Cardiac Workup of Ischemic Stroke

Abstract

Background and Purpose-Discovering potential cardiac sources of stroke is an important part of the urgent evaluation of the ischemic stroke patient as it often impacts treatment decisions that are essential for determining secondary stroke prevention strategies, yet the optimal approach to the cardiac workup of an ischemic stroke patient is not known. Methods-A review of the literature concerning the utility of cardiac rhythm monitoring (ECG, telemetry, Holter monitors, and event recorders) and structural imaging (transthoracic and transesophageal echocardiography) was performed. Results-Data supporting a definitive, optimal, and cost-effective approach are lacking, though some data suggest that appropriate patient selection can improve the diagnostic and therapeutic yield of rhythm monitoring and echocardiography in the evaluation of stroke etiology. Conclusions-Based on available data, an algorithmic approach for the evaluation of patients with acute ischemic cerebrovascular events that takes into account therapeutic and diagnostic yield as well as cost-efficiency is proposed.

The Causative Classification of Stroke system

“…High variance in expert opinion for echocardiography is not unanticipated because there is no uniform recommended approach for performance of echocardiography for evaluation of stroke. 17,18 CCS requires echocardiography only if there is clinical suspicion of cardiac embolism and if clinical history, cardiac examination, and EKG do not reveal a source. CCS now allows classification of patients with known sources of cardiac embolism into relevant subtypes regardless of the expert opinion for echocardiography.…”

Diagnostic Yield of Emergency Department Arch-to-Vertex CT Angiography in Patients with Suspected Acute Stroke

“…[1][2][3][4][5][6] Subsequent investigation of risk factors for stroke is an elective process and typically does not begin until after the acute event has passed. [7][8][9] With improvement in CT technology, the limitations on scan coverage of neurovascular CTA have relaxed, and single-pass imaging from the aortic arch to the skull vertex has become commonplace. [10][11][12][13][14][15] Nevertheless, we have found no studies that evaluated benefit to the patient from this practice.…”

A Structured Reading Algorithm Improves Telemetric Detection of Atrial Fibrillation After Acute Ischemic Stroke

“…1,6 However, paroxysmal forms pose special diagnostic challenges: silent episodes may recur in timely clusters 1,5 and escape a single electrocardiogram (ECG) on admission. 7,8 Current guidelines recommend cardiac monitoring for at least 24 hours after an acute cerebrovascular event, 9,10 but evidence for a clear superiority among different modalities of monitoring is lacking. In clinical practice, evaluation of telemetric data is often not standardized and AF episodes may remain unrecognized although being captured by the monitoring.…”