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Larsen BS, Biering-Sørensen T, Olsen FJ. Ischemic stroke and the emerging role of left atrial function. Expert Rev Cardiovasc Ther 2024; 22:289-300. [PMID: 38943632 DOI: 10.1080/14779072.2024.2370814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION Ischemic stroke is a leading cause of morbidity and mortality worldwide. Emerging evidence suggests that left atrial (LA) dysfunction could play a role in the pathophysiology of ischemic stroke, as a possible contributor and as a predictive biomarker. AREAS COVERED This narrative review details the intricate relationship between LA function, atrial fibrillation (AF), and ischemic stroke. We discuss imaging techniques used to assess LA function, the mechanisms by which impaired LA function may contribute to stroke, and its potential as a prognostic marker of stroke. EXPERT OPINION There is a lack of evidence-based treatments of LA dysfunction in both primary and secondary stroke prevention. This is partly due to the lack of a practical clinical definition and unanswered questions concerning the clinical implications of LA dysfunction in patients without AF. Until such questions are resolved, addressing well-known cardiovascular risk factors, like hypertension and obesity, should be prioritized for preventing AF and ischemic stroke. These risk factors are closely tied to atrial remodeling, emphasizing the importance of targeting primary modifiable factors for preventing future morbidity and mortality.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
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Balmforth C, Whittington B, Tzolos E, Bing R, Williams MC, Clark L, Corral CA, Tavares A, Dweck MR, Newby DE. Translational molecular imaging: Thrombosis imaging with positron emission tomography. J Nucl Cardiol 2024:101848. [PMID: 38499227 DOI: 10.1016/j.nuclcard.2024.101848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Abstract
A key focus of cardiovascular medicine is the detection, treatment, and prevention of disease, with a move towards more personalized and patient-centred treatments. To achieve this goal, novel imaging approaches that allow for early and accurate detection of disease and risk stratification are needed. At present, the diagnosis, monitoring, and prognostication of thrombotic cardiovascular diseases are based on imaging techniques that measure changes in structural anatomy and biological function. Molecular imaging is emerging as a new tool for the non-invasive detection of biological processes, such as thrombosis, that can improve identification of these events above and beyond current imaging modalities. At the forefront of these evolving techniques is the use of high-sensitivity radiotracers in conjunction with positron emission tomography imaging that could revolutionise current diagnostic paradigms by improving our understanding of the role and origin of thrombosis in a range of cardiovascular diseases.
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Affiliation(s)
- Craig Balmforth
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Beth Whittington
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Evangelos Tzolos
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Laura Clark
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Carlos Alcaide Corral
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Adriana Tavares
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Marc Richard Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David Ernest Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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Prabakar D, Sabesan V, Emenogu OP, Mai C. Recurrent Multifocal Embolic Strokes in a 50-Year-Old Male: Unmasking Occult Squamous Cell Carcinoma. Cureus 2023; 15:e45091. [PMID: 37842450 PMCID: PMC10568952 DOI: 10.7759/cureus.45091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Recurrent cryptogenic embolic strokes pose a diagnostic challenge, often necessitating an extensive evaluation to determine the underlying cause. Cancer-related stroke is a frequently overlooked etiology, accounting for a substantial proportion of cryptogenic strokes. This case study underscores the importance of considering occult malignancies in patients with recurrent strokes of unknown origin and emphasizes the need for a comprehensive diagnostic workup to detect hidden malignancies. A 50-year-old male with a complex medical history presented with expressive aphasia and blurred vision resembling previous stroke episodes. Neurological examinations revealed right hemianopsia, paraphasia, and abnormal coordination. Neuroimaging studies showed multiple chronic infarctions, a large hemorrhagic infarction in the left posterior cerebral artery territory, and a small acute-to-subacute left parietal infarction. Due to the time of presentation and the presence of hemorrhagic transformation, the patient did not meet the criteria for intravenous tissue plasminogen activator administration. Given the recurrent nature of the strokes, an extensive evaluation was initiated to determine the underlying cause. Vascular imaging, including magnetic resonance angiography (MRA) of the head and neck and a CT angiogram, showed no significant stenosis. Vasculitis workup and cardiac evaluation yielded negative results. The blood workup was notable for elevated D-dimer levels. The involvement of multiple vascular territories and recurrent stroke despite adequate treatment and the absence of traditional risk factors for stroke raised a high clinical suspicion of occult malignancy. Further investigations led to the diagnosis of locally advanced squamous cell carcinoma (P16+), metastatic to the right neck lymph nodes (cTxN3M0). Although the primary source of cancer could not be identified, the P16+ status suggests the right tonsil or base of the tongue as the probable origin. Anticoagulation therapy was initiated, and the patient was scheduled for chemoradiation therapy. Although routine cancer investigation is not justified in ischemic strokes, the possibility of an occult malignancy should be considered in the presence of multifocal infarctions across different vascular territories with elevated D-dimer levels, particularly when traditional risk factors have been ruled out. A detailed physical exam can help localize the malignancy and early identification of occult malignancies can guide appropriate management strategies and help prevent future strokes. Further clinical trials are needed to establish optimal therapeutic approaches for preventing stroke recurrence in cancer-related strokes.
