Arboix Adrià, Alió Josefina
Cerebrovascular Division, Department of Neurology, Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, Spain.
Curr Cardiol Rev. 2010 Aug;6(3):150-61. doi: 10.2174/157340310791658730.
This article provides the reader with an overview and up-date of clinical features, specific cardiac disorders and prognosis of cardioembolic stroke. Cardioembolic stroke accounts for 14-30% of ischemic strokes and, in general, is a severe condition; patients with cardioembolic infarction are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of cardioembolic infarction, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The more common high risk cardioembolic conditions are atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy, and mitral rheumatic stenosis. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhyhtmia can be detected by Holter monitoring. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. In our experience, in-hospital mortality in patients with early embolic recurrence (within the first 7 days) was 77%. Patients with alcohol abuse, hypertension, valvular heart disease, nausea and vomiting, and previous cerebral infarction are at increased risk of early recurrent systemic embolization. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent.
本文为读者提供了心源性栓塞性卒中的临床特征、特定心脏疾病及预后的概述和最新信息。心源性栓塞性卒中占缺血性卒中的14 - 30%，总体而言病情严重；心源性梗死患者易于早期及长期发生卒中复发，不过急性期的恰当治疗及随访时的严格控制或许可预防复发。某些临床特征提示心源性梗死，包括起病急骤至最大功能缺损、起病时意识水平下降、无偏瘫的韦尼克失语或完全性失语、卒中发作时的瓦尔萨尔瓦动作，以及脑栓塞与系统性栓塞并存。腔隙性临床表现、腔隙性梗死尤其是多发性腔隙性梗死，提示心源性栓塞的可能性不大。较常见的高风险心源性栓塞情况有房颤、近期心肌梗死、机械人工瓣膜、扩张型心肌病及二尖瓣风湿性狭窄。经胸及经食管超声心动图可揭示心脏结构疾病。动态心电图监测可检测阵发性心房节律不齐。与其他类型的脑梗死相比，心源性栓塞性卒中的院内死亡率（在我们的系列研究中为27.3%）最高。根据我们的经验，早期栓塞复发（在头7天内）患者的院内死亡率为77%。有酗酒、高血压、瓣膜性心脏病、恶心呕吐及既往脑梗死的患者，早期反复发生系统性栓塞的风险增加。对于不存在如跌倒、依从性差、癫痫未控制或胃肠道出血等禁忌证的、有复发性心源性栓塞性卒中高风险的患者，应尽可能立即启动抗凝二级预防。
