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STATE-OF-THE-ART PAPER

Cardiogenic and Aortogenic Brain Embolism

Eleni Doufekias, MD^_*, Alan Z. Segal, MD and Jorge R. Kizer, MD, MSc, FACC^_*,,_*

^_* Department of Medicine, Weill Medical College of Cornell University, New York, New York
Department of Neurology, Weill Medical College of Cornell University, New York, New York
Department of Public Health, Weill Medical College of Cornell University, New York, New York.

Manuscript received August 21, 2007; revised manuscript received November 12, 2007, accepted November 14, 2007.

^_* Reprint requests and correspondence: Dr. Jorge R. Kizer, Box 222, Weill-Cornell Medical Center, 525 East 68th Street, New York, New York 10065. (Email: jok2007{at}med.cornell.edu).

Cardioaortic brain embolism is a potentially devastating condition that presents frequent diagnostic and therapeutic challenges. In this report, we review key aspects of the etiology, clinical presentation, diagnosis, prognosis, and treatment of cardiogenic and aortogenic stroke. Emphasis is on advances in diagnostic imaging capabilities and on recent literature addressing secondary prevention for specific cardioembolic sources, upon which diagnosis and prognosis primarily depend. While early evaluation with modern neuroimaging techniques offers to enhance diagnostic accuracy, additional study is required to define optimal utilization. Appropriate imaging of the heart and aorta is paramount to identifying potential sources of embolism. Secondary prevention for high-risk embolic sources generally involves anticoagulation, but immediate initiation of anticoagulation is not routinely indicated. Medium-risk sources have more modest or undefined risks and little randomized comparative evidence to guide management, but antiplatelet therapy is generally favored. One possible exception is patent foramen ovale, for which high-risk features may warrant anticoagulation or mechanical closure. Definitive recommendations for this and other findings await completion of ongoing clinical trials.

Abbreviations and Acronyms   AF = atrial fibrillation   ASA = atrial septal aneurysm   CAA = complex aortic atheroma   CSE = cardiac source of embolism   CT = computed tomography   INR = international normalized ratio   LV = left ventricle/ventricular   MRI = magnetic resonance imaging   PFO = patent foramen ovale   TEE = transesophageal echocardiography   TTE = transthoracic echocardiography