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Cardioaortic sources of cerebral embolism

Cardioaortic sources of cerebral embolism
Sources with high primary risk for ischemic stroke Sources with low or uncertain primary risk for ischemic stroke
Atrial fibrillation Cardiac sources of embolism:
Paroxysmal atrial fibrillation Mitral annular calcification
Left atrial thrombus Patent foramen ovale
Left ventricular thrombus Atrial septal aneurysm
Sick sinus syndrome Atrial septal aneurysm and patent foramen ovale
Atrial flutter Left ventricular aneurysm without thrombus
Recent myocardial infarction (within one month prior to stroke) Left atrial spontaneous echo contrast ("smoke")
Mitral stenosis or rheumatic valve disease Congestive heart failure with ejection fraction <30%
Mechanical heart valves Bioprosthetic heart valves
Chronic myocardial infarction together with low ejection fraction (<28%) Apical akinesia
Dilated cardiomyopathy (prior established diagnosis or left ventricular dilatation with an ejection fraction of <40% or fractional shortening of <25%) Wall motion abnormalities (hypokinesia, akinesia, dyskinesia) other than apical akinesia
Nonbacterial thrombotic endocarditis Hypertrophic cardiomyopathy
Infective endocarditis Left ventricular hypertrophy
Papillary fibroelastoma Left ventricular hypertrabeculation/non-compaction
Left atrial myxoma Recent aortic valve replacement or coronary artery bypass graft surgery
Presence of left ventricular assist device Paroxysmal supraventricular tachycardia
  Aortic sources of embolism:
  Complex atheroma in the ascending aorta or proximal arch (protruding with >4 mm thickness, or mobile debris, or plaque ulceration)
The high- and low-risk cardioaortic sources in this table are separated using an arbitrary 2% annual or one-time primary stroke risk threshold.
Data from:
  1. Ay H, Benner T, Arsava EM, et al. A computerized algorithm for etiologic classification of ischemic stroke: the Causative Classification of Stroke System. Stroke 2007; 38:2979.
  2. Ay H, Furie KL, Singhal A, et al. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005; 58:688.
  3. Arsava EM, Ballabio E, Benner T, et al. The Causative Classification of Stroke system: an international reliability and optimization study. Neurology 2010; 75:1277.
  4. Kamel H, Elkind MS, Bhave PD, et al. Paroxysmal supraventricular tachycardia and the risk of ischemic stroke. Stroke 2013; 44:1550.
  5. Kirklin JK, Pagani FD, Kormos RL, et al. Eighth annual INTERMACS report: Special focus on framing the impact of adverse events. J Heart Lung Transplant 2017; 36:1080.

Reproduced and modified with permission from: Ay H, Furie KL, Singhal A, et al. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005; 58:688. Copyright © 2005 American Neurological Association.

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