Embolic Stroke

Vinnie Charlieta Leonardo (406181071)

Syahrurrozi (406181088)
Verren Natasya Nonski (406182053)
Kurnia Elsa Oktaviana (406182087)
 Embolic Stroke
Definition

• A type of ischemic stroke that occurs when a

blood clot or a plaque wanders into the brain and
becomes trapped inside an artery. Other, less
frequent cause of embolic strokes incl. :
• Septic emboli
• Atmospheric air
• Embolic myxoma
• Deep venous thromboses
 Embolic Stroke
Aetiology

• Emboli can originate from thrombus in the heart,

especially in the following conditions:
• Atrial fibrillation
• Rheumatic heart disease : mitral stenosis
• Post myocardial infarction
• Vegetation on the heart valves in bacterial or
marantic endocarditis
• Prosthetic valve
• Open heart surgery / atheromas in the neck
arteries or in the aortic arch, after an invasive
cardiovascular procedure (eg, catheterization)
• Air embolism : decompression cases
 Epidemiology

 • Strokes are much common

among older people > younger
Philippines
alduts
• >  people > 65 y.o.
• > 50% : occur in men
• > 60% of death due to stroke
occur in women
• WHO (April 2011) in Philippines
• 40.245 (9,55%) of total death
 Risk Factor

• Stenotic carotid atherosclerotic plaques

• Mechanical cardiac valves
• AF
• Mitral valve prolapse
• Aortic valve stenosis or calcification
• Patent Foramen Ovale
 PATHOPHYSIOLOGY
• Emboli are thrombotic in nature and can be formed in an artery,
cardiac chamber, heart valve, or vein. Emboli may consist of
nonthrombotic material, whereas in certain cases they may contain
both thrombotic and nonthrombotic material, as it may occur in
infected vegetations, valvular calci cations, and other pathologies

• Arteriogenic thrombi are most frequently formed at a ruptured

atherosclerotic plaque and embolize to cerebral arteries.

• These platelet-rich emboli tend to be smaller than fibrin-rich emboli

originating in cardiac chambers, and transient isch- emic attacks
and small cortical infarcts are relatively more common than large,
territorial infarcts associated with atrial fibrillation (AF).
 PATHOPHYSIOLOGY
• Emboli may originate from thrombi formed because of
nonatherosclerotic arterial pathologies

• The majority of cardiac thrombi are formed within a chamber (ie, the
left ventricle, the left atrial appendage, or the left atrium). In other
patients, thrombi are formed on pathological cardiac valves. thrombi
may be either purely thrombotic in nature or mixed with
nonthrombotic material such as vegetations and calcied material. In
some infrequent cases, nonthrombotic material may originate from
the heart and embolize distally

• Paradoxical embolism is the term used to describe emboli that are

formed in the venous vasculature and embolize distally into the
cerebral arterial vasculature, bypassing the pulmonary circulation
through a patent foramen ovale (PFO), atrial septal defects, or
pulmonary arteriovenous fistulas
 Signs and Symptoms

• Numbness or weakness of the face, arm, or leg, especially on one side of the body
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Visual disturbances
• Difficulty walking, dizziness, or loss of balance or coordination
• Sudden severe headache
• Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted.
• Cardiac embolism often lodges in distal arteries supplying the cerebral cortex while small-vessel occlusion aff
ects subcortical tissue

• Cardioembolic stroke can be differentiated from lacunar stroke by cortical signs such as aphasia or visual fiel
d deficits.
 Diferential Diagnosis
• Stroke mimics commonly confound the clinical diagnosis of stroke.
• One study reported that 19% of patients diagnosed with acute ischemic stroke by neu
rologists before cranial CT scanning actually had non-cerebrovascular causes for
their symptoms.
• The most frequent stroke mimics include the following:
– Seizure (17%)
– Systemic infection (17%)
– Brain tumor (15%)
– Toxic-metabolic disorders, such as hyponatremia and hypoglycemia (13%)
– Positional vertigo (6%)
– Conversion disorder
• Although the definitive distinction of ischemic stroke from hemorrhagic stroke requires neuroimaging, a meta-
analysis found that the following clinical findings increase the probability of hemorrhagic stroke   :
o Coma
o Neck stiffness
o Seizures accompanying the neurologic deficit
o Diastolic blood pressure >110 mm Hg
o Vomiting
o Headache
o Findings that decrease the probability of hemorrhage include cervical bruit and prior transient ischemic attack
 Neuroimaging profile

