Indications for echocardiography in patients with ischemic stroke

Estimation of stroke etiology from lesion patterns on diffusion-weighted magnetic resonance imaging in patients with carotid artery occlusive disease

BACKGROUND

Various mechanisms can be considered in ischemic stroke with internal carotid artery (ICA) occlusive diseases. We clarified the etiologic mechanisms from lesion patterns on diffusion-weighted imaging (DWI).

METHODS

One hundred and twenty consecutive ischemic stroke patients with ipsilateral ICA occlusive diseases were enrolled and classified into 3 groups according to the size of DWI lesions: group A, massive; group B, moderate-to-large; and group C, small. Group C was divided into 3 subgroups according to the number of lesions: C1, 1-3; C2, 4-9; and C3, 10 or more. The relationship between the DWI findings and stroke subtypes according to the TOAST classification was investigated.

RESULTS

Cardioembolism was significantly more common in groups A and B than in group C, while large-artery atherosclerosis (LAA) was more frequent in group C than in groups A and B. In group A, cardioembolism accounted for 32%, while LAA was not observed. Statistical analyses showed trends toward a higher frequency of LAA in groups C2 and C3 than in group C1.

CONCLUSIONS

Mechanisms of acute stroke in ICA diseases can be simply assessed from the lesion size and number, which may be useful in considering acute therapeutic strategies.

Pulmonary-artery cineangiocardiography and echocardiography for detection of cardiac sources of cerebral embolism

Sixty-two patients with ischemic stroke possibly due to embolism of cardiac origin were investigated by pulmonary artery-cineangiography (PACAC) and echocardiography (UCG) to detect intracardiac thrombi. The proportion of intracardiac thrombi found by PACAC was 31% and by UCG 15%. The presence or absence of atrial fibrillation correlated well with PACAC findings of an intraventricular clot but poorly with UCG. Similarly, there was a significant association between ischemic heart disease and intraventricular thrombi detected by PACAC investigations but not with the results obtained by UCG. PACAC seems superior to UCG in the detection of intracardiac thrombi after possible embolic stroke.

Transesophageal echocardiography: Diagnostic and clinical applications in the evaluation of the stroke patient

OBJECTIVES

Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) in diagnosing cardiac abnormalities that may result in cerebral embolism. The clinical importance of these abnormalities is unclear.

METHODS

We classified 96 consecutive stroke patients into high- or low-risk groups for cardioembolism based on historical criteria. The presence of left atrial thrombus, atrial smoke, patent foramen ovale, atrial septal aneurysm, and plaque in the ascending aorta was assessed with TEE. Stroke type and other possible stroke mechanisms were evaluated.

RESULTS

Left atrial thrombus occurred only in the high-risk group. Patent foramen ovale, atrial septal aneurysm, and most cases of left atrial smoke occurred in the presence of another embolic source or were associated with a stroke related to hypertensive small vessel disease. Protruding atherosclerotic plaque in the ascending aorta and aortic arch was the most significant cause of stroke diagnosed by TEE because it frequently occurred in those without other risk factors for stroke. TEE identified aortic plaque in one and left atrial smoke in two patients with lacunar infarction without risk factors for small vessel disease.

CONCLUSIONS

TEE should be considered in both lacunar and nonlacunar stroke that occur in the absence of stroke risk factors, although optimal management of most TEE findings is yet to be determined.

Low yield of transthoracic echocardiography for cardiac source of embolism

To test the hypothesis that the yield for a cardiac source of embolism is very low using transthoracic echocardiography, we reviewed the echocardiographic reports of 1,010 consecutive patients with cerebrovascular accidents who had undergone echocardiography to rule out a cardiac source of embolism; risk factor information was also available in 493 patients. We also used 325 controls who had undergone echocardiography for other reasons during the same period. Each report was examined for the presence of predefined findings depending on their propensity for causing cerebrovascular accidents via an embolic process. The prevalence of a highly probable source of embolism was low in cases (< 3%) and no different from controls after adjusting for age and other risk factors. The prevalence of a possible cardiac source of embolism was also low (< 5%) and similar in cases and controls. The presence of definite or possible thrombus on echocardiography resulted in alteration in therapy in only 2% of cases, of whom 77% had either heart failure, atrial fibrillation, or Q waves on the electrocardiogram. We conclude that the yield of highly probable or possible cardiac source of embolism in patients with cerebrovascular accidents is very low with transthoracic echocardiography, and is no higher than that noted in similar patients without cerebrovascular accidents.

