Cardioembolic Stroke

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Cardioembolic Stroke

• Robert A. Felberg, MD
• Stroke Program Director
• Department of Neurology
• Geisinger Medical Center
• Danville, Pennsylvania

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Irregularly , Irregular Rhythm in a Regular
elderly female

• 87 year old Black Female
• History of Hypertension, well compensated
  Congestive Heart Failure, Hip Fracture 2 years
  ago with pinning
• Chief Complaint Lightheadedness
• Exam reveals
• Irr. Irr. rhythm
• EKG Atrial Fibrillation rate 83/min
• Normal Recent Thyroid Studies

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Irr. Irr. Rhythm in a Regular elderly female

• How do you treat this patient?
• A Benign Neglect
• B Check Echo and Chemically Convert to NSR
• C Aspirin 325mg Daily and write note about fall
  risk in chart
• D Warfarin 5mg Daily (Goal INR 2.0-2.5)

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Irr. Irr. Rhythm in a Regular elderly female

• How do you treat this patient?
• A Benign Neglect
• B Check Echo and Chemically Convert to NSR
• C Aspirin 325mg Daily and write note about fall
  risk in chart
• D Warfarin 5mg Daily (Goal INR 2.0-2.5)

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Overview of Trials
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Examples of Other Stratifications
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A Warfarin Treatment GuidelineBased Largely on
SPAF
High risk embolism one or more of the following-
mitral stenosis, prosthetic valve, Previous
TIA/Stroke, thyrotoxicosis, LV dysfctn, current
systolic HTN, female gt75, ECHO smoke, LA
thrombus Intermediate embolism none of the high
risk, HX of HTN High bleeding non compliance,
active bleeding, recent ICH Intermediate
bleeding age gt80, leukoareosis, HX of falls
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Stroke in the Young

• 34 year old right handed white female. No
  significant PMHx.
• Sudden onset of Right Hemiparesis and Aphasia.
• Receives IV-TPA in the Emergency room with
  dramatic recovery.

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Stroke in the Young

• MRI shows a small area of acute stroke in the
  Left MCA territory
• And B/L embolic sub acute stroke in both
  hemispheres as well as Right Cerebellum
• Carotid U/S is Normal
• Non-Smoker, Normotensive, Normal Lipids
• No history of DVT or miscarriage

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Stroke in the Young

• How do you manage this patient?
• Antiplatelet therapy and discharge
• Check 2-d transthoracic echo
• Check hypercoagulable Labs
• Check Tran-esophageal echo and hypercoagulable
  labs

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Stroke in the Young

• How do you manage this patient?
• Antiplatelet therapy and discharge
• Check 2-d transthoracic echo
• Check hypercoagulable Labs
• Check Tran-esophageal echo and hypercoagulable
  labs

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To Diagnose Cardioembolic Stroke- Youll need to
look at the films!

• The pattern of Stroke on imaging is key to
  finding the etiology
• Especially MRI imaging

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Embolic Stroke

• Wedge Shaped
• Peripheral
• Typically Cortical

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Cardioembolic Strokes

• Multiple Strokes
• Embolic
• Separated by Time
• Separated by Location

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Cardioembolic Strokes

• Isolated PCA or Superior Cerebellar Strokes

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Cardioembolic Strokes

• Isolated Posterior Division MCA

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Clinical Clues to Suggest Cardioembolism

• Stroke during Valsalva Maneuver
• Cough
• Sneeze
• Sexual Intercourse
• Pain consider dissection
• Blue Toe Syndrome
• Splinter Hemorrhages
• Renal Failure
• Corneal hemorrhages

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Clinical Clues to Suggest Cardioembolism

• Clinical Point
• AFIB is the most common cause of stroke in
  patients over the age of 80
• Clinical Point
• To evaluate for Stroke
• 2D echo is not valuable
• TEE with Bubble study is the national standard of
  care

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Diagnosis of Cardioembolic Sources

• For Stroke Evaluation
• TEE is the Standard of Care
• TTE is not sufficient, not indicated, not
  sensitive, not appropriate, and not likely to
  lead to diagnosis or change in therapy
• Can not bill for TTE
• An echo is not required for every patient
• Only those with a suspected cardiac source
• Perform a Bubble study with the TEE
• TCD can be a non-invasive screen Screen

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TCD/PMD IMAGING FOR DIAGNOSIS OF PFO
courtesy Dr. Merrill Spencer
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What are we looking for?

• The micro bubbles will cross the right to left
  shunt
• Enter the cerebral circulation
• Be detected by TCD

Courtesy of Mark Moehring Spencer Technolgy
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• Patent Foramen Ovale
• Significant cause of stroke in the young
• PFO found in 40 of Idiopathic Stroke cases

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PFO in stroke Pathophysiology
Paradoxical Embolism
Focal Thrombosis
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Incidence of PFO in cryptogenic stroke versus
normals
P value
Control
Cryptogenic Stroke

• Lechat, NEJM 1988
• Webster, NEJM 1988
• De Belder 1992
• Di Tullio 1992
• Hausmann 1992
• Cabanes 1993

54 50 13 47 50 56
10 15 3 4 11 18
lt 0.01 lt 0.01 lt 0.01 lt 0.01 lt 0.01 lt 0.01
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RA
LA
RV
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The MAS Study

• A Multi-Center Prospective Observational Study to
  determine the rate of recurrent stroke/TIA in
  young idiopathic stroke patients with sub-group
  comparison of those with septal abnormalities to
  those with normal septal findings.
• Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L,
  Derumeaux G, Coste J Patent Foramen Ovale and
  Atrial Septal Aneurysm Study Group. Recurrent
  cerebrovascular events associated with patent
  foramen ovale, atrial septal aneurysm, or both. N
  Engl J Med. 2001 Dec 13345(24)1740-6.