• About half of cardioembolic strokes involve multiple cerebral arterial territories (i.e., both internal cerebral
arteries or one internal cerebral artery as well as the basilar artery),which distinguishes cardiac embolism fro
m artery-to-artery embolism due to large-artery atherosclerosis in the cerebral circulation.

• In the acute phase, vascular imaging of the intracranial circulation, such as with computed tomographic or
magnetic resonance angiography, often reveals an abrupt vessel cut-off without significant atherosclerotic
narrowing of the upstream vessel.
 Vascular and Cardiac Evaluation

• Vascular imaging of the extracranial (cervical) carotid arteries to rule out carotid stenosis and a 12-lead
electrocardiogram (ECG) to rule out AF or recent MI.

• About 70% perform vascular imaging of the intracranial cerebral circulation to rule out intracranial plaque and
transthoracic echocardiography to rule out high-risk sources of cardiac thrombus.

• Only 20% perform transesophageal echocardiography, about 50% perform inpatient cardiac telemetry or
24-hour Holter monitoring to rule out AF, and only about 20% perform prolonged (>24 hours) heart-rhythm
monitoring.
• If fever or leukocytosis is present, blood cultures for infective endocarditis are warranted.

• CBC, coagulation profile, urinalysis, and chemistry and lipid panels

• Before initiating antithrombotic therapy, a complete blood cell (CBC) count, platelet count, prothrombin time
(PT) or international normalized ratio (INR) and activated partial thromboplastin time (aPTT), erythrocyte
sedimentation rate (ESR), serum glucose, electrolytes, lipids, urinalysis are recommended, as well as plain.
radiography. 
 Echocardiography

• Transthoracic echocardiography (TTE) is usually the initial cardiac imaging modality, and reliably detects left
ventricular wall motion abnormalities, left ventricular thrombi, and (with contrast) interatrial shunts.  

• However, transesophageal echocardiography (TEE) provides more information about the atria than does TTE.
In 40% of patients with normal TTE results, a cardiac source of embolism was detected by TEE, independent
of age.
 Cardiac MRI
Indications for cardiac magnetic resonance imaging (MRI) include the following: 

• Patients with a transthoracic echocardiography (TTE) result that is questionable for the presence of left
ventricular (LV) thrombus 
• Further evaluation of a cardiac mass seen on a TTE
• Patients who cannot tolerate transesophageal echocardiography (TEE) and/or cannot undergo TEE secondar
y to medical reasons
• Patients with inconclusive TEE results
• Suspected false-negative TEE results, in which cardiac MRI can adequately image potentially missed sources
of embolus such as LV thrombus, cardiac masses, aortic plaque, or left atrial appendage (LAA) thrombus
 CT Scanning, MRI, Angiography

• Hemorrhagic infarct or multiple arterial infarcts (not lacunar) on computed tomography (CT) scans or magneti
c resonance images (MRIs) and/or an embolus "in transit" on angiography are radiologic findings that, when
associated with clinical features, are suggestive of cardioembolic stroke.
 Electrocardiography
• An electrocardiogram (ECG) can demonstrate atrial arrhythmias, myocardial infarction. 

• Ambulatory ECGs are indicated for elderly patients in whom paroxysmal atrial fibrillation is suspected
(eg, history of palpitations, enlarged left atrium on echocardiography).  

• In elderly patients with cryptogenic hemorrhagic cortical infarctions or other cardioembolic features, many
clinicians obtain ambulatory ECG monitoring seeking occult atrial fibrillation that would necessitate
anticoagulation

• Prolonged ECG monitoring may help in detecting occult arrhythmias in patients with cryptogenic stroke, but.
the duration of monitoring and absolute benefit of prolonged monitoring remain poorly defined at this time. 
Thank you