Transoesophageal echocardiography in the investigation of stroke: experience in 135 patients with cerebral ischaemic events

BACKGROUND

The importance of cardiogenic embolism as a cause of cerebral ischaemic events may be underestimated if potential cardiac sources of embolism remain undetected. Transoesophageal echocardiography (TOE) is more sensitive in detecting such abnormalities than earlier methods and may result in more frequent recognition of cardiogenic embolism.

AIMS

To establish in an unselected stroke population the prevalence of potential cardiac sources of embolism detectable on TOE and their relationship to atrial fibrillation and carotid stenosis.

METHODS

One hundred and thirty-five consecutive patients with cerebral ischaemic events were studied using transthoracic and monoplane transoesophageal contrast echocardiography and carotid Duplex imaging or cerebral angiography.

RESULTS

Thirty patients (22%) had atrial fibrillation. In 43 patients (32%), no cardiac source of embolism was identified; in eight echocardiography was normal. At least one potential cardiac source of embolism was identified in 92 patients (68%) with multiple findings in 41; these patients were older (70 +/- 9 years vs 61 +/- 14 years; p = 0.0001), more frequently in atrial fibrillation (28/92 vs 2/43; p = 0.0017) and more frequently had cortical or large subcortical stroke (71/92 vs 23/43; p = 0.005). Carotid stenoses were detected in 55% of patients, not significantly different in those with and without cardiac abnormalities.

CONCLUSION

When bias in selection of patients is avoided, TOE detects a potential cardiac source of embolism in most patients with cerebral ischaemia, particularly those older and in atrial fibrillation. Multiple cardiac abnormalities and coexistent carotid disease are common. The implication of these findings for prevention of stroke awaits age-matched controlled studies.

Heart disease in patients with stroke: incidence, impact, and implications for rehabilitation. Part 1: Classification and prevalence

Heart disease is found in about 75% of patients who have suffered a stroke. Cardiovascular diseases can be risk factors, etiologic mechanisms, associated conditions, or direct consequences of stroke. Cardiac comorbidity may delay initiation of rehabilitation, complicate the course and care of the patient with stroke, inhibit participation in a therapeutic exercise program, limit functional outcomes, and contribute to early mortality in the individual with cerebrovascular disease. Part 1 of this two-part article describes the various forms of heart disease that may be seen in stroke patients, and reviews the incidence figures for each type of associated cardiac condition.

The role of transesophageal echocardiography in the detection of left atrial thrombi

Sensitivity of transthoracic echocardiography in the detection of left atrial thrombi, in particular thrombi confined to the left atrial appendage, is surprisingly low (33%-72%). Concerning the detection of left atrial thrombi, transthoracic echocardiography appears as an inadequate technique in patients with suspected cardiogenic embolism with a success rate of only 0.8% in earlier, and about 3% in recent studies. Imaging from the esophagus substantially increases the detection rate for left atrial thrombi, and is the only clinically relevant semiinvasive technique to diagnose thrombi confined to the left atrial appendage. Transesophageal echocardiography has markedly increased the diagnostic power of cardiovascular ultrasound in patients with suspected cardiogenic embolism and/or atrial fibrillation. Meta-analysis of pooled studies using the transesophageal approach in these patients revealed thrombi within the left atrial cavity in about 7% and within the atrial appendage in about 12% of cases.

Limitations of transoesophageal echocardiography in patients with focal cerebral ischaemic events

OBJECTIVE

To investigate the detection rate of cardiac sources of embolism by transoesophageal echocardiography in patients with focal cerebral ischaemic events and to relate the echocardiographic findings to other clinical findings.

DESIGN

Prospective study with blinded analysis of the echocardiographic data and subsequent comparison with the other clinical findings.