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Affiliation(s)
- Deipthan Prabakar
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Vaishnavi Sabesan
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Oluwasegun P Emenogu
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Cuc Mai
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
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Lanzone AM, Albiero R, Boldi E, Safari D, Serafin P, Lussardi G, Rigamonti ER, Anselmi A. Clinical and echocardiographic outcomes after percutaneous closure of patent foramen ovale: a single center experience. Minerva Cardiol Angiol 2023; 71:157-164. [PMID: 33703865 DOI: 10.23736/s2724-5683.21.05609-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patent foramen ovale (PFO) has a high estimated prevalence (25% of the general population) and has been implicated in the pathogenesis of cryptogenic stroke and transient ischemic attack (TIA), as well as in the pathogenesis of migraine headache. This study evaluated the effectiveness of percutaneous transcatheter PFO closure with Amplatzer™ (Abbott Laboratories, Abbott Park, IL, USA) devices, from a large single-center experience. METHODS From January 1998 to December 2014, 577 patients (243 males and 334 females, mean age 50 years, range 11-82 years) with documented PFO and history of at least one episode of cryptogenic stroke/TIA (N.=356) or occasional finding of previous ischemic lesions on MRI (N.=221) underwent percutaneous transcatheter closure of PFO using an Amplatzer™ Occluder (Abbott Laboratories). All the procedures were performed under general anesthesia or mild sedation and were assisted by transesophageal or intracardiac echocardiography. RESULTS Procedural success was 100%. After a median follow-up period of 2.7 years with echocardiographic evaluations, the rate of recurrent adverse cerebral events was 0.4%. Two patients (0.4%) required a secondary procedure for significant residual shunt. Of 36 patients with minor residual shunt, 30 (83%) showed spontaneous shunt regression at follow-up. There was a consistent decrease after procedure in headache migraine, platypnea-orthodeoxia, fainting episodes, syncope, and coenesthesia phenomena. CONCLUSIONS Transcatheter PFO closure is an effective and safe therapy for the prevention of thromboembolic events in the patients with cryptogenic stroke/TIA or an occasional finding of a positive cerebral MRI. Late follow-up shows device stability and clinical improvement in the majority of patients.
