Clinical and echocardiographic predictors of silent cerebral infarctions in patients with persistent atrial fibrillation

Open access


Aim. The aims of the study were to evaluate prevalence of silent cerebral infarctions (SCI) and determine their clinical and echocardiographic predictors in patients with atrial fibrillation (AF).

Patients and methods. In prospective cross sectional study we examined 134 patients with non-valvular AF. Clinical examination, laboratory tests, transoesophageal, transthoracic echocardiography and multislice computed tomography of the brain were performed for all patients. According to current guidelines, SCI was defined as imaging (≥3 mm) or neuropathological evidence of central nervous system infarction, without a history of acute neurological dysfunction attributable to the lesion.

Results. Silent cerebral infarctions were detected in 34.3% (n = 46) of patients, and infarctions ≥ 15 mm (mean diameter 31.3 mm) were detected in 11.2% (n = 15) of patients. Superficial SCIwere found in 12.7%and basal SCI in 21.6% of cases. In multivariate analysis low creatinine clearance < 90 ml/min was independently associated with small basal SCI (p = 0.04). In univariate analysis age ≥ 65 years was significantly associated with basal SCI, p = 0.004, but not with SCI ≥ 15 mm or superficial SCI. The results of multivariate analysis showed that CHA2DS2VASc score was an independent predictor of superficial SCI; low left atrial appendage velocity (LAAV) < 30 cm/s was independently associated both with SCI ≥ 15 mm (p = 0.03) and superficial SCI (p = 0.02).

Conclusions. Large and superficial SCI were significantly and independently associated with low LAAV < 30 cm/s and other echocardiographic embolic risk factors and in case of absence of significant large arteries atherosclerosis may be considered as those of cardiac origin. Small basal SCI were associated with age and low creatinine clearance < 90 ml/min which was their independent predictor. CHA2DS2VASc score is useful for assessment of risk of cerebral infarctions even those without history of acute symptoms

[1] Brant-Zawadzki M, Fein G, Van Dyke C, Keirman R, Davenport L, De Groot J. MR imaging of the aging brain. Am J Neuroradiol 1985;6:675-82.

[2] Price T, Manolio T, Kronmal R, Kittner S, Yue N, Robbins J, Anton-Culver H. Silent brain infarction on magnetic resonance imaging and neurological abnormalities in community-dwelling older adults: the Cardiovascular Health Study: CHS Collaborative Research Group. Stroke 1997;28:1158-64.

[3] Sacco R, Kasner S, Broderic J, Caplan L, Connors J, Culebras A, et al. An updated definition of stroke for the 21st century. A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:2064-89.

[4] Brott T, Tomsick T, Feinberg W, Johnson C, Biller J, Broderick J, et al. Baseline silent cerebral infarction in the Asymptomatic Carotid Atherosclerosis Study. Stroke 1994;25:1122-9.

[5] Ezekowitz M, James K, Davenport J, Broderick J, Gupta S, Thadani V, et al. Silent cerebral infarction in patients with nonrheumatic atrial fibrillation. The Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. Circulation 1995;92:2178-82.

[6] Hara M, Ooie T, Yufu K, Tsunematsu Y, Kusakabe T, Ooga M, et al. Silent cortical strokes associated with atrial fibrillation.Clin Cardiol 1995;18:573-4.

[7] Russmann H, Vingerhoets F, Ghika J, Maeder P, Bogousslavsky J. Acute infarction limited to the lenticular nucleus: clinical, etiologic, and topographic features. Arch Neurol 2003;60(3):351-5.

[8] Ferguson G, Eliasziw M, Barr H, Clagett G, Barnes R, Wallace M, et al. Symptomatic carotid endarterectomy trial surgical results in 1415 patients for the North American Symptomatic Carotid Endarterectomy Trial (NASCET) Collaborators. Stroke 1999;30:1751-8.

[9] Vincelj J, Sokol I, Jaksic O. Prevalence and clinical significance of left atrial spontaneous echo contrast detected by transesophageal echocardiography. Echocardiography 2002;19:319-24.