SETTING

Regional cardiothoracic unit based in a teaching hospital.

PATIENTS

131 consecutive patients with focal ischaemic cerebral events (49 with a transient ischaemic attack, 77 with a cerebrovascular accident, and five with a retinal arterial embolus) referred for echocardiography.

INTERVENTIONS

Full M mode, cross sectional, Doppler, and contrast echocardiography by both the precordial and transoesophageal techniques.

RESULTS

Precordial echocardiography detected a cardiac abnormality in 72 patients. Transoesophageal echocardiography confirmed all the precordial findings (except left ventricular hypertrophy, which at present cannot be defined with this technique) and detected other abnormalities in a further 20 patients (18 with potential right-to-left shunts and two with valve vegetations). It also showed spontaneous contrast echoes in 27 of 28 patients with a large left atrium and showed atrial thrombus in three. Cardiac abnormalities were clinically detected in 53 patients, all of which were confirmed or documented by echocardiography. In the 78 patients with no clinically detectable cardiac abnormality six had mitral valve prolapse and one had a regional wall motion defect (identified by precordial echocardiography) and 17 had potential right-to-left shunts (11 of which were identified only by transoesophageal echocardiography).

CONCLUSIONS

Transoesophageal echocardiography is more sensitive than precordial echocardiography in detecting potential sources of embolism in these patients. However, except for the detection of a potential right-to-left shunt, the yield in patients with no cardiac abnormality is low. Moreover, the abnormalities detected in those with previously detected cardiac disease merely confirm the clinical diagnosis. Patients with left atrial spontaneous contrast echoes may benefit from anticoagulation but this requires further study. Until more data are available on this feature and on the role of potential right-to-left shunts in this population, the contribution of echocardiography, precordial or transoesophageal, remains limited.

Role of transoesophageal echocardiography in evaluation of cardiogenic embolism

OBJECTIVE

To determine the value of transoesophageal echocardiography in the assessment of selected patients at risk of cardiogenic embolism or after it.

DESIGN

Prospective comparison of the results of transoesophageal and transthoracic echocardiography. Transoesophageal echocardiography was performed with a 5 MHz single plane phased array transducer.

SETTING

University teaching hospital.

PATIENTS

100 patients referred for transoesophageal echocardiography after a cerebral ischaemic event or peripheral arterial embolism (n = 63), before percutaneous balloon dilatation of the mitral valve (n = 23), or before electrical cardioversion of atrial fibrillation (n = 14).

RESULTS

Transthoracic echocardiography showed potential sources of embolism in four patients including left ventricular thrombus in two patients (with one false positive), left atrial appendage thrombus (n = 1), and patent foramen ovale (n = 1). Transoesophageal echocardiography showed 59 potential embolic sources in 45 patients including left atrial spontaneous echo contrast (n = 33), left atrial appendage thrombus (n = 13), left ventricular thrombus (n = 5), patent foramen ovale (n = 3), left ventricular spontaneous echo contrast (n = 2), mitral valve prosthesis thrombus (n = 1), mitral valve prolapse (n = 1), and pronounced aortic atheroma (n = 1). Transoesophagal echocardiography showed potential embolic sources in 36/53 (68%) patients with atrial fibrillation compared with 9/47 (19%) patients in sinus rhythm. Percutaneous balloon dilatation of the mitral valve was performed without embolic complications in 18 patients without left atrial thrombi and in three patients with small fixed thrombi in the left atrial appendage. It was cancelled in two patients with large thrombi in the left atrial appendage. Cardioversion was performed without embolic complications in 14 patients without left atrial thrombi.

CONCLUSIONS

Transoesophageal echocardiography detects potential sources of embolism better than transthoracic echocardiography in selected patients at risk of cardiogenic embolism or after it.

Investigation of acute stroke: what is the most effective strategy?

