Cardioembolic cerebral infarction due to atrial fibrillation: clinical epidemiological profile

INTRODUCTION

Atrial fibrillation (AF) is among the main causes of ischemic stroke of cardioembolic origin, especially in the elderly population, and is associated with more severe events, recurrence, and cognitive impairment. (1,2) Globally, cerebrovascular disease is the third leading cause of morbidity and mortality worldwide, the second leading cause of mental disability, and the leading cause of motor disability in adults. (3)

In emergency departments, it is common to see cases where the presence of risk factors such as advanced age, high blood pressure, diabetes mellitus, smoking, and alcoholism point to the possibility of arterial occlusions in situ due to intraluminal thrombi. (4)

However, in many cases, these same risk factors are associated with the onset of underlying cardiac arrhythmias that are unknown to the patient. (5,6) These constitute risk factors that increase the likelihood of developing a first stroke and subsequent recurrences after an event when appropriate therapies are not applied to stop the advancement of fragments considered emboli toward the cerebral vascular tree. (7)

The presence of atrial fibrillation is heterogeneous; it can occur in the presence or absence of demonstrable heart disease. It is characterized by a series of uncoordinated atrial contractions with ineffective ventricular filling, resulting in a rapid and irregular heart rhythm. (8,9) The most common form in the elderly population is persistent atrial fibrillation. (10)

Although the diagnosis is based on the electrocardiogram and supplemented by echocardiography and although validated scales (CHADS-VASc for thromboembolic risk; HAS-BLED for hemorrhagic risk) are available to guide anticoagulation therapy, a significant number of patients are diagnosed with AF only after suffering a stroke. (11) However, a significant number of patients have not been previously diagnosed and are identified only once a cerebrovascular event has occurred. (12)

The objective of this study was to characterize patients with cardioembolic cerebral infarction secondary to atrial fibrillation and identify the associated factors, presentation patterns, and degree of resulting disability.

METHODS

An observational, descriptive, cross-sectional study of patients admitted with a diagnosis of ischemic cerebrovascular disease to the Neurology Department of the Miguel Enríquez Teaching Hospital between January and December 2025 was conducted.

The sample consisted of 162 patients who were admitted with a confirmed diagnosis of cerebral infarction and aged between 25 and 97 years.

A sample of 42 patients who were found to have atrial fibrillation upon admission was studied.

Individual data (age, sex, toxic habits, and personal medical history) were collected from hospital records.

The diagnosis of cerebral infarction was made through a computed axial tomography imaging study using Shimadzu single-slice equipment, in addition to a basic investigation protocol for stroke patients.

Atrial fibrillation was determined using 12-lead electrocardiographic recordings taken upon arrival at the hospital and 72 hours after admission.

A quantitative assessment of the focal neurological defect was performed using the National Institutes of Health Stroke Scale upon the patient’s arrival in the neurology ward. The scale consists of 12 parameters to be evaluated during the neurological physical examination, with a score ranging from 1 to 42, with the highest score indicating the most severe condition. These parameters are defined as follows: NIHSS score of 2–5 points: mild neurological damage; NIHSS score of 6–15 points: moderate neurological damage; NIHSS score of 16–20 points: severe neurological damage; and NIHSS score greater than 20 points: serious neurological damage.

SPSS version 22 statistical software was used for data processing, and descriptive statistics were used to calculate absolute and relative frequencies for qualitative variables and the mean and standard deviation for the quantitative variable of age. The results are presented in a contingency table and figures.

RESULTS

Among the 162 patients in the department with a confirmed diagnosis of cerebral infarction, 42 had active atrial fibrillation at the time of admission, representing 25.9% of the total number of patients.

Of these, 26 were male (61.9%), while 16 were female (38.1%).

Although stroke patients ranged in age from 35 to 97 years, the minimum age at which atrial fibrillation was reported was 64 years, with a mean age of 73.4 ± 8.5 years. The greatest number of patients detected were in the 70–79 years age group in both sexes, accounting for 52.4% of all patients detected.

In terms of medical history, only 7 patients had a previous history of arrhythmia detected and studied by the cardiology service, representing 16.7% of the total sample. The remaining patients were unaware that they had cardiac arrhythmia at the time of detection.

