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Despite the unquestionable superiority of Transesophageal echocardiography (TEE) over Transthoracic echocardiography (TTE), the impact of TEE on the long term management of cardio-embolic strokes remains uncertain. The purpose of present study was to determine the extent to which TEE, influenced the decision regarding long-term anticoagulant management of patients with ischemic stroke in a University Hospital. Between January 1992 and May 1995, TEE was performed in 122 out of 485 consecutive patients with ischemic stroke enrolled in the Maryland Stroke Data Bank. The indication to perform TEE was unexplained cerebral infarction. Twenty five patients had a possible cardiac source of embolism (CSOE) detected only after a TEE out of whom 17 were placed on anticoagulant therapy. From the remaining 8 patients, 2 expired, 2 were already receiving anticoagulants for different reasons and 4 were managed with antiplatelet agents. To conclude, in 17 of 122 ischemic stroke patients (14%) who underwent TEE, the decision regarding long term anticoagulation was made only because TEE revealed a cardioembolic source.

The clinical symptoms of stroke may result from the infarction of brain tissue or from the occurrence of a hemorrhage within the brain itself. Prior to the development of modern imaging techniques, many brain hemorrhages were not recognized as such, and were diagnosed as infarctions based on the patient's symptoms. CT scanning and magnetic resonance imaging (MRI) now permit the clear distinction of infarction from primary hemorrhage. (Of course, some hemorrhage may also occur as a secondary consequence of infarction.) The Stroke Data Bank was organized as a large prospective study for the evaluation of stroke patients. Of the 1,805 patients in the data bank, 237 had parenchymous hemorrhage. (This is a hemorrhage within the brain substance itself, distinct from other cranial hemorrhages such as a subarachnoid hemorrhage resulting from an aneurysm.) Thirty-four of these hemorrhages were secondary, and 31 were in the brain stem or cerebellum. The remaining 172 may be divided into lobar hemorrhages, which lie within or just under the cerebral cortex, and deep hemorrhages, which affect the central gray matter. (The central gray matter, deep within the brain, includes the basal ganglia and the thalamus.) Severe headache was a more common symptom among the 65 patients with lobar hemorrhage. Motor deficits were more common among the 107 patients with deep hemorrhage. Hypertension, the most important risk factor for cerebral hemorrhage, was more common among the patients with deep hemorrhage. Many other clinical features, such as seizures, focal neurological deficits, and decreased consciousness or coma, were found with comparable frequency among the patients with lobar hemorrhage and those with deep hemorrhage. (Consumer Summary produced by Reliance Medical Information, Inc.)

At first glance, anosognosia seems quite peculiar. Anosognosia is the inability of the patient to recognize an impairment. It is most common in strokes of the right, or nondominant, hemisphere, which produce hemiparesis on the left side of the body. In cases involving a right-side stroke and anosognosia, the patient is unaware of the deficit on the left side of the body. While the condition might be considered to be a form of hemineglect, in which the patient pays little attention to the left side of his world, cases of anosognosia without hemineglect have been observed, as well as cases of hemineglect without anosognosia. Many patients with anosognosia are quite cheerful, which seems to be consistent with their inability to perceive their deficit. Some researchers have gone so far as to state that major depression, which is common among stroke victims, cannot co-exist with anosognosia. However, two recent cases illustrate that this is not true. Both patients suffered cerebrovascular lesions in the right hemisphere; an infarct in one patient and a hemorrhagic lesion in the other. Both patients developed syndromes that included hemineglect of the left world, anosognosia, left sided hemiparesis or weakness, and major depression immediately following their cerebrovascular accident. In one patient the hemineglect and anosognosia resolved within two months, but the depression persisted; in the other the depression responded to treatment with nortriptyline, but the neglect and anosognosia persisted much longer. Both the existence of the cases and the fact that the depression and other deficits had different time courses in each patient, indicate that major depression and anosognosia are independent consequences of stroke and may occur separately or together. (Consumer Summary produced by Reliance Medical Information, Inc.)