الفهرس Only 14 pages are availabe for public view
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Abstract
Stroke is a major public health problem because it is frequent, dangerous and expensive. Moreover, it can often be prevented, and may now be treatable in the acute stage.
Cardio-embolic strokes make up to 25% of all ischemic strokes and atrial fibrillation is not the only cardiac disease that may be complicated by ischemic strokes.
In our study we tried to explore acute ischemic stroke patients for cardiac diseases mainly heart failure patients that may contribute independently to their cerebrovascular event and further to explore the effect of the patients existing cardiac diseases on the severity of their current stroke, infarct size and its location. We tried also to explore the effects or relationship between various structural and functional echocardiographic findings like diastolic dysfunction or low ejection fraction on the stroke variables like severity, outcome and subtype of stroke on Modified Oxfordshire classification.
Regarding atrial fibrillation, we found patients with atrial fibrillation to have significantly higher scores on NIHSS score at admission but at discharge the difference did not reach statistical difference although atrial fibrillation patients still tended to have higher scores on NIHSS.
Although our findings did not reach statistical significance except in the previously documented relationship between atrial fibrillation and ischemic stroke, we found many associations that other studies, although few but larger than ours, pointed to.
These findings were mainly with heart failure patients whom we found were more likely to have higher NIHSS score at both admission and follow-up and were more likely to have larger infarct size manifested by the fact that 62% of these patients had partial anterior circulation infarction and this may be due an underlying embolic potential as previously proposed by others like
High percentage (87.5%) of these patients also had leucoaraiosis which is related to cerebral hypoperfusion which is multifactorial in heart failure patients in our study as all of them who had undergone carotid Doppler study had significant carotid stenosis and 87.5% of those who had done MRA had significant intra-cranial vessel stenosis these findings combined with finding that heart failure patients also had worse mortality rate demonstrate that these patient deserve intensified primary and secondary prevention programs, to our best knowledge at this time, by tight control of any comorbid risk factor as hypertension , diabetes mellitus or dyslipidaemia and using agents as antiplatelets and agents known or proposed to protect against vascular events as angiotensin converting enzyme inhibitors and statins. The role of anti-coagulants and their risk to benefit ratio remain to be more investigated in these high risk patients especially that leucoaraiosis, known to increase the risk of bleeding with anti-coagulants, is highly prevalent in these patients.
In our study we could not document causal relationship between ischemic stroke and other echocardiographic findings as left ventricular hypertrophy, dilated left atrium, segmental wall motion abnormality and diastolic dysfunction, the former two findings were demonstrated to have marginal causative relationship in other studies, these may have been in part due to the cut-off points that were determined from the start and the matters may have changed if we had stratified the degree of abnormality of each variable as subdividing left atrial enlargement into mild, moderate or severe. But the finding of such abnormalities with this high degree of prevalence in stroke patients such as diastolic dysfunction in 88%, left atrial dilatation in 56% or left ventricular hypertrophy in 53% of patients should alert us to their possible causation or association and may call for other studies targeting these variables individually.
Our study came in accordance with previous Egyptian studies documenting the high prevalence of intra-cranial vessel stenosis among Egyptian population but this seems to have little influence on the approach to primary or secondary prevention at this time, although there are still few proponents of anti-coagulation in patients with significant intracranial vessel stenosis but evidence from large trials of benefit from using warfarin rather than aspirin in these patients is lacking as was demonstrated by chimowitz et al., (1995). And results assessing the role of stenting of these intracranial stenosed vessels or the role of drugs targeting endothelial proliferation as cilostazol remains to elucidated.