Can Embolic Stroke Be Diagnosed on the Basis of Neurologic Clinical Criteria?

Ramírez-Lassepas, Manuel; Cipolle, Robert J.; Bjork, Randall J.; Kowitz, J. J.; Snyder, Bruce D.; Weber, Jan C.; Stein, Steven D.

doi:10.1001/archneur.1987.00520130067019

Cited by 75 publications

(16 citation statements)

References 29 publications

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“…It has been shown in adult stroke patients that a rapid onset of symptoms is a clinical criterion that is significantly associated with a cardiac source of embolus. 15 It is easy to conceive that a cardiac embolus, or a distal artery-to-artery embolization originating from proximal dissection or atherosclerosis, leads to acute occlusion of a major cerebral artery, giving rise to a sudden onset of neurological deficits. The abrupt onset in our 5 patients with anterior circulation arterial dissection is in agreement with a distal embolic occlusion.…”

Section: Onset Predicts Etiologymentioning

confidence: 99%

Mode of Onset Predicts Etiological Diagnosis of Arterial Ischemic Stroke in Children

Braun

Rafay²,

Uiterwaal³

et al. 2007

Stroke

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Background and Purpose-In children, early differentiation among various etiologies of arterial ischemic stroke (AIS) is important. Cerebral arteriopathy is a frequently identified cause of childhood stroke. Children with arteriopathies require a different therapeutic approach from children with AIS of nonarteriopathic origin. We aimed to investigate the association between temporal features of the onset of neurological symptoms and stroke etiology in children with AIS. Methods-From a consecutive cohort of children (6 months to 18 years) with a confirmed diagnosis of AIS at one center, we selected all patients with transient cerebral arteriopathy (nϭ10), postvaricella angiopathy (nϭ20), dissection (nϭ8), cardio-embolic (nϭ8), and cryptogenic stroke (nϭ10). We retrospectively reviewed medical charts for mode of onset and classified the onset as either abrupt, reaching maximum severity of symptoms within 30 minutes, or nonabrupt, including a progressing, stuttering, or recurring course. We compared the mode of onset in patients with known cerebral arteriopathy to those with nonarteriopathic stroke using multivariate logistic regression modeling. Results-There were no significant differences for age, gender, location of infarction, seizures, and headache between the arteriopathic and nonarteriopathic group. Most children with nonarteriopathic AIS had an abrupt onset (72%), compared with 32% in children with arteriopathic stroke. With nonabrupt onset, the odds of having an arteriopathic etiology was 6.1 (95% CI, 1.6 to 22.8; Pϭ0.007) after correction for possible confounders.

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Section: Onset Predicts Etiologymentioning

confidence: 99%

Mode of Onset Predicts Etiological Diagnosis of Arterial Ischemic Stroke in Children

Braun

Rafay²,

Uiterwaal³

et al. 2007

Stroke

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“…Then, the category weight, ofy is determined so that the weight, Yks is small whenthe cases belong to the same group and large whenthey belong to different groups. This is equivalent to obtaining the category weight with the maximumcorrelation ratio (7]2). The total variance (cT2) of Yks is obtained from the sum of the between-group variance (oB2) and the within-group variance (gw2).…”

Section: Quantitative Differentiationmentioning

confidence: 99%

“…However, differentiation of the pathophysiological mechanisms during the acute stage is often difficult. Clinical diagnostic criteria for embolic stroke have been proposed, mainly for cardioembolic stroke (1)(2)(3)(4)(5)(6)(7), whereas the characteristics, severity and treatment appear somewhat different between cardiogenic and artery-to-artery brain embolism (8). There are no useful clinical diagnostic criteria for nonembolic stroke, which has different mechanisms, thrombotic and hemodynamic,however, there have been a few reports suggesting differences in the clinical features according to pathogenetic and pathophysiological mechanisms among embolic and thrombotic or hemodynamic stroke (2)(3)(4)(5).…”

Section: Introductionmentioning

confidence: 99%

Differences in Clinical Features and Computed Tomographic Findings between Embolic and Non-Embolic Acute Ischemic Stroke: A Quantitative Differential Diagnosis.

