Diagnostic Evaluation of Stroke Etiology

Abstract

OBJECTIVEPrecise therapies require precise diagnoses. This article provides an evidence-based approach to confirming the diagnosis of ischemic stroke, characterizing comorbidities that provide insights into the pathophysiologic mechanisms of stroke, and identifying targets for treatment to optimize the prevention of recurrent stroke.LATEST DEVELOPMENTSIdentifying the presence of patent foramen ovale, intermittent atrial fibrillation, and unstable plaque is now routinely included in an increasingly nuanced workup in patients with stroke, even as ongoing trials seek to clarify the best approaches for treating these and other comorbidities. Multicenter trials have demonstrated the therapeutic utility of patent foramen ovale closure in select patients younger than age 60 years. Insertable cardiac monitors detect atrial fibrillation lasting more than 30 seconds in about one in ten patients monitored for 12 months following a stroke. MRI of carotid plaque can detect unstable plaque at risk of being a source of cerebral embolism.ESSENTIAL POINTSTo optimize the prevention of recurrent stroke, it is important to consider pathologies of intracranial and extracranial blood vessels and of cardiac structure and rhythm as well as other inherited or systemic causes of stroke. Some aspects of the stroke workup should be done routinely, while other components will depend on the clinical circumstances and preliminary testing results.

Neurological Consequences of Cardiac Arrhythmias: Relationship Between Stroke, Cognitive Decline, and Heart Rhythm Disorders

“…An ultrasound of the heart can assess its anatomical structure and physiological function, including the evaluation of cardiac valves, chamber size, and any structural abnormalities that may contribute to arrhythmias [ 23 ]. To assess blood flow to the carotid arteries as well as detect any emboli, a carotid ultrasound can be done [ 23 ]. Electrophysiological studies of the heart, although an invasive procedure, are very useful to map the electrical activity and identify the source of arrhythmia.…”

Diagnosis and Management of Cardioembolic Stroke

“…A transesophageal echocardiogram can also identify less common cardioembolic sources such as cardiac myxoma or fibroelastoma that may require surgery. This topic is discussed in more detail in the article “Diagnostic Evaluation of Stroke Etiology,” by James F. Meschia, MD, FAAN, in this issue of Continuum 3 …”