Cardioembolic
cerebral infarction (CI) is the most severe subtype of
ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific
cardiac disorders and prognosis of CI. CI accounts for 14-30% of
ischemic strokes; patients with CI are prone to early and long-term
stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's
aphasia or
global aphasia without
hemiparesis, a Valsalva manoeuvre at the time of
stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a
lacunar infarct and especially multiple
lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include
atrial fibrillation, recent
myocardial infarction, mechanical prosthetic valve, dilated
myocardiopathy and mitral rheumatic
stenosis.
Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic
infarction. Mitral annular calcification can be a marker of complex aortic
atheroma in
stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural
heart diseases. Paroxysmal atrial dysrhythmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in
cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of
cerebral infarction.
Secondary prevention with
anticoagulants should be started immediately if possible in patients at high risk for recurrent
cardioembolic stroke in which
contraindications, such as falls, poor compliance, uncontrolled
epilepsy or gastrointestinal
bleeding are absent.
Dabigatran has been shown to be non-inferior to
warfarin in the prevention of
stroke or systemic
embolism. All significant structural defects, such as
atrial septal defects, vegetations on valve or severe
aortic disease should be treated.
Aspirin is recommended in
stroke patients with a
patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.