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Management of Cardioembolic Stroke 161

endarterectomy of aortic arch plaque forsecondary CONCLUSION :
stroke prevention is not recommended (III; C).
The choice of an anticoagulant may be influenced by
ARTERIAL DISSECTION : Patients with extracranial clinical features , patterns of risk factors, and comor-
carotid or vertebral arterial dissection with ischemic bidities. Newer anticoagulants have revolutionized
stroke or TIA , 3- 6 months of either antiplatelet or the anticoagulation management.
anticoagulant therapy is reasonable. (11A, b).In pa- Stroke burden to be reduced by detection and treat-
tients with recurrent cerebral ischemic events despite ment of cardiac risk factors addressing knowledge
medical therapy, endovascular therapy is considered. gaps about thrombogenic atrial substrate , treatment
Surgical management in those who fail.(11b,C) of occult AF and optimal antithrombotic strategies.
PACEMAKERS: Sick sinus syndrome patients who
convert to atrial fibrillation or who have a ventric- REFERENCES
ular-demand pacemaker might represent high-risk 1. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekow-
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pacemaker insertion is not rare, and pacing does not for the prevention of stroke in patients with stroke and transient ischemic
appear to be protective. attack. Stroke. 2014 Jan 1:STR-0000000000000024.
2. Font M, Krupinski J, Arboix A. Antithrombotic medication for cardioembolic
CARDIAC PROCEDURES : In high-risk populations stroke prevention. Stroke research and treatment. 2011 Jun 22;2011.
the safest approach to be followed during coronary 3. Werner N, Zahn R, Zeymer U. Stroke in patients undergoing coronary
angiography to prevent peri-interventional stroke angiography and percutaneous coronary intervention: incidence, predictors,
.Recommendation are based on expert opinions and outcome and therapeutic options. Expert review of cardiovascular therapy.
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cal embolectomy in patients are emerging therapeu- 4. Culebras A, Messé SR, Chaturvedi S, Kase CS, Gronseth G. Summary of
tic options, but needs further research by randomized evidence-based guideline update: Prevention of stroke in nonvalvular atrial
clinical trials to validate their safety and efficacy pro- fibrillation Report of the Guideline Development Subcommittee of the
file in this special setting. Treatment is individualized . American Academy of Neurology. Neurology. 2014 Feb 25;82(8):716-24.
5. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH,
Hindricks G, Kirchhof P, Bax J, Baumgartner H, Ceconi C. 2012 Focused
ANTICOAGULATION IN PREGNANCY Update of the ESC Guidelines for the Management of Atrial Fibrillation.
WITH MECHANICAL PROSTHETIC HEART Revista Espanola de Cardiologia. 2013 Jan;66(1):54-.
VALVES 6. Messe SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G, Kasner
SE. Practice parameter: recurrent stroke with patent foramen ovale and
Warfarin is recommended to achieve a target (INR) in atrial septal aneurysm report of the Quality Standards Subcommittee of
the second and third trimesters (1B). the American Academy of Neurology. Neurology. 2004 Apr 13;62(7):1042-
50.
Discontinuation of warfarin with initiation of intrave-
nous UFH (aPTT) >2 times control) is recommended
before planned vaginal delivery (1 C). Continuation of
warfarin during the first trimester is reasonable if the
dose of warfarin is 5 mg/day or less to achieve a
target INR after discussing the risks and benefits (
IIa, B). Dose-adjusted LMWH bid (with a target anti-Xa
level of 0.8–1.2 U/mL, 4–6 h postdose) during the first
trimester is reasonable if the dose of warfarin is >5
mg/day (11a: B),(I1b,B ) if the dose of warfarin is 5 mg/
day or less to achieve a therapeutic INR.
Dose-adjusted continuous intravenous UFH (with an
aPTT atleast two times control) during the first tri-
mester if the dose of warfarin is >5 mg/day (11a: B),
(11b: B) if the dose of warfarin is 5 mg/day or less to
achieve a therapeutic INR

TIMING OF RESTARTING OF ANTICOAGULATION:
By 1-3-6-12 rule OAC may be restarted on the 3 day
rd
in mild stroke, 5-7 days in moderate stroke , after 12-
14 days in severe stroke after ruling out haemorrhagic
transformation.

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