eMedicine Specialties > Neurology > Neuro-vascular Diseases

Cardioembolic Stroke: Differential Diagnoses & Workup

Author: Michael J Schneck, MD, Associate Professor, Departments of Neurology and Neurosurgery, Stritch School of Medicine, Loyola University; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center
Coauthor(s): Lei Xu, MD, PhD, Resident Physician, Department of Neurology, Loyola University Chicago, Stritch School of Medicine; Santiago Palacio, MD, Neurology Fellow, Department of Medicine (Division of Neurology)
Contributor Information and Disclosures

Updated: Feb 13, 2008

Differential Diagnoses

Seizures and Epilepsy: Overview and Classification

Other Problems to Be Considered

No quantitatively valid clinical criterion standards exist for diagnosis of cardioembolic stroke. Clinical diagnosis is based on demonstration of a potential cardiac source of embolism, exclusion of other potential sources of cerebral ischemia, and consideration of neurologic features.

Differential diagnoses include the conditions listed above.

Workup

Laboratory Studies

  • If fever or leukocytosis is present, blood cultures for infective endocarditis are warranted.
  • Before initiating antithrombotic therapy, a CBC, platelet count, prothrombin time or INR and activated partial thromboplastin time (aPTT), erythrocyte sedimentation rate, serum glucose, electrolytes, lipids, urinalysis, and plain radiograph are recommended.
  • In patients with PFO, determination of protein C antigen and activity, protein S antigen and activity, antithrombin III antigen and activity, factor V Leiden, activated protein C resistance, and prothrombin gene mutation are often recommended, particularly in patients with a history of venous thrombosis or a family history of unusual thrombosis. Several of these are acute phase reactants and can be artificially abnormal if obtained in the weeks following acute stroke. Protein C and S levels are suppressed by warfarin; antithrombin III levels and activity are suppressed by heparin.

Imaging Studies

  • 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. The following is a list of sources detected by transthoracic echocardiography:
      • Left ventricular thrombus
      • Myxomatous mitral valvulopathy with prolapse
      • Mitral annulus calcification
      • Mitral stenosis
      • Aortic valve vegetations
      • Left ventricular wall motion abnormality (possible predictor of intracardiac thrombosis but not an embolic source per se)
    • Transesophageal echocardiography (TEE) provides more information about the atria than TTE. In 40% of patients with normal TTE results, a cardiac source of embolism was detected by TEE, independent of age. More than 1 in 8 patients of any age with normal TTE results had a major cardiac risk factor revealed on TEE, in whom anticoagulation is warranted. (Sebastiaan, 2006) The following is a list of sources better detected on TEE:
      • Atrial septal aneurysm
      • Atrial septal defect
      • PFO
      • Atrial myxoma
      • Atrial thrombus
      • Atrial appendage thrombus
      • Aortic arch atheroma/thrombi
      • Mitral valve vegetations - Infective endocarditis, nonbacterial thrombotic endocarditis
  • Cardiac magnetic resonance (CMR): Current indications include the following:
    • Patients with a TTE result that is questionable for the presence of LV thrombus
    • Further evaluation of a cardiac mass seen on a TTE
    • Patients who cannot tolerate TEE and/or cannot undergo TEE secondary to medical reasons
    • Patients with inconclusive TEE results
    • Suspected false-negative TEE results, where CMR can adequately image potentially missed sources of embolus such as LV thrombus, cardiac masses, aortic plaque, or LAA thrombus
  • Radiologic studies: Several radiologic findings, when associated with clinical features, are suggestive of cardioembolic stroke, including the following:
    • Hemorrhagic infarct on CT scanning or MRI
    • Multiple arterial infarcts on CT scanning or MRI (not lacunar)
    • Embolus "in transit" on angiography

Other Tests

  • ECG - Atrial arrhythmias, myocardial infarction
  • Ambulatory ECG - 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.

More on Cardioembolic Stroke

Overview: Cardioembolic Stroke
Differential Diagnoses & Workup: Cardioembolic Stroke
Treatment & Medication: Cardioembolic Stroke
Follow-up: Cardioembolic Stroke
Multimedia: Cardioembolic Stroke
References
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References

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Further Reading

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Keywords

cardiogenic embolism, cardiac embolism, cardioembolic stroke, atrial fibrillation, atrial flutter, heart attack, transient ischemic attack, TIA, coronary artery disease, CAD, congestive heart failure, CHF, myocardial infarction, MI

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Contributor Information and Disclosures

Author

Michael J Schneck, MD, Associate Professor, Departments of Neurology and Neurosurgery, Stritch School of Medicine, Loyola University; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center
Michael J Schneck, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Neurocritical Care Society, and Stroke Council of the American Heart Association
Disclosure: boehringer-ingelheim Honoraria Speaking and teaching; sanofi/bms Honoraria Speaking and teaching; pfizer Honoraria Speaking and teaching; genentech Honoraria Speaking and teaching; ucb pharma Honoraria Speaking and teaching; talecris Consulting fee Other; nmt medical  Independent contractor; NIH Grant/research funds Independent contractor; vernalis Grant/research funds Independent contractor; sanofi Grant/research funds Independent contractor

Coauthor(s)

Lei Xu, MD, PhD, Resident Physician, Department of Neurology, Loyola University Chicago, Stritch School of Medicine
Lei Xu, MD, PhD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Santiago Palacio, MD, Neurology Fellow, Department of Medicine (Division of Neurology)
Santiago Palacio, MD is a member of the following medical societies: American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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