Techniques of investigation of acute stroke syndromes have progressed rapidly in recent years, outpacing developments in effective stroke treatment. The clinician is thus faced with a variety of tests, each with different cost implications and each altering management to a greater or lesser extent. This review will concentrate on the basic tests which should be performed for all strokes (full blood count, ESR, biochemical screen, blood glucose, cholesterol, syphilis serology, chest X-ray and electrocardiogram). Additional tests may be required in selected cases: CT scan to diagnose 'non-stroke' lesions, to exclude cerebral haemorrhage if anti-haemostatic therapy is planned, and to detect strokes which may require emergency intervention (such as cerebellar stroke with hydrocephalus); echocardiography to detect cardiac sources of emboli; and in a few cases lumbar puncture and specialized haematological tests. Other tests, which are currently research tools, may be suitable for widespread use in the future including NMR, SPECT and PET scanning.

Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: relation to cerebrovascular events

Transthoracic and transesophageal echocardiography was performed in 23 consecutive adult patients with an atrial septal aneurysm. In three patients with a cerebrovascular event the diagnosis was established by the transesophageal approach only. Interatrial shunting on transthoracic imaging with use of echocardiographic contrast imaging or Doppler color mapping, or both, was detected in 7 (41%) of 17 patients. On performing contrast imaging in combination with color flow mapping during transesophageal echocardiography, positive shunting was demonstrated in 15 (83%) of 18 patients. Echocardiographic identification of multiple fenestrations (n = 4) and thrombus within the aneurysm (n = 2) could be achieved for the first time by transesophageal ultrasound application. Cerebrovascular events occurred in 12 (52%) of 23 patients and were regarded as being definitely thromboembolic in 10 (43%); 8 (67%) of the 12 patients had repeated cerebral events. Except for mitral valve prolapse in one patient, no other potential cardiac source of embolism could be identified despite the use of transesophageal echocardiography. A thickening of the aneurysmal membrane greater than or equal to 5 mm was found in 9 (75%) of 12 patients with versus 3 (27%) of 11 patients without a cerebrovascular event (p less than 0.05); this proved to be the only significant difference between the two patient groups. The mechanism of embolization may be both primary thrombus formation within the aneurysm and paradoxic embolization through an interatrial communication as demonstrated by the findings in two patients. It is concluded that atrial septal aneurysm is a cardiac abnormality with thromboembolic potential. In patients with this lesion and a history of an embolic event, long-term anticoagulant therapy is indicated.

Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks

Using both precordial and transesophageal echocardiography, we studied 72 consecutive patients with a recent unequivocal transient ischemic attack or nondisabling stroke to determine the relative value of the two techniques for detecting potential intracardiac sources of cerebral emboli. Group 1 (n = 53) patients had no clinical cardiac abnormality, and group 2 (n = 19) patients had abnormal cardiac findings upon clinical examination. In group 1, precordial echocardiography detected an abnormality in only one patient (aortic valve thickening) but transesophageal echocardiography defined morphologic abnormalities in five patients (one with a left atrial appendage mass lesion, one with aortic dissection, one with mitral valve prolapse, one with a mitral leaflet mass lesion, and one with aortic valve thickening). In group 2, both precordial and transesophageal echocardiographic studies were normal in 13 patients, while both were abnormal in the remaining six patients. Five of these six patients had pathologic left atrial and/or left ventricular dilatation, but only transesophageal echocardiography defined a left atrial appendage thrombus in two of the six. The sixth patient had mitral chordal rupture, seen on both precordial and transesophageal echocardiography. In addition, in 32 of the 72 patients transesophageal echocardiography identified widespread thoracic aortic atherosclerotic plaques not visualized by precordial echocardiography. We conclude that transesophageal echocardiography significantly increases the yield in visualizing potential intracardiac sources of emboli compared with precordial echocardiography. However, the precise clinical value of the former in the management of such patients requires further study as the number of abnormal transesophageal echocardiographic findings is not high and a causative relation with transient ischemic attacks cannot be proven.

Acute homonymous field loss: really a diagnostic dilemma

A young woman developed the sudden onset of a congruous right lower quadratic visual field defect two weeks prior to examination. The remainder of her history and physical examination were noncontributory. Discussion revolves around the differential diagnosis of retro chiasmal field defects in young individuals. An MRI scan was most compatible with the diagnosis of disseminated sclerosis.