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Affiliation(s)
- Alberto M Lanzone
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Remo Albiero
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Emiliano Boldi
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Davood Safari
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Paolo Serafin
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Gianluca Lussardi
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Elia R Rigamonti
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Amedeo Anselmi
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France -
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Gogos C, Zarvalis E, Pantelidis P, Davora F, Karakanas A, Pitetzis D, Stamatiadis N, Moschovidis V, Konstantinidou M, Oikonomou E, Deretzi G, Rudolf J, Styliadis I. Excessive supraventricular ectopic activity and future onset of atrial fibrillation in patients with cryptogenic stroke. J Stroke Cerebrovasc Dis 2022; 31:106820. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
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Hira K, Ueno Y, Watanabe M, Shimura H, Kurita N, Miyamoto N, Haginiwa H, Yamashiro K, Hattori N, Urabe T. Impact of D-dimer for pathologic differentiation on transesophageal echocardiography in embolic stroke of undetermined source: a single-center experience. BMC Neurol 2022; 22:338. [PMID: 36076175 PMCID: PMC9454212 DOI: 10.1186/s12883-022-02867-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background Embolic stroke of undetermined source (ESUS) encompasses diverse embologenic mechanisms, which transesophageal echocardiography (TEE) is critical to detect. Specific markers related to each embolic source in ESUS is not fully studied. We focused on D-dimer levels, and explored the association of D-dimer with potential embolic sources (PES) identified on TEE in ESUS. Methods Consecutive patients with ESUS were included in this study. Clinical characteristics including D-dimer levels were compared between ESUS patients with and without TEE, and among none of, one, and at least two PES in ESUS patients undergoing TEE. Factors related to elevation of D-dimer were analyzed. Results A total of 211 patients (age, 69.3 ± 13.2 years; 149 males) with ESUS were enrolled. Of these, 115 received TEE, displaying significantly younger age and lower D-dimer levels than patients without TEE (P < 0.05), and 20 (17%), 61 (53%), and 34 (30%) patients were classified into none of, one, and ≥ two PES, respectively. On multiple logistic regression analysis, D-dimer levels were related to one PES (odds ratio [OR]: 9.01; 95% confidence interval [CI]: 1.00–81.51; P = 0.050) and PES ≥ two (OR: 9.76; 95% CI: 1.07–88.97; P = 0.043). Right-to-left shunt (RLS) with deep venous thrombosis (DVT)(OR: 13.94; 95% CI: 1.77–109.99; P = 0.012) and without DVT (OR: 3.90; 95% CI: 1.20–12.70; P = 0.024) were associated with elevation of D-dimer. Conclusions D-dimer levels were higher in patients with PES. Among PES, RLS, with and without DVT, were associated with increase of D-dimer in ESUS.
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Affiliation(s)
- Kenichiro Hira
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.,Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Masao Watanabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Hideki Shimura
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Naohide Kurita
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Haruna Haginiwa
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
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Xu L, Zhou C, Pan X, Zhou J, Sun H, Xu T. Effect of ASA on the risk of cerebrovascular ischemic events in patients with PFO. Ann Clin Transl Neurol 2022; 9:1384-1391. [PMID: 35894517 PMCID: PMC9463951 DOI: 10.1002/acn3.51638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/17/2022] [Accepted: 07/14/2022] [Indexed: 12/20/2022] Open
Abstract
Background Whether atrial septal aneurysm (ASA) increases the risk of cerebrovascular ischemic events in patients with patent foramen ovale (PFO) remains controversial. Objective We constructed a detailed meta‐analysis to assess the effect of ASA on risk of cerebrovascular ischemic events in patients with PFO. Methods Randomized controlled trials (RCTs) and observational studies (cohort studies and case‐control studies) that compared PFO‐ASA against PFO alone were included. Pooled odds ratios (OR) estimates and 95% CI were calculated using the fixed‐effect and random‐effect models. Results Four RCTs and twelve observational studies (five cohort studies and seven case‐control studies) contributed to the meta‐analysis. The pooled results of case‐control studies showed that ASA increased the risk of cerebrovascular ischemic events in patients with PFO (fixed‐effect model: OR = 3.69; 95% CI: 2.67–5.09; p < 0.01, random‐effect model: OR = 3.63; 95% CI: 2.51–5.24; p < 0.01). However, poole results from RCTs (fixed‐effect model: OR = 1.24; 95% CI: 0.78–1.95; p = 0.36, random‐effect model: OR = 1.27; 95% CI: 0.78–2.08; p = 0.34) and cohort studies (fixed‐effect model: OR = 1.35; 95% CI: 0.81–2.23; p = 0.25, random‐effect model: OR = 1.40; 95% CI: 0.84–2.33; p = 0.20) found no evidence. Overall analysis showed that ASA increased the risk of cerebrovascular ischemic events (fixed‐effect model: OR = 2.30; 95% CI: 1.84–2.87; p < 0.01, random‐effect model: OR = 2.11; 95% CI: 1.48–3.01; p < 0.01). The sensitivity analysis confirmed the stability of all results. Conclusions Although case‐control studies support ASA to increase the risk of cerebrovascular ischemic events in patients with PFO, RCTs and cohort studies challenged the credibility. Further prospective studies are needed to confirm the effect of ASA on patients with PFO.
