1. Embolic Stroke Emily Chang PGY-3 May 4, 2010

2. Definition Particles of debris that originate from another source that lead to blockage of arterial perfusion of a region in the brain Approximately 20-30% of ischemic strokes are cardioembolic Generally worse prognosis than thrombotic strokes as the area infarcted is usually larger due to large emboli

3. What to Look For Cardiac arrhythmias Cardiac murmurs Signs of CHF Recent MI Concomitant diseases (SLE, endocarditis, neoplasias) Other signs of systemic embolism

4. Time course Usually abrupt onset that is maximal at the start Symptoms may clear entirely since the emboli can migrate and lyse Multiple sites in different vascular beds may be affected leading to different symptoms at different times

5. Types known cardiac source possible cardiac or aortic source based on TTE or TEE arterial source unknown source with negative tests for embolic sources

6. Major risk sources Atrial fibrillation (accounts for 50%) Rheumatic valve disease Bioprosthetic and mechanical heart valves Atrial or ventricular thrombus SSS Sustained atrial flutter MI within one month CHF with EF<30% Dilated CM Endocarditis Left atrial myxoma

7. Minor risk sources Patent Foramen Ovale Atrial Septal Aneurysms Mitral Valve Prolapse Calcific Aortic Valve or Bicuspid Aortic Valve Mitral Annular Calcification Fibroelastomas (benign tumors on valves) Lambi excrescences (filliform outgrowths from free borders of valves)

8. Treatment Primary prophylaxis depends on the particular risk factor but centers primarily around anti-coagulation, especially in the high-risk group (except for endocarditis and myxoma) Primary prophylaxis for medium or low risk factors is less clear as benefit of anti-coagulation is not yet proven Treatment of acute embolic stroke depends on the source of the stroke but centers primarily around anti- coagulation

9. References Caplan, Louis. “Etiology and classification of Stroke.” Up to Date Online. Web. 30 Sept 2009. Schneck, Michael. “Cardioembolic stroke.” emedicine. WebMD. Web. 13 Feb 2008. Alguire, Patrick; Epstein, Paul. MKSAP 14. ACP. 2006.