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Background

• Despite many theories regarding therapy, there is
  poor natural history data regarding the absolute
  and relative risk of PFO and ASA in the setting
  of stroke in the young
• An observational study was undertaken to
  determine the natural history of PFO/ASA vs
  non-PFO/ASA in young idiopathic stroke
• NOTE Not a comparison of stroke patients vs.
  normal controls.

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Clarification ASA
Aspirin
Atrial Septal Aneurysm
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Trial Design

• Concurrent Idiopathic Stroke Patients
• age 18-55
• All patients had a standard stroke evaluation
• Excluded those for whom cause was found
• Lacunar stroke
• Atrial fibrillation
• Hypercoagulable States
• All patients had a TEE with bubble study
• Patients were split into 4 groups and followed
  for 2 years
• No septal abnormality
• PFO only
• ASA only
• PFOASA in combination

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• 331 patients with stroke
• gt60 years of age
• TEE Confirmed Aortic Atheroma
• Graded
• Aortic plaques gt4 mm thick (including the
  thickness of the aortic wall)
• Recurrent brain infarction
• relative risk, 3.8
• P 0.0012
• All vascular events
• relative risk, 3.5
• Plt0.001

• KaplanMeier Analysis of Survival without
  Vascular Events (Brain Infarction, Myocardial
  Infarction, Peripheral Embolism, or Death from
  Vascular Causes), According to Plaque Thickness
  in the Aortic Arch Proximal to the Ostium of the
  Left Subclavian Artery.
• The French Study of Aortic Plaques in Stroke
  Group. NEJM 3341216-1221

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Kaplan-Meier Estimates of the Risk of Recurrent
Cerebrovascular Events within Four Years after
the Index Stroke
Mas, J.-L. et al. N Engl J Med 20013451740-1746
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What IS PICCS?

• Patent Foramen Ovale In Cryptogenic Stroke Study
• Substudy of WARRS
• A study designed to compare ASA and warfarin for
  the prevention of recurrent ischemic stroke in
  patients with prior (lt30 days) noncardioembolic
  ischemic stroke

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What IS PICCS?

• Patients eligible if event not attributed to
  high-grade carotid stenosis for which surgery was
  planned and not associated with an inferred
  cardioembolic source
• Composite endpoint of death or recurrent ischemic
  stroke over two years after enrollment

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PICSS Results

• Death was the endpoint in 23 of patients
• Composite endpoint for entire group (at 2 yrs)
  13.2 in aspirin group vs 16.5 in warfarin group
  (pNS)
• Composite endpoint in group with cryptogenic
  stroke and PFO (n98) 17.9 in ASA group vs 9.5
  in warfarin group (pNS)
• This group of 98 (4.4 of the original 2206)
  patients represents the only group of cryptogenic
  stroke/PFO patients enrolled in a randomized
  trial (not placebo-controlled) of medical therapy.

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• The STARFlex Occluder
• Double umbrella design with auto centering
  microsprings
• Framework is MP35n
• Tissue matrix is polyester fabric (Dacron)

NMT Medical, Inc.
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The Amplatzer Occluder
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PFO in Embolic Stroke
Annual recurrence rate (Stroke, TIA,) after PFO
closure

• Hung et. al. Circulation 2000 3.2
• Meier Circulation Feb 2000 2.5
• Sievert et al, Abstract AHA Nov 2001, 3.1
• Palacios, Circulation, Aug 2002 0.9
• Lock Circulation Jan 2003 3.0

March 2003
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Very little information to make an informed
treatment decision
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Especially if you wish to rely on evidence and
not anecdote
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Remember Some evidence is more reliable than
others
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PFO in Embolic Stroke
What do we really know about recurrent event
rates for each form of therapy?
Only that a definitive, randomized, controlled
study is needed!
March 2003
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Investigating the PFO Stroke connection
NMT Medical, Inc.
RESPECT TRIAL
AGA Medical
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Other Cardioembolic Sources of Stroke

• Artificial Valves
• New devices
• New Anticoagulants
• Arrythmias
• Atrial Fibrillation
• Frequent PACs
• Cardiomyopathy
• WARCEF trial

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Aortic Arch Atheroma
lt1 mm

• Atherosclerotic disease of the aortic arch is
  found in 60 percent of patients 60 years of age
  or older who have had brain infarction
• Usually divided into three groups according to
  the thickness of the wall of the aortic arch
• lt1 mm
• 1 to 3.9 mm
• gt4 mm

gt4 mm
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