty in the LAA group was 52.1% (25/48), which was significantly higher than the proportion in the CE group (4.7% [4/86], χ2＝38.121, P0.01). The incidence of postoperative intracranial hemorrhage was significantly lower in the LAA group than that in the CE gorup (10.4% [5/48] vs 32.6% [28/86], χ2＝8.136, P＝0.004). There were no significant differences in the incidence of symptomatic intracranial hemorrhage, endovascular recanalization rate, or good prognosis rate or mortality 3 months after operation between the two groups (all P0.05). Conclusion Compared with the patients with AIS due to LAA M1 segment occlusion, the CE patients have more severe symptoms and higher postoperative hemorrhage rate after endovascular treatment. The strategy of endovascular treatment is different in the two types of AIS, while there are no differences in prognosis and mortality after treatment.

Ischemic Stroke after Heart Transplantation / 대한뇌졸중학회지

Cerebrovascular complications after orthotopic heart transplantation (OHT) are more common in comparison with neurological sequelae subsequent to routine cardiac surgery. Ischemic stroke and transient ischemic attack (TIA) are more common (with an incidence of up to 13%) than intracranial hemorrhage (2.5%). Clinically, ischemic stroke is manifested by the appearance of focal neurologic deficits, although sometimes a stroke may be silent or manifests itself by the appearance of encephalopathy, reflecting a diffuse brain disorder. Ischemic stroke subtypes distribution in perioperative and postoperative period after OHT is very different from classical distribution, with different pathogenic mechanisms. Infact, ischemic stroke may be caused by less common and unusual mechanisms, linked to surgical procedures and to postoperative inflammation, peculiar to this group of patients. However, many strokes (40%) occur without a well-defined etiology (cryptogenic strokes). A silent atrial fibrillation (AF) may play a role in pathogenesis of these strokes and P wave dispersion may represent a predictor of AF. In OHT patients, P wave dispersion correlates with homocysteine plasma levels and hyperhomocysteinemia could play a role in the pathogenesis of these strokes with multiple mechanisms increasing the risk of AF. In conclusion, stroke after heart transplantation represents a complication with considerable impact not only on mortality but also on subsequent poor functional outcome.

Intravenous thrombolysis is more effective in ischemic cardioembolic strokes than in non-cardioembolic? / A trombólise endovenosa é mais eficaz nos acidentes vasculares cerebrais isquêmicos cardioembólicos do que nos não cardioembólicos?

It was suggested that intravenous thrombolysis (IT) leads to larger extent recanalization in cardioembolic stroke. In this work we assess if this has beneficial clinical traduction. METHOD: We evaluated 177 patients undergoing IT, which were categorized into cardioembolic (CE) and non-cardioembolic (NCE). National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale were compared. RESULTS: The mean age was 67.4±12.01 and 53.8 percent were male. The mean NIHSS was: 14 (admission), 9 (24 h) and 6 (discharge), similar in subgroups. The difference between NIHSS at admission and 24 hours was 4.17±4.92 (CE: 4.08±4.71; NCE: 4.27±5.17, p=0.900) and at admission and discharge there was an average difference of 6.74±5.58 (CE: 6.97±5.68; NCE: 6.49±5.49, p=0.622). The mRS at discharge and 3 months was not significantly different by subtype, although individuals whose event was NCE are more independent at 3 months. CONCLUSION: Ours findings argue against a specific paper of IT in CE. It can result from heterogeneity of NCE group.

Alguns estudos sugerem que a trombólise endovenosa (TE) conduz a melhor recanalização nos acidentes vasculares cerebrais isquêmicos (AVCI) cardioembólicos. Neste trabalho questionamos se isto terá tradução em benefício clínico. MÉTODO: Avaliamos 177 doentes submetidos a TE, os quais foram categorizados como cardioembólicos (CE) e não cardioembólicos (NCE). Compararam-se a National Institutes of Health Stroke Scale (NIHSS) e escala de Rankin modificada. RESULTADOS: A idade média foi 67,4±12,01 e 53,8 por cento eram homens. NIHSS média foi: 14 (admissão), 9 (24 h), 6 (alta), semelhante nos subgrupos. A diferença entre NIHSS à admissão e 24 h foi de 4,17±4,92 (CE: 4,08±4,71; NCE: 4,27±5,17, p=0,900) e entre a admissão e a alta de 6,74±5,58 (CE: 6,97±5,68; NCE: 6,49±5,49, p=0,622). A classificação na mRS não foi significativamente diferente nos subgrupos (alta e 3 meses), mas os doentes com eventos NCE estavam mais independentes aos 3 meses. CONCLUSÃO: Os nossos resultados não documentam um papel específico da TE nos CE, o que pode resultar da heterogeneidade do grupo NCE.

Topographic Characteristics of Middle Cerebral Artery Territorial Infarct in Patients with Atrial Fibrillation

BACKGROUND: Atrial fibrillation (AF) is known as a major independent risk factor of cardioembolic stroke. The aim of this study is to compare topographic characteristics of the middle cerebral artery (MCA) territory infarction between in patients with AF and without AF, which explain the cardioembolic infarction as a main manifestation in patients with AF. METHODS: We retrospectively investigated patients with MCA territory infarcts on routine MRI. Thirty-two patients with AF (AF group) and forty-two patients with normal sinus rhythm (NSR group) were compared. Topographic patterns and vascular status of intracranial vessels were analyzed in two groups. RESULTS: In AF group, possible or probable cardioembolic stroke was 78%. The significant stenosis of extra- or intracranial artery was 19% in AF group. The simultaneous involvement of cortical and basal ganglia (p < 0.01) and silent infarctions on contralateral hemisphere (p < 0.01) were more frequent in AF group. The involvement of insular cortex was common in both groups. CONCLUSIONS: In our study, cardioembolism is the most probable cause of cerebral infarction in AF group. Above find-ings may be applied to the proper management of cerebral infarction associated with AF.