Cardiac evaluation of the patient with stroke

Coronary artery disease and ischemic cerebrovascular disease are leading causes of morbidity and mortality in the United States. Coronary artery disease often coexists with asymptomatic carotid artery atherosclerosis, transient ischemic attacks, or ischemic stroke. Numerous studies have shown that mortality from all forms of ischemic cerebrovascular disease is primarily due to coronary artery disease. Thus, there is increasing interest in identifying coronary artery disease in patients with cerebrovascular disease, including those without clinical manifestations of heart disease. We review the use of current noninvasive techniques to detect coronary artery disease and present practical approaches to screen for ischemic heart disease. Current diagnostic imaging methods for potential cardioembolic sources of cerebral infarction are also discussed.

Stroke

The annual incidence of stroke in the elderly approaches 2 per cent. The major tasks of the physician are to attempt to prevent recurrence and to supervise rehabilitation. Prevention of recurrence involves a careful consideration of differential diagnosis, treatment of contributory disease, and the initiation of therapy specific to large vessel infarction (atherothrombotic or cardiogenic embolic), lacunar infarction, or intracerebral hemorrhage. The high prevalence of lacunar infarction and the focal nature of posterior circulation transient ischemic attacks and strokes are not generally appreciated. Cardiogenic embolism due to atrial fibrillation and intracerebral hemorrhage due to congophilic angiopathy are of particular importance in the elderly. Treatment of stroke or transient ischemic attacks should be initiated quickly as the risk of recurrence is highest immediately following the signal event. History, neurologic and neurobehavioral examinations are important adjuncts in compensating for the inadequacy of CT and MRI in enabling the stroke classification necessary for proper treatment. Supportive care and rehabilitation can have a major impact on stroke morbidity and mortality and the management of risk factors can significantly reduce stroke incidence.

The potential role for ultrafast cardiac computed tomography in patients with stroke

We studied 40 patients with stroke of potential cardioembolic origin by cardiac ultrafast computed tomography and two-dimensional echocardiography. Cardiac ultrafast computed tomography was more sensitive (positive in eight of 14 instances) than two-dimensional echocardiography (positive in two of 14 instances) for the detection of intracardiac thrombus, which was found in 13 patients. Mitral anular calcification was diagnosed more often by two-dimensional echocardiography (four of five instances) than by cardiac ultrafast computed tomography (one of five instances); this implies a high incidence of false-positives for the former. Cardiac ultrafast computed tomography showed that one half of the patients (21 of 40) had coronary artery calcification, indicating a high incidence of coronary atheroma in this patient population. Future studies comparing brain and cardiac pathology with the findings of cardiac ultrafast computed tomography and patient prognosis are needed to define the significance and utility of this technique in patients with stroke.

Cardioembolic stroke from atrial septal aneurysm

Atrial septal aneurysm is an uncommon occult cardiac source of cerebral embolism. It is usually asymptomatic, and clinical cardiologic examination and electrocardiography fail to reveal its presence. We report a case of a 34-year-old woman with sudden right hemiplegia and aphasia from occlusion of the left carotid siphon in whom an atrial septal aneurysm was detected by two-dimensional echocardiography. The absence of atherosclerotic risk factors and vascular lesions proximal to the carotid occlusion strengthened a causal relation between atrial septal aneurysm and cerebral infarction. Consequently, two-dimensional echocardiography may be advisable in every patient with unexplained ischemic stroke to detect possible occult embolic cardiac abnormalities.

Benign disappearance of ventricular thrombus after embolic stroke. A case report

The source for a patient's middle cerebral artery territory embolic stroke was found by echocardiography to be a left ventricular cardiac thrombus. The apical mass was large, pedunculated, and moved with systole into the ventricular cavity. The absence of ventricular dyskinesia was thought to favor a tumor, and surgery was considered before repeat echocardiography showed disappearance of the mass, making thrombus the likely diagnosis. No further embolic events occurred during or since the disappearance of the thrombus while on anticoagulation therapy. Serial echocardiography for change in or disappearance of a ventricular mass may be critical in distinguishing thrombus from tumor.