Among the comorbidities recorded, the most frequent was high blood pressure, which was recorded in 39 patients (92.9%), which was the main cerebrovascular risk factor. The second most important factor was diabetes mellitus in 18 patients (42.9%), followed by ischemic heart disease, dyslipidemia, chronic kidney disease, and respiratory infections such as community-acquired pneumonia, which were present as coexisting elements in the patients’ medical history or recorded in the studies conducted. Among the vascular risk factors, 12 (28.6%) were smoking, and 5 (5) were alcoholism. (Table 1)

Source: Background information collected from medical records and protocol investigations. Own elaboration.

For the quantitative assessment of neurological deficit in patients, the National Institutes of Health Stroke Scale (NIHSS) was applied upon admission, with the results showing that a total of 17 patients had a moderate disability assessment (40.5%), while only 4 patients had a severe damage assessment (9.5%). (Figure 1)

Figure 1. Neurological disability upon admission.

Mild: NIHSS score of 2–5 points: 12 patients (28.6%),

Moderate: NIHSS score of 6–15 points: 17 patients (40.5%),

Severe: NIHSS score of 16–20 points: 9 patients, 21.4%

Severe: NIHSS score greater than 20 points; 4 patients, 9.5%

Source: Neurological physical examination. Own elaboration

In patients diagnosed with cerebral infarction associated with atrial fibrillation, there was a higher frequency of lesions related to involvement of the left middle cerebral artery, with a total of 15 cases (35.7%). In 8 patients, vascular damage to the right middle cerebral artery was detected, with a total of 19.0%. Lesions in the vertebrobasilar territories were found in a total of 6 patients (14.3%); however, a total of 13 patients had lesions in several arterial territories as part of the dysfunction of several areas, constituting 31%. These findings were generally consistent with the distribution of lesion locations in patients with ischemic stroke. (Figure 2)

Figure 2. Anatomical location of the brain lesions.

Source: Data obtained from tomographic images. Own elaboration.

DISCUSSION

Atrial fibrillation has become a factor in the search for the causes of ischemic stroke in the elderly population, both in the detection of the first event and in recurrences. (13)

The detection of 25.9% of patients with AF in this study is close to that obtained by other researchers in the field of epidemiology, such as López et al. (14), who reported a prevalence of 30% in patients over 65 years of age. These studies confirm that the incidence of cases is proportional to aging and that 75% of cases are detected at the time of hospital admission, often because of the occurrence of a neurological complication. (15)

The frequent coexistence of high blood pressure and diabetes mellitus in our patients reflects a common denominator: atherosclerosis. This finding coincides with the findings of Romero et al. ((16)), who highlighted advanced age, diabetes, and valvular heart disease, and with the report by Guevara et al. (5) in Ecuador, which also included smoking and the presence of carotid plaques.

A relevant finding of our study was the predominance of moderate neurological disability. These findings contrast with those of previous studies, such as those of Giner-Soriano et al. (17), who associated milder deficits with rapid access to health services and the use of latest-generation anticoagulant drugs with proven efficacy in the primary or secondary prophylaxis of a cerebral ischemic event. This discrepancy could be explained by variations in regional protocols, time of arrival at the emergency department, a more complex comorbidity profile, or differences in access to optimal prophylactic treatments. (18)

From a pathophysiological point of view, the middle cerebral artery territory is the most commonly affected and acts as a direct recipient of cardiac emboli because of its anatomical location. However, as observed in our series, it is not uncommon for emboli to fragment, leading to multivascular disease that can manifest acutely or through recurrent strokes. (19)

AF is responsible for a high rate of recurrence of cerebral infarcts and causes a large number of patients with cognitive impairment due to vascular dementia, especially when effective therapy is not implemented. (2,18)

CONCLUSIONS

Atrial fibrillation is a prevalent etiology associated with aging in elderly patients with ischemic stroke. Given its embolic pathophysiology and high risk of recurrence, early initiation and strict maintenance of effective anticoagulation are essential to modify the prognosis, significantly reducing the recurrence of ischemic cerebral events and limiting the accumulation of neurological disability and vascular cognitive impairment, which have a significant impact on the quality of life in this population. The optimal management of atrial fibrillation should be considered a priority in the secondary prevention of stroke among elderly people.

INFORMED CONSENT

The authors declare that they have obtained permission to use the diagnostic images included in this article.

References

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