et al. 1998

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A diagnosis based on the presumed mechanismof stroke onset is useful for management strategies in acute ischemic stroke. Ninety-two patients with embolic (cardiac or artery-to-artery) and 107 with non-embolic (thrombotic or hemodynamic)stroke were diagnosed on strict cerebral angiographic criteria alone. To clearly discriminate between these two groups, the neurological and computed tomographic (CT) findings were then compared. Rapidity of onset, vomiting, urinary incontinence, level of consciousness, cervical bruit, anisocoria, tongue deviation, sensory disturbance, and CT findings (location ofhypodense area, findings of brain edema and hemorrhagic transformation) were discriminatory factors between the two groups (p<0.01). According to these ll items, weprepared a numerical table for quantitative differential diagnosis. A diagnostic accuracy of 98.9% for embolic and 87.9% for non-embolic stroke in internal verification, and 90.0% and 82.9% , respectively, in external verification was observed. The differences in clinical features and CTfindings between embolic and non-embolic stroke may reflect the pathophysiological mechanisms of the occlusive process of cerebral artery as well as the extent and severity of ischemia.

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“…However, cardioembolic ischemic stroke may occlude a larger-sized intracranial artery in its resultant vascular territory compared to small vessel disease or perforator vessel disease (e.g., middle cerebral artery [M1] segment occlusion [5]). The sudden onset of neurologic symptoms is not specific for cardioembolism because this overlaps with other stroke causes [5,6]. Seizures are more likely to occur from embolism to distal cortical brain tissue compared to small vessel disease infarcts in deep locations.…”

Section: Introductionmentioning

confidence: 99%

“…Cardioembolic stroke may also present with a "stuttering" or fluctuating neurologic deficits pattern, especially those that display features of alternating right or left hemisphere or anterior and posterior hemisphere localization. Clinical and neuroimaging predictors of cardioembolic stroke include rapid or "dramatic" improvement of a major neurologic deficit [5], a maximal deficit from onset [5,6], simultaneous ischemic strokes in different vascular territories (especially anterior and posterior circulation), and hemorrhagic transformation of an ischemic infarct that suggests recanalization and reperfusion injury [4]. Transient ischemic attacks (TIAs) are less frequent predecessors of cardioembolic stroke than large-vessel atherosclerotic stroke [5] such as carotid artery to distal artery embolism.…”

Section: Introductionmentioning

confidence: 99%

Prevention of Cardioembolic Stroke

Freeman

Aguilar

2011

Neurotherapeutics

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Cardiac causes of ischemic stroke lead to severe neurological deficits from large intracranial artery occlusion compared to small vessel ischemic stroke. The most common cause of cardioembolic stroke is atrial fibrillation (AF), which has an increasing incidence with age. AF stroke trials demonstrate that anti-coagulation is superior to anti-platelet therapy in terms of ischemic stroke prevention. Recently, warfarin was compared with dabigatran, an oral, direct thrombin inhibitor, and was found to be at least equally effective in reducing ischemic stroke with less intracranial bleeding risk. Future research is investigating other direct thrombin inhibitors as potential alternatives to warfarin, which has a narrow therapeutic index, requires frequent blood monitoring, has multiple drug interactions, and a higher rate of intracranial bleeding. Other causes of cardioembolic stroke include myocardial infarction, left ventricular thrombus, reduced ejection fraction, valvular abnormalities, and endocarditis. Patent foramen ovale is a common finding on echocardiograms in patients with and without stroke (up to 20% of the population), and it is a controversial source of cryptogenic stroke. The best way to prevent cardioembolic stroke remains early detection and treatment of AF, and treating the underlying stroke mechanism. Cardiac magnetic resonance imaging is an emerging technology and reveals some sources of cardiac embolism missed by echocardiography, and might provide an additional diagnostic tool in investigating cardioembolic stroke.

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Can Embolic Stroke Be Diagnosed on the Basis of Neurologic Clinical Criteria?

Cited by 75 publications

References 29 publications

Mode of Onset Predicts Etiological Diagnosis of Arterial Ischemic Stroke in Children

Mode of Onset Predicts Etiological Diagnosis of Arterial Ischemic Stroke in Children

Differences in Clinical Features and Computed Tomographic Findings between Embolic and Non-Embolic Acute Ischemic Stroke: A Quantitative Differential Diagnosis.

Prevention of Cardioembolic Stroke

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