Brain cardioembolism. Issues in diagnosis and management

The diagnosis of cardioembolism is always based on circumstantial evidence. Echocardiography has a limited useful yield and should be reserved for young patients or older patients with clinical heart disease. Primary prophylaxis with anticoagulants appears to be reasonable for patients with acute anterior wall myocardial infarction, rheumatic valvular disease, or dilated cardiomyopathy and, possibly, for those with chronic nonvalvular atrial fibrillation. Secondary prophylaxis (after an initial embolism) is reasonable for the same conditions and, possibly, for mitral valve prolapse. Acute anticoagulation therapy is warranted when a large infarct is excluded by computed tomography 24 hours after a cerebral embolism.

Internal carotid artery occlusion in a young female with mitral valve prolapse

A healthy 28 year old housewife presented with sudden right hemiplegia and aphasia. No predisposing factors could be ascertained apart from posterior cusp mitral value prolapse on two dimensional echocardiography. Extensive investigations confirmed the presence of cerebral infarction and persistent occlusion of the left internal carotid artery near its origin.

Cerebral ischemia and asymptomatic coronary artery disease: a prospective study of 83 patients

A prospective cardiologic evaluation was performed in 83 consecutive patients with transient cerebral ischemia or mild stroke and without symptoms or electrocardiographic signs of ischemic heart disease. Patients were studied with an electrocardiographic exercise test; a positive test was followed by exercise Thallium-201 myocardial scintigraphy. Results were compared to those obtained in a group of 83 age and sex-matched healthy subjects submitted to the same study protocol. Asymptomatic coronary artery disease was detected in 28% of cerebrovascular patients with adequate electrocardiographic exercise test. A scintigraphic perfusion defect of variable extension was found in 19 of them. In the control group the electrocardiographic exercise test was positive in only 6% (p less than 0.01). Our results support the concept that: asymptomatic ischemic heart disease is often associated with cerebrovascular disease; therefore cerebral ischemic attacks may be a marker of coronary artery disease, an active investigation of the heart should be considered in cerebrovascular patients in order to plan optimal, comprehensive management.

Cerebral ischemic attacks as a complication of heart disease: the value of echocardiography

The association of heart disease and cerebral ischemic attacks, and the usefulness of echocardiography in detecting heart disease and possible embolic source, were studied in 194 patients with transitory cerebral ischemic attack or stroke. The study revealed 95 patients with heart disease, and 63 of them had positive echocardiographic findings. All together, 35 patients had heart disease as a probable source for systemic embolism. An undetected cardiac disorder, not found by clinical examination or electrocardiography, was detected in 25 patients. The cardiac disorder found by echocardiography only, was most frequently aortic and mitral valve disease. Thus, echocardiography is an useful tool in detecting heart disease in these patients.

Echocardiographic evaluation of young adults with nonhemorrhagic cerebral infarction

We reviewed echocardiographic findings in patients aged 15 to 45 years with acute nonhemorrhagic cerebral infarction (NHCI). Among 132 patients with NHCI, 96 (72.7%) had M-mode and two-dimensional echocardiography, including contrast echocardiography with intravenous saline injection when clinically indicated. Echocardiograms were abnormal in 33 patients. Of these, 7 had other conditions that could cause NHCI. Echocardiography corroborated the clinical diagnosis of a cardiogenic source for cerebral infarction in 17 others. The other 9 had no other clues for cardiovascular disease. Potential etiologies of NHCI diagnosed by echocardiography in these 9 cases included: paradoxical embolism, 5 patients; right atrial myxoma, 1; rheumatic mitral valve vegetation, 1; myxomatous mitral valve (marantic endocarditis at postmortem), 1; and left atrial enlargement associated with decreased left ventricular function, 1. Routine echocardiography frequently conveys useful information in patients under age 45 with NHCI. In young patients with cerebral embolism of unknown etiology if routine M-mode and two dimensional echocardiographic studies are normal, contrast echocardiographic studies should be performed to rule out intracardiac shunts and the possibility of paradoxical cerebral embolism.

