Background and Objectives: Embolic stroke is a leading cause of cerebrovascular events, characterized by sudden focal neurologic deficits. Most cases arise from fragments of thrombi in the heart, with other sources including intra-arterial thrombi and atheromatous plaques. Cardioembolic strokes account for about 15% of all strokes and are considered preventable. Methodology: We evaluated 40 patients with cardioembolic stroke through clinical history, physical examination, and necessary investigations. Results: Of the 40 patients, 36 were male, all presented with hemiparesis. Rheumatic valvular heart disease was identified in 22 cases, and 19 patients had atrial fibrillation, with the middle cerebral artery affected in 62.5%. Conclusions: Most strokes occurred during the day, with hemiplegia as the primary symptom. Rheumatic heart disease was a significant factor, particularly in cases of multivalvular involvement. Atrial fibrillation was prevalent, and the middle cerebral artery was the most commonly involved artery.
Embolic phenomena are the leading cause of cerebrovascular events, characterized by focal neurologic deficits. Most cerebral embolisms arise from thrombus fragments in the heart, while others may originate from distal arteries or atheromatous plaques (1). Cardioembolic strokes account for approximately 15% of all strokes and are largely preventable (2). Identifying cardiac lesions, such as atrial fibrillation and valvular disease, is crucial for both primary and secondary prevention, as these conditions significantly increase the risk of recurrent strokes (3).
The study on cardioembolic stroke was conducted at Kurnool Medical College's Department of Medicine, a tertiary care referral center, from November 2018 to October 2020. A total of 40 patients who met the inclusion criteria were evaluated after obtaining verbal consent from their relatives. Inclusion criteria included stroke as defined by the WHO, CT-proven ischemic stroke, and echocardiographic or electrocardiographic evidence of cardiac lesions. Exclusion criteria encompassed transient ischemic attacks, hemorrhagic strokes, and patients with a healthy heart.
Data collection involved comprehensive medical histories, focusing on presenting complaints, onset, seizures, and prior conditions such as ischemic heart disease. Neurological assessments occurred 24 hours post-admission, examining for cranial nerve palsies, sensory deficits, and limb weakness. Cardiovascular evaluations aimed to identify congenital or valvular heart diseases. Routine investigations included chest X-rays and ECGs, with additional echocardiography to evaluate cardiac lesions and CT scans for initial neuroimaging. Follow-up evaluations occurred on the fifth day and at four weeks, utilizing the Barthel Index to assess functional improvement and providing education on ongoing care, rehabilitation, and medication adherence.
The study included 40 patients, comprising 36 males and 4 females, all presenting with sudden onset hemiparesis. Hemiparesis was maximal at onset in all cases, with 22 patients previously diagnosed with rheumatic valvular heart disease. Notably, some lacked typical rheumatic histories, but historical records indicated rheumatic symptoms in over 20 cases, with the youngest patient exhibiting symptoms at age 14. All patients underwent cardiac evaluations, CT, and MRI, confirming ischemic infarcts in various arterial territories.
The sex distribution revealed 10 males and 2 females under 45, and 26 males and 2 females over 45. In terms of onset timing, 37.5% of strokes occurred between 6:00 AM and 2:00 PM, and 30% occurred overnight. Activities at stroke onset showed 50% were working, 27.5% at rest, and 22.5% sleeping. Age distribution indicated 22.5% of patients were between 20-40 years, 27.5% between 40-60 years, and 50% above 60.
Cardiac lesions included mitral stenosis in 22.5% and coronary artery heart disease in 27.5%, with atrial fibrillation present in 47.5% of patients. The clinical profile showed (Graph 1) that all patients experienced hemiparesis, with additional symptoms including hemianaesthesia (15%), hemianopia (27.5%), and aphasia (62.5%). Most cases involved the middle cerebral artery (62.5%), with recovery patterns indicating 20% mortality, 30% static condition, and 50% improvement in function.
Graph 1: clinical profile
This longitudinal hospital-based study investigates the evolution of cardioembolic stroke, focusing on clinical profiles and the types of cardiac lesions involved. Inclusion and exclusion criteria were adapted from similar studies, enabling a robust analysis. A follow-up occurred four weeks post-stroke, during which activities of daily living showed a positive correlation with direct assessments, ensuring effective monitoring. Significant changes in disability were not expected within the initial stroke period, which justified the four-week follow-up. Our study revealed a high incidence of stroke among males (90%), especially those over 45 years (60%). Among the 40 participants, the median age was 51 for males and 50 for females. This aligns with a study from Santiago, Chile, where the male-to-female ratio was 85:15(4,5,6).
The majority of strokes occurred in the morning, often during work. All patients exhibited hemiparesis or hemiplegia, with aphasia present in 62.5%. The leading cause of stroke was rheumatic valvular heart disease (65%), followed by ischemic heart disease (27.5%)(7,8) . Atrial fibrillation was noted in 47.5% of cases, reinforcing its significance in stroke etiology (9).
Comparatively, a study in Eastern Nepal highlighted that valvular heart disease and atrial fibrillation are significant predictors of cardioembolic stroke (10). Our findings also suggest that specific cardiac lesions did not lead to distinct neurological symptoms, likely due to our limited sample size.
Regarding outcomes, 50% of patients showed improvement, 30% remained static with residual effects, and 20% died during hospitalization. This study adds to the existing literature by emphasizing the need for awareness of both clinical manifestations and underlying cardiac conditions in managing cardioembolic stroke.
In this study, the median age of presentation for cardioembolic stroke was 51, with the earliest case at 25. The condition predominantly affected males, with stroke onset occurring mostly between 6 AM and 10 PM in 30 patients, often during daily work activities (50%). Hemiparesis was the most common clinical presentation, consistently correlating with CT findings, while the facial nerve was the only cranial nerve involved. Rheumatic heart disease was identified as the cause in 65% of cases, with multivalvular involvement being more frequent than isolated lesions. Atrial fibrillation was present in 47.5% of cases, and mitral stenosis was the predominant isolated valvular lesion. Consistent with other studies, the middle cerebral artery was the most commonly affected arterial territory, and coronary artery disease was significant among patients. No specific clinical profiles were linked to particular cardiac lesions.
Download PDF
Download PDF
Download PDF
Download PDF
+91 9063922599
+91 9063922599
editor@healthcare-bulletin.co.uk
Download XML