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Affiliation(s)
- Liang Xu
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
| | - Chang Zhou
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
| | - Xuemei Pan
- Department of Ultrasound, The Third People's Hospital of Yichang City, Yichang, Hubei Province, China
| | - Jun Zhou
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
| | - Heng Sun
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
| | - Tao Xu
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
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Aghamiri SH, Mansouri B, Mehrpour M, Karani SMH, Ghaffari M, Lima BS, Komlakh K. Efficacy of mechanical thrombectomy in stroke patients with large vessel involvement. Eur J Transl Myol 2022; 32. [PMID: 35736402 PMCID: PMC9295169 DOI: 10.4081/ejtm.2022.10456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/30/2022] [Indexed: 11/24/2022] Open
Abstract
Ischemic stroke is a common disease worldwide and leads to a significant rate of mortality and disability in patients every year, and imposes high costs on the health care system. The aim of this study was to evaluate the efficacy of the invasive method of mechanical thrombectomy for rapid intervention in ischemic stroke patients with large vessel involvement. Patients suspected of having a stroke, who were referred to Imam Hossein Hospital, were examined, and the diagnosis of stroke was confirmed. In the next stage, patients' MRS index was measured and the possibility of emergency thrombectomy was evaluated in patients. Patients who underwent thrombectomy were considered as the case group and the other patients were contemplated as the control group; then, the cases of the two groups were evaluated and compared. The mean age of patients was 66.63 ± 12.26 years. the use of emergency thrombectomy in the study group significantly reduced the MRS index of patients after 90 days (p <0.001), while a significant increase in the mean scores of the MRS index was seen in patients receiving pharmacological treatments. Also, there was no significant difference in terms of gender between the group of patients undergoing thrombectomy and the group receiving other treatments (p = 0.375). Emergency mechanical thrombectomy significantly reduces disability in stroke patients in the long term and can be a good alternative to conventional drug treatments..
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Affiliation(s)
- Seyed Hossein Aghamiri
- Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran.
| | - Behnam Mansouri
- Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran.
| | - Masoud Mehrpour
- Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran.
| | | | - Mehran Ghaffari
- Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran.
| | - Behnam Safarpour Lima
- Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran.
| | - Khalil Komlakh
- Department of Neurosurgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran.
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Larsen BS, Aplin M, Høst N, Dominguez H, Christensen H, Christensen LM, Havsteen I, Prescott E, Jensen GB, Vejlstrup N, Bertelsen L, Sajadieh A. Atrial cardiomyopathy in patients with ischaemic stroke: a cross-sectional and prospective cohort study-the COAST study. BMJ Open 2022; 12:e061018. [PMID: 35545392 PMCID: PMC9096525 DOI: 10.1136/bmjopen-2022-061018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Despite workup for the aetiology of ischaemic stroke, about 25% of cases remain unexplained. Paroxysmal atrial fibrillation is typically suspected but often not detected. Even if atrial fibrillation (AF) is detected, the quantitative threshold of clinically relevant AF remains unclear. Emerging evidence suggests that left atrial (LA) functional and structural abnormalities may convey a risk of ischaemic stroke in which AF is only one of several features. These abnormalities have been termed 'atrial cardiomyopathy'. This study uses cardiac magnetic resonance (CMR) to evaluate atrial cardiomyopathy among patients with stroke of undetermined aetiology compared with those with an attributable mechanism and controls without established cardiovascular disease. METHODS AND ANALYSIS This cross-sectional and prospective cohort study included 100 patients with recent ischaemic stroke and 50 controls with no established cardiovascular disease. The study will assess LA structural and functional abnormalities with CMR. Inclusion began in March 2019, and follow-up is planned to be complete in January 2023. There are two scheduled follow-ups: (1) 18 months after individual inclusion, counting from the index diagnostic MRI of the brain, (2) end of study follow-up