Cardiac abnormalities in stroke patients with negative arteriograms

Sixty-five consecutive patients with recent unequivocal TIA (33) or stroke (32), but nondiagnostic arteriograms, had two-dimensional echocardiograms (2DE) and electrocardiograms (ECG) to determine the incidence of cardiac abnormalities which could cause embolic stroke. Abnormalities were classified according to increasing probability of causing an embolic event: non-specific, possible emboligenic abnormality (PEA) or definite emboligenic abnormality (EA). Although 2DE was abnormal in 33 patients (51%), and ECG in 38 (59%), many abnormalities were nonspecific. Only four patients (6%) had EA on ECG and two (3%) on 2DE. Since one patient had EA on both tests, 2DE identified only one patient (mitral valve prolapse) not already identified by ECG. All patients with EA had a prior history of cardiac disease. PEA was present on ECG in 11 patients (17%), and on 2DE in 25 (38%). There was no correlation between age, CT results, or neurologic symptoms commonly associated with embolic stroke and the presence of EA or PEA on ECG or 2DE. Although TIA and stroke patients with negative arteriograms have a high incidence of abnormalities on ECG and 2DE, the percentage of patients with EA is low, and cardiac history and ECG identify most patients. 2DE provides little additional information.

How often can an embolic stroke be diagnosed clinically? A clinicopathological correlation

A retrospective case note survey of 103 autopsy proven cases of cerebral infarction was carried out to assess how often a cardiac source for embolism had been correctly suspected on clinical grounds. Only 61% of 46 patients with cardiac embolic sources were so identified. Cases of rheumatic heart disease and bacterial endocarditis were more frequently identified than cases of mural thromboembolism from ischaemic heart disease. This relative failure of unaided clinical diagnostic criteria probably accounts for the discrepancy between the autopsy evidence of cardiac embolism as a cause of stroke (about 40%), and clinical studies (about 20%).

Value of cardiac monitoring and echocardiography in TIA and stroke patients

One hundred and eighty-four consecutive patients admitted to an Investigative Stroke Unit with transient ischemic attacks (TIA) and cerebral infarction (stroke) had 48-hour automated arrhythmia monitoring, 55 patients had additional Holter monitoring and 127 patients had 2-D echocardiography. One hundred and sixteen presented with stroke (63%) and 68 patients with TIA (37%). One hundred and twenty-two were men (66.3%) and 62 were women (33.7%), mean age 63.5 years, range 25-86. The monitoring identified twelve (6.5%) patients with significant arrhythmias undetected by history, examination and admission electrocardiogram: six with atrial fibrillation (AF), four with 2 degrees heart block type Mobitz II and one each with 3 degrees heart block and sick sinus syndrome. Two-D echocardiography showed a previously unknown potential source for cardiac emboli in 22 patients (17.3%): segmental ventricular disease in eleven, mitral valve prolapse in seven, left ventricular thrombus in six, left ventricular aneurysm in three and one each with mitral valve endocarditis and global myocardial dysfunction. Only the mitral valve findings were expected on the basis of a previous M-mode echocardiographic study carried out in our city on healthy elderly volunteers. From the clinical history and all cardiac investigations, we found 59 patients (32%) with a possible cardiac source for cerebral emboli. After cerebral angiography, 29 of these 59 patients also showed a vascular lesion in the appropriate carotid artery and we could not decide definitely which lesion was responsible for the cerebral embolus. In the remaining 30 patients (16.4%), the evidence implicated the heart as the most likely source.(ABSTRACT TRUNCATED AT 250 WORDS)

Occlusive cerebrovascular disease in young adults

This retrospective study documents the experience of two large Canadian teaching hospitals with occlusive cerebrovascular disease in young adults. Chart review disclosed 76 patients aged 15-40 years during a recent six year period. An apparent cause, or significant coincident risk factors were found in 51 patients (67%). The most prevalent recognized causes were atherosclerosis, emboli from cardiac sources or intracranial aneurysms, and complicated migraine. Pregnancies or use of oral contraceptives were apparent coincident risk factors.