Chinese Expert Consensus on the Diagnosis of Cardiogenic Stroke (2019)

Chinese Expert Consensus on the Diagnosis of Cardiogenic Stroke (2019)

Cardioembolic stroke (CES), also known as cardiogenic stroke, is a clinical syndrome caused by a cardiogenic embolus originating from the heart, which travels through the circulation to occlude a cerebral artery, leading to corresponding brain dysfunction. CES is associated with greater severity, poorer outcomes, and a higher recurrence rate compared to other subtypes of ischemic stroke. Despite its clinical significance, universal diagnostic criteria for CES have not been well established. This consensus aims to provide a comprehensive framework for the diagnosis of CES, incorporating the latest developments in clinical research to improve diagnostic accuracy and facilitate prevention and treatment.

Classification of CES Etiology

The etiology of CES is classified based on the potential causes outlined in the A-S-C-O (phenotype) classification system and its epidemiological characteristics. The consensus divides CES into nine categories: atrial fibrillation (AF), heart failure, acute coronary syndrome, patent foramen ovale (PFO), rheumatic heart disease, artificial heart valve, infective endocarditis, dilated cardiomyopathy, and cardiac myxoma. These categories help clinicians identify the underlying cardiac conditions that may lead to CES, guiding targeted diagnostic and therapeutic strategies.

Clinical Features

CES can occur in patients of all ages, but the majority have a history of heart disease. The onset of CES is typically abrupt, with severe neurological symptoms corresponding to cerebral cortex damage, such as aphasia or visual field defects. These symptoms often peak rapidly at the onset and may be accompanied by signs of systemic thromboembolism, including edge-shaped infarction of the kidney or spleen, Osler nodes, and blue toe syndrome. Recognizing these clinical features is crucial for the early identification of CES.

Auxiliary Examination

Neuroimaging plays a pivotal role in the diagnosis of CES. Cranial computed tomography (CT) or magnetic resonance imaging (MRI) often reveals single or multiple infarcts distributed in the cerebral cortex, subcortical regions, cerebellum, and brainstem. These infarcts frequently exceed the territory of a single vascular supply, may exist at different stages, and are prone to hemorrhagic transformation. T2*-weighted gradient-echo imaging can reveal a two-layered susceptibility vessel sign and a high overestimation ratio, which are indicative of CES.

Vascular and cardiac assessments are essential to identify high-risk cardiogenic embolism and exclude large artery plaque shedding. Echocardiography, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), is used to detect intracardiac thrombi, vegetations, or tumors. Contrast TEE, contrast transthoracic echocardiography, and contrast-enhanced transcranial Doppler ultrasound (cTCD) can identify right-to-left shunts in the cardiac cavity. Transcranial Doppler (TCD) monitoring may reveal microembolic signals, and repetitive TCD/cTCD evaluations can show rapid recanalization of occluded major brain arteries. Carotid ultrasound typically shows no atherosclerotic stenosis in the carotid or vertebral arteries.

Electrocardiogram (ECG) examination is another critical diagnostic tool. A standard 12-lead ECG may display abnormalities such as AF or recent myocardial infarction. Remote ECG monitoring, 24-hour Holter ECG monitoring, and long-term ECG monitoring (over 24 hours) can identify arrhythmias, particularly paroxysmal AF.

Vascular neuroimaging, including computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography, often shows multi-segmental clots or abrupt vessel cut-offs in the main trunk or branches of intracranial large vessels, in the absence of significant atherosclerotic narrowing of upstream vessels. High-resolution intracranial vessel wall imaging typically reveals no atherosclerotic plaques in intracranial arteries.

Blood biochemistry tests, such as measuring B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, are significant in differentiating CES from non-cardiogenic stroke.

Clinical Scale

The CHA2DS2-VASc score, which includes congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, prior stroke/transient ischemic attack (doubled), vascular disease, age 65-74 years, and sex category (female), is generally used to evaluate the risk of stroke in non-valvular AF. The risk of paradoxical embolism score can assess the correlation between stroke and PFO.

Pathology

Autopsy analysis may provide a definitive diagnosis by indicating mural thrombi, valvular vegetations, or tumor fragments (e.g., myxoma) in the middle cerebral artery (MCA) and/or vertebrobasilar arterial system.

Diagnosis and Risk Stratification

The Chinese expert consensus categorizes CES into definite, probable, and possible CES based on clinical and neuroimaging features, along with vascular and cardiac assessments. Definite CES is diagnosed when two of the typical clinical manifestations (A) are present, along with at least one of the cardiogenic embolus findings on echocardiography (B) and the exclusion of other diseases (C). Probable CES is diagnosed when two of (A) are present, or at least one of (A) and at least one of (B) are present. Possible CES is diagnosed when at least one of (A) is present.

Risk stratification is crucial for guiding CES treatment and reducing recurrence and mortality. When the cause of CES remains unclear after diagnosis, the risk of embolism should be evaluated immediately. The consensus recommends using a standard from the Journal of the American Society of Echocardiography for risk stratification, which includes factors related to high and low embolic potential.

Conclusion

This consensus provides a comprehensive and structured approach to the diagnosis of CES, incorporating clinical features, neuroimaging, vascular and cardiac assessments, blood biochemistry, clinical scales, and pathology. By improving diagnostic accuracy, this consensus aims to enhance the prevention and treatment of CES, ultimately reducing its severity, recurrence, and associated mortality.

doi.org/10.1097/CM9.0000000000001217

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