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Stroke From Cardiogenic Embolism

Alternate Names

  • brain attack
  • Stroke in progress

Definition

A stroke is the death of brain tissue that occurs when the brain does not get enough blood and oxygen. A stroke from cardiogenic embolism occurs when blood clots travel from the heart to an artery supplying the brain.

What is going on in the body?

A stroke from cardiogenic embolism is classified as an ischemic stroke, which means it is caused when the blood supply to the brain is interrupted. In this case, a blood clot is formed in the heart and travels through the bloodstream to block one of the arteries supplying the brain. The brain cells then die from lack of oxygen. The products released when cells die cause swelling in the brain. Since the skull doesn't allow much room for expansion, this swelling can damage the brain tissue even further.

Risks

What are the causes and risks of the condition?

A stroke from cardiogenic embolism is caused by a blood clot from the heart traveling to the blood vessels supplying the brain. Blood clots from the heart may be caused by an irregular heartbeat called atrial fibrillation, a condition in which the upper chambers of the heart beat very quickly and erratically. This irregular beating allows blood to pool and thus form clots within the left atrial appendage of the heart.

The second most common form of a cardioembolic stroke is due the presence of a patent foramen ovale (PFO). They are very common (about 20% of the population have one) and most of the time do not cause a problem.

A PFO is caused by the failure of the two parts of the atrial septum to seal after a person is born.
Most persons never have a complication such as a transient ischemic attack (TIA) or stroke from this condition.
A cardiogenic embolism may also be caused by severe congestive heart failure, a condition in which the weakened heart is unable to pump blood effectively. The sluggish blood flow through the heart allows clots to form in the apex or bottom of the heart.
Other conditions that increase the risk of a blood clot forming in the heart include infections of a heart valve and the presence of a surgically implanted artificial heart valve.
Clots can also form when the heart muscle is damaged, as from a heart attack.
The person's risk of stroke from cardiogenic embolism is increased if other risk factors for stroke are also present.
The American Heart Association has recently issued guidelines for stroke prevention. The guidelines discuss risk factors for stroke in 3 categories:
  • nonmodifiable,
  • well-documented modifiable, and
  • less well-documented or potentially modifiable.
The nonmodifiable factors are ones that cannot be changed by the individual, and include:
  • increasing age. A person's risk of stroke doubles each year after age 55.
  • race. Strokes occur approximately twice as often in blacks and Hispanics as they do in whites.
  • gender. Men have a 50% higher chance of stroke than women do.
  • family history of stroke or transient ischemic attack (TIA). A TIA is a short, reversible form of stroke that may serve as an early warning sign of stroke.
Well-documented modifiable risk factors are those that can be changed by the individual in conjunction with his or her healthcare provider.

These factors are linked to stroke by strong research findings, and there is documented proof that changing the risk factor lowers a person's risk of stroke.

These factors include:
  • high blood pressure
  • smoking
  • diabetes
  • asymptomatic carotid stenosis, or narrowing of one of the arteries in the neck
  • sickle cell anemia, a blood disorder that forms abnormal red blood cells
  • high cholesterol levels in the blood, including total cholesterol and LDL or "bad" or "lethal" cholesterol.
  • Low levels of HDL, "healthy" or "good" cholesterol, are also cause for concern.
  • atrial fibrillation, an abnormal heart rhythm
Less well-documented or potentially modifiable risk factors for stroke are those that have less proof of either a link to stroke or the impact of modifying the risk factor. These factors include:
  • obesity
  • sedentary lifestyle
  • alcohol abuse
  • There are numerous "hypercoaguable" factors, such as homecysteine, that promote the clotting process in the blood stream , that can lead to a stroke.
  • drug abuse
  • blood disorders, such as blood that clots easily or deficiencies of various blood components
  • hormone replacement therapy (HRT). The AHA currently states that the risk of stroke associated with HRT appears low but needs further study.
  • use of birth control pills, or oral contraceptives (especially for women who smoke or who are older than 35 years of age)
  • inflammatory processes, such as a chronic infection with Chlamydia
Several recent studies have identified factors that seem to increase or decrease the risk of stroke in particular groups of people. These studies, which warrant further investigation, include these findings:
  • People who were treated for high blood pressure with thiazide diuretics, such as hydrochlorothiazide, had a significantly lower stroke risk than people on ACE inhibitors or calcium channel blockers.
  • Women ages 39 to 50 who ate more fish and omega-3 polyunsaturated fatty acids had a reduced risk of stroke. This was particularly true in women who did not take aspirin regularly.
  • Women ages 15 to 44 who had 2 drinks of wine a day had a 40% to 60% lower risk of stroke than women who did not drink alcohol.
  • Phenylpropanolamine, a compound contained in appetite suppressants and cold remedies, significantly increased the risk of hemorrhagic stroke in women 18 to 49 years of age. The Food and Drug Administration (FDA) has since asked manufacturers to remove phenylpropanolamine from their products.
  • In one study, people who were treated in emergency departments for transient ischemic attacks (TIA) had a 25% chance of having a stroke or other serious health event within the next 90 days.

Prevention

What can be done to prevent the condition?

Effective treatment of atrial fibrillation, congestive heart failure, and heart attack can help to prevent a stroke from cardiogenic embolism. People with heart valve disease or artificial heart valves may take antibiotics before surgery or dental work as a precaution against infection.
People can also lower their risk of stroke from cardiogenic embolism by addressing other risk factors for stroke. The American Heart Association guidelines for stroke prevention address both modifiable and less well-documented or potentially modifiable risk factors.
Measures to reduce the modifiable risk of high blood pressure, a major cause of stroke, include:
  • measurement of blood pressure in adults at least every 2 years to screen for high blood pressure
  • weight control
  • physical activity
  • moderation in alcohol intake
  • moderate sodium intake
  • for those who smoke, quitting smoking
  • medications to treat high blood pressure if the person's blood pressure is over 140/90 after 3 months of these lifestyle modifications, or if the initial blood pressure is over 180/100
Other measures to reduce an individual's modifiable risk factors for stroke may include:
  • smoking cessation using nicotine patches, counseling, and formal smoking programs
  • control of blood sugar levels in a person with diabetes through medication, diet, and exercise
  • the use of ramipril (i.e., Altace) in people with diabetes. A recent study showed that people with diabetes have a 33% lower risk of ischemic stroke if they take ramipril.
  • careful evaluation of asymptomatic carotid stenosis to determine the need for surgery.
  • Coronary artery surgery, such as an endarterectomy, may be indicated. An endarterectomy opens the narrow portion of the artery and increases the blood flow to the brain. People with carotid stenosis should also work closely with their healthcare providers to control other risk factors for stroke.
  • semiannual screening of children with sickle cell anemia, using ultrasound to determine the child's risk of stroke
  • treatment of atrial fibrillation with blood thinners such as aspirin or warfarin, depending on the person's age and other risk factors
  • monitoring of high levels of total cholesterol or LDL, as well as low levels of HDL.
Depending on the blood levels and the person's other risk factors, medications to lower cholesterol may be given.
Measures to reduce less well-documented or potentially modifiable risks for stroke may include:
  • weight reduction in overweight persons
  • 30 or more minutes of moderate exercise a day for most individuals. People with heart disease or disabilities should be in a medically supervised exercise program.
  • a healthy diet for preventing heart disease, containing at least 5 fruits and vegetables a day
  • for those who drink alcohol, drinking in moderation. The AHA defines moderate drinking as no more than 2 drinks a day for men and 1 drink a day for women.
  • seeking treatment for drug abuse
  • monitoring of blood levels of homocysteine. For most individuals, a well-balanced diet following the food guide pyramid will provide enough folic acid and B vitamins to maintain a healthy homocysteine level. For people with elevated homocysteine levels, supplements containing folic acid and B vitamins may be recommended.
  • avoiding the use of oral contraceptives in women with other stroke risk factors
Some people have early warning signs that they are at risk for strokes. The most common warning sign is what is known as a transient ischemic attack, or TIA. This is a type of reversible stroke that often goes away after a few minutes. These people can often get treatment that will prevent a stroke in the future. For instance, people may be advised to take aspirin or have carotid artery surgery to correct a blockage in a neck artery.

Diagnosed

How is the condition diagnosed?

Cranial MRIs and cranial CT scans may be ordered to show the type, size, and location of the stroke.
If the stroke is due to a cardiogenic embolus, the embolus can usually be diagnosed with a standard echocardiogram. An echocardiogram uses ultrasound waves to visualize the heart as it is beating. Blood clots in the heart can often be seen using this test.
Occasionally, transesophageal echocardiography may be required. In a standard echocardiogram, the X-ray probe is placed on the skin of the chest wall. With transesophageal echocardiography, the X-ray probe is placed through the patient's mouth into the food tube, or esophagus, to get a different view of the heart.

Long Term Effects

What are the long-term effects of the condition?

Strokes can cause death or permanent disability. Though many people recover some function in the first several months after a stroke, others show no improvement. Some people have several small strokes over time and slowly get worse with each one.

Other Risks

What are the risks to others?

Strokes are not contagious and pose no risk to others.

Treatments

What are the treatments for the condition?

Most people with strokes are treated right away with only aspirin if they do not have bleeding into the brain. This only serves to help prevent further strokes.
In cases when a stroke is caught in the first three hours (180 minutes), a clot-busting medication may be used to attempt to reverse a stroke.
This is why early recognition of a stroke can be important. If someone has the early warning signs of stroke, the emergency medical system should be contacted immediately.
These signs include a sudden onset of:
  • severe headache
  • weakness or numbness of the face, arm, or leg, especially on one side of the body
  • dizziness
  • trouble walking or loss of balance, known as ataxia
  • confusion
  • speech impairments, including trouble speaking or understanding speech
  • visual impairments
Supportive therapy may also be needed with some strokes. This may include an artificial breathing machine, or ventilator, and an artificial feeding tube if the person cannot swallow.
Rehabilitation services can help to improve a person's function after a stroke. Physical therapy and other therapy, such as speech therapy or occupational therapy, may be used to maximize recovery.

Side Effects

What are the side effects of the treatments?

Side effects depend on the treatments used. For instance, aspirin may cause allergic reactions, stomach upset, or bleeding. Clot-busting medications can cause excessive bleeding. A ventilator may sometimes cause damage to the lungs or an infection.

After Treatment

What happens after treatment for the condition?

After the person is stable, treatment of the risk factors for stroke, as well as the cause of the stroke, is important to prevent further strokes. For instance, stopping smoking and controlling high blood pressure, diabetes, and high cholesterol are advised for most people. Treatment for atrial fibrillation and congestive heart failure will be given as needed.
Many people need assistance of one form or another after a stroke. This may range from using a walking cane to needing 24-hour-a-day skilled nursing care. Ongoing therapy to improve function is usually advised for at least 6 months if the person is able.

Monitor

How is the condition monitored?

After having a stroke due to cardiogenic embolism, a person may need a repeat echocardiogram with routine follow-up visits to the healthcare provider's office to check for new clots in the heart.
If an individual takes blood thinners, blood tests are normally done to assure the correct dose. These tests let a healthcare provider know if the person's blood is too "thin" or too "thick," which may require a dosage adjustment. Any new or worsening symptoms should be reported to the healthcare provider.

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