[10] Kleemann T, Becker T, Strauss M, Schneider S, Seidl K. Prevalence and clinical impact of left atrial thrombus and dense spontaneous echo contrast in patients with atrial fibrillation and low CHADS2 score. Eur J Echocardiogr 2009;10(3):383-8.

[11] Lang R, Bierig M, Devereux R, Flachskampf F, Foster E, Pellikka P, et al. Recommendations for chamber quantification: A report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440-63.

[12] Nagueh S, Appleton C, Gillebert T, Marino P, Oh J, Smiseth O, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009;22(2):107-33.

[13] Kutner M, Nachtsheim C, Neter J. Applied Linear Regression Models, 4th ed. 2004.

[14] Vermeer S, Hollander M, van Dijk E, Hofman A, Koudstaal P, Breteler M, Rotterdam Scan Study. Silent brain infarcts and white matter lesions increase stroke risk in the general population: the Rotterdam Scan Study. Stroke 2003;34:1126-9.

[15] Mangla R, Kolar B, Almast J, Ekholm S. Border zone infarcts: pathophysiologic and imaging characteristics. RadioGraphics 2011;31:1201-14.

[16] Pollanen M, Deck J. The mechanism of embolic watershed infarction: experimental studies. Can J Neurol Sci 1990;17(4):395-8.

[17] Mauro P, Evangelista A, Nihoyannopoulos P, Flachskampf F, Athanassopoulos G, Colonna P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2010;11:461-76.

[18] Yonemura K, Kimura K, Minematsu K, Uchino M, Yamaguchi T. Small centrum ovale infarcts on diffusion-weighted magnetic resonance imaging. Stroke 2002;33:1541-4.

[19] Camm J, Kirchhof P, Lip G, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31(19):2369-429.

[20] Zabalgoitia M, Halperin J, Pearce L, Blackshear J, Asinger R, Hart R. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators. J Am Coll Cardiol 1998;31(7):1622-6.

[21] Thambidorai S, Murray R, Parakh K, Shah T, Black I, Jasper S, et al. Utility of transesophageal echocardiography in identification of thrombogenic milieu in patients with atrial fibrillation (an ACUTE ancillary study). Am J Cardiol 2005;96:935-41.

[22] Vogels S, Emmelot-Vonk M, Verhaar H, Koek H. The association of chronic kidney disease with brain lesions on MRI or CT: a systematic review. Maturitas 2012;71(4):331-6.

[23] IkramM, VernooijM, Hofman A, NiessenW, van der Lugt A, Breteler M. Kidney function is related to cerebral small vessel disease. Stroke 2008;39(1):55-61.

[24] Wada M, Nagasawa H, Iseki C, Takahashi Y, Sato H, Arawaka S, et al. Cerebral small vessel disease and chronic kidney disease (CKD): results of a cross-sectional study in community-based Japanese elderly. J Neurol Sci 2008;272(1-2):36-42.

[25] Kobayashi A, Iguchi M, Shimizu S, Uchiyama S. Silent cerebral infarcts and cerebral white matter lesions in patients with nonvalvular atrial fibrillation. J Stroke Cerebrovasc Dis 2012;21(4):310-7.

[26] Jeerakathil T, Wolf P, Beiser A, Massaro J, Seshadri S, D’Agostino R, DeCarli C. Stroke risk profile predicts white matter hyperintensity volume: the Framingham Study. Stroke 2004;35(8):1857-61.

[27] Pisters R, Olesen J, Lip G. The role of echocardiography in stroke risk assessment in patients with atrial fibrillation: is it additive or does it simply echo clinical risk factors? Europace 2012;14(1):1-2.

[28] Bernick C, Kuller L, Dulberg C, Longstreth WT Jr, Manolio T, Beauchamp N, et al. Cardiovascular Health Study Collaborative Reseach Group. Silent MRI infarcts and the risk of future stroke: the cardiovascular health study. Neurology 2001;57(7):1222-9.

Seminars in Cardiovascular Medicine

The Journal of Lithuanian Heart Association

Journal Information


All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 134 134 19
PDF Downloads 29 29 7