Background: This study was aimed at determining the frequency and coexistent patterns of high- and medium-risk cardiac sources of embolism (CSE) as defined by the Trial of ORG 10172 in the Acute Stroke Treatment (TOAST) classification system and at investigating how identified CSE contributed to this classification. Methods: We analyzed data from 2,482 patients with acute cerebral infarctions who registered in the Yonsei Stroke Registry over a 10-year period. Cardiac sources were divided into high- and medium-risk groups based on the TOAST classification. Results: Of the 2,482 patients, 1,130 (46%) underwent echocardiographic studies. At least one CSE was detected in 629 patients (25%). Atrial fibrillation was the most common high-risk CSE. Patent foramen ovale, spontaneous echo contrast and congestive heart failure comprised most of the medium-risk CSE. Atrial fibrillation frequently accompanied coexistent CSE (69%) such as spontaneous echo contrast, congestive heart failure, and left atrial/appendage thrombus, while patent foramen ovale was detected in isolation in more than 90% of the patients. Patients with a high-risk CSE were more likely to be diagnosed with cardioembolism (83%) than patients with only a medium-risk CSE (58%). Conclusions: Our study elucidated the frequency and various coexistent patterns of CSE in Korean stroke patients as defined by the TOAST classification system. In addition, we have demonstrated a higher correlation between high-risk CSE and cardioembolism than with medium-risk CSE and cardioembolism.

Keywords:
Brain infarction, Cardioembolism, Classification
1.
Ferro JM: Cardioembolic stroke: an update. Lancet Neurol 2003;2:177–188.
2.
Cardiogenic Brain Embolism: The second report of the cerebral embolism task force. Arch Neurol 1989;46:727–743.
3.
Cardiogenic Brain Embolism: Cerebral embolism task force. Arch Neurol 1986;43:71–84.
4.
Bornstein NM, Pavlovic AM: Non-valvular atrial fibrillation: an important cause of stroke; in Barnett HJM, Bogousslavsky J, Meldrum H (eds): Advances in Neurology. Philadelphia, Lippincott Williams & Wilkins, 2003, vol 92, pp 203–212.
5.
Rauh G, Fischereder M, Spengel FA: Transesophageal echocardiography in patients with focal cerebral ischemia of unknown cause. Stroke 1996;27:691–694.
6.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of ORG 10172 in acute stroke treatment. Stroke 1993;24:35–41.
7.
Paradowski B, Maciejak A: TOAST classification of subtypes of ischaemic stroke: diagnostic and therapeutic procedures in stroke. A 4-year observation. Cerebrovasc Dis 2005;20:319–324.
8.
Kammersgaard LP, Olsen TS: Cardiovascular risk factors and 5-year mortality in the Copenhagen stroke study. Cerebrovasc Dis 2006;21:187–193.
9.
De Silva DA, Woon FP, Lee MP, Fook-Chong S, Chang HM, Chen CL, Wong MC: Ischemic cerebrovascular disease: differences between ethnic South Asian and ethnic Chinese patients. Cerebrovasc Dis 2005;20:407–409.
10.
Ruo B, Capra AM, Jensvold NG, Go AS: Racial variation in the prevalence of atrial fibrillation among patients with heart failure: the epidemiology, practice, outcomes, and costs of heart failure (EPOCH) study. J Am Coll Cardiol 2004;43:429–435.
11.
Conway DS, Lip GY: Ethnicity in relation to atrial fibrillation and stroke (the West Birmingham Stroke Project). Am J Cardiol 2003;92:1476–1479.
12.
Kizer JR, Silvestry FE, Kimmel SE, Kasner SE, Wiegers SE, Erwin MB, Schwalm SA, Viswanathan MN, Pollard JR, Keane MG, St. John Sutton MG: Racial differences in the prevalence of cardiac sources of embolism in subjects with unexplained stroke or transient ischemic attack evaluated by transesophageal echocardiography. Am J Cardiol 2002;90:395–400.
13.
Ghandehari K, Izadi-Mood Z: The Khorasan Stroke Registry: results of a 5-year hospital-based study. Cerebrovasc Dis 2007;23:132–139.
14.
Lee BI, Nam HS, Heo JH, Kim DI: Yonsei Stroke Registry. Analysis of 1,000 patients with acute cerebral infarctions. Cerebrovasc Dis 2001;12:145–151.
15.
Bonita R, Stewart A, Beaglehole R: International trends in stroke mortality: 1970–1985. Stroke 1990;21:989–992.
16.
Amarenco P, Duyckaerts C, Tzourio C, Henin D, Bousser MG, Hauw JJ: The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992;326:221–225.
17.
White H, Boden-Albala B, Wang C, Elkind MSV, Rundek T, Wright CB, Sacco RL: Ischemic stroke subtype incidence among Whites, Blacks, and Hispanics: The Northern Manhattan Study. Circulation 2005;111:1327–1331.
18.
Yip PK, Jeng JS, Lee TK, Chang YC, Huang ZS, Ng SK, Chen RC: Subtypes of ischemic stroke. A hospital-based stroke registry in Taiwan (SCAN-IV). Stroke 1997;28:2507–2512.
19.
Wu LA, Malouf JF, Dearani JA, Hagler DJ, Reeder GS, Petty GW, Khandheria BK: Patent foramen ovale in cryptogenic stroke: current understanding and management options. Arch Intern Med 2004;164:950–956.
20.
Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J: Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001;345:1740–1746.
21.
Overell JR, Bone I, Lees KR: Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000;55:1172–1179.
22.
Vincelj J, Sokol I, Jaksic O: Prevalence and clinical significance of left atrial spontaneous echo contrast detected by transesophageal echocardiography. Echocardiography 2002;19:319–324.
23.
Hart RG, Halperin JL: Atrial fibrillation and stroke: concepts and controversies. Stroke 2001;32:803–808.
24.
Inoue H, Nozawa T, Hirai T, Iwasa A, Okumura K, Lee JD, Shimizu A, Hayano M, Yano K: Accumulation of risk factors increases risk of thromboembolic events in patients with nonvalvular atrial fibrillation. Circ J 2006;70:651–656.
25.
Bernhardt P, Schmidt H, Sommer T, Luderitz B, Omran H: Atrial fibrillation patients at high risk for cerebral embolism. Clin Res Cardiol 2006;95:148–153.
26.
The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography: Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. Ann Intern Med 1998;128:639–647.
27.
Oppenheimer SM, Lima J: Neurology and the heart. J Neurol Neurosurg Psychiatry 1998;64:289–297.
28.
Nighoghossian N, Derex L, Loire R, Perinetti M, Honnorat J, Riche G, Barthelet M, Ninet J, Chazot G, Chassignolle J, Trouillas P: Giant Lambl excrescences. An unusual source of cerebral embolism. Arch Neurol 1997;54:41–44.
29.
Cabanes L, Coste J, Derumeaux G, Jeanrenaud X, Lamy C, Zuber M, Mas JL: Interobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography. J Am Soc Echocardiogr 2002;15:441–446.
30.
Meissner I, Whisnant JP, Khandheria BK, Spittell PC, O’Fallon WM, Pascoe RD, Enriquez-Sarano M, Seward JB, Covalt JL, Sicks JD, Wiebers DO: Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: The SPARC study. Stroke Prevention: Assessment of Risk in a Community. Mayo Clin Proc 1999;74:862–869.
© 2007 S. Karger AG, Basel
2007
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.