at 18 months after inclusion of the last patient, assessing the incidence of recurrent ischaemic stroke, AF and cardiovascular death. The primary endpoint is the extent of CMR-assessed atrial fibrosis in the LA at baseline. The study is powered to detect a difference of 6% fibrosis between stroke of undetermined aetiology and stroke of known mechanism with a SD of 9%, a significance level of 0.05, and power of 80%. ETHICS AND DISSEMINATION This study has been approved by the Danish National Committee on Health Research Ethics (H-18055313). All participants in the study signed informed consent. Results from the study will be published in peer-reviewed journals regardless of the outcome. TRIAL REGISTRATION NUMBER NCT03830983.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Mark Aplin
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Louisa Marguerite Christensen
- Department of Neurology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Inger Havsteen
- Department of Radiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Gorm Boje Jensen
- Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Litten Bertelsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
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Jarvis K, Soulat G, Scott M, Vali A, Pathrose A, Syed AA, Kinno M, Prabhakaran S, Collins JD, Markl M. Investigation of Aortic Wall Thickness, Stiffness and Flow Reversal in Patients With Cryptogenic Stroke: A 4D Flow MRI Study. J Magn Reson Imaging 2021; 53:942-952. [PMID: 32864836 DOI: 10.1002/jmri.27345] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Stroke etiology is undetermined in approximately one-sixth to one-third of patients. The presence of aortic flow reversal and plaques in the descending aorta (DAo) has been identified as a potential retrograde embolic mechanism. PURPOSE To assess the relationships between aortic stiffness, wall thickness, and flow reversal in patients with cryptogenic stroke and healthy controls. STUDY TYPE Prospective. POPULATION Twenty one patients with cryptogenic stroke and proven DAo plaques (69 ± 9 years, 43% female), 18 age-matched controls (age: 65 ± 8 years, 61% female), and 14 younger controls (36 ± 9 years, 57% female). FIELD STRENGTH/SEQUENCE 1.5T; 4D flow MRI and 3D dark blood T1 -weighted turbo spin echo MRI of the aorta. ASSESSMENT Noncontrast aortic 4D flow MRI to measure 3D flow dynamics and 3D dark blood aortic wall MRI to assess wall thickness. 4D flow MRI analysis included automated quantification of aortic stiffness by pulse wave velocity (PWV) and voxelwise mapping of the flow reversal fraction (FRF). STATISTICAL TESTS Analysis of variance (ANOVA) or Kruskal-Wallis tests, Student's unpaired t-tests or Wilcoxon rank-sum tests, regression analysis. RESULTS Aortic PWV and FRF were statistically higher in patients (8.9 ± 1.7 m/s, 18.4 ± 7.7%) than younger controls (5.3 ± 0.8 m/s, P < 0.0167; 8.5 ± 2.9%, P < 0.0167), but not age-matched controls (8.2 ± 1.6 m/s, P = 0.22; 15.6 ± 5.8%, P = 0.22). Maximum aortic wall thickness was higher in patients (3.1 ± 0.7 mm) than younger controls (2.2 ± 0.2 mm, P < 0.0167) and age-matched controls (2.7 ± 0.5 mm) (P < 0.0167). For all subjects, positive relationships were found between PWV and age (R2 = 0.71, P < 0.05), aortic wall thickness (R2 = 0.20, P < 0.05), and FRF (R2 = 0.47, P < 0.05). Patients demonstrated relationships between PWV and FRF in the ascending aorta (R2 = 0.32, P < 0.05) and arch (R2 = 0.24, P < 0.05). DATA CONCLUSION This study showed the utility of 4D flow MRI for evaluating aortic PWV and voxelwise flow reversal. Positive relationships between aortic PWV, wall thickness, and flow reversal support the hypothesis that aortic stiffness is involved in this retrograde embolic mechanism. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 1.
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Affiliation(s)
- Kelly Jarvis
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gilles Soulat
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Scott
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Alireza Vali
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ashitha Pathrose
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amer Ahmed Syed
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Menhel Kinno
- Department of Cardiology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Biological Sciences, Chicago, Illinois, USA
| | | | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
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11
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Holt JN. A case of multifocal stroke-the first presentation of underlying ovarian malignancy. J Surg Case Rep 2