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The most common stroke subtype among atrial fibrillation (AF) patients not receiving anticoagulants is cardioembolic. In the SPORTIF III and V trials, the oral direct thrombin inhibitor ximelagatran was as effective as warfarin in reducing the risk of stroke in patients with nonvalvular AF. We assessed any differential effect of warfarin versus ximelagatran on the risk and outcome of cardioembolic and noncardioembolic stroke.
7329 patients with AF and ≥1 risk factors for stroke were randomized to treatment with warfarin (target international normalized ratio 2.0-3.0) or fixed-dose ximelagatran. Strokes were classified into specific subtypes. Therapeutic effect of warfarin and ximelagatran, adverse events, and stroke outcomes were assessed according to stroke subtype.
The annual stroke rate was low for both cardioembolic (ximelagatran, 0.39%; warfarin, 0.47%) and noncardioembolic stroke (ximelagatran, 0.57%; warfarin, 0.37%). In ischemic strokes, 33.9% (ximelagatran) and 34.3% (warfarin) had strokes of presumed cardioembolic origin. When fatal stroke, disabling stroke, myocardial infarction, and death from any cause were combined as poor outcome, patients with cardioembolic strokes had the highest rate of poor outcome (40%) but this was non- significant.
In SPORTIF III and V the efficacy of warfarin and ximelagatran were similar for prevention of cardioembolic and noncardioembolic strokes. Overall outcome tended to be worse following cardioembolic stroke. Ximelagatran has been withdrawn from the market due to hepatic side effects, but similar compounds are presently being studied.
Brain imaging is necessary to assess the exact diagnosis and the acute pathophysiological state of the brain. This chapter explores the questions of what unenhanced computed tomography (CT) is able to assess in patients with acute stroke, how accurate this information is, and whether imaging with CT has any impact on stroke diagnosis, stroke treatment and, finally, on the clinical outcome of patients. CT has the capacity to identify different pathophysiological states that results in the same clinical picture of an acute stroke syndrome: intracranial hemorrhage, ischemic edema and ischemia without ischemic edema. Surgery or autopsy regularly confirms the CT finding of intracranial hemorrhage. CT was the first imaging modality that could reliably differentiate between hemorrhagic and ischemic stroke. MRI was introduced into clinical practice as the second modality that can image brain parenchyma, and is now considered as an evolving standard of care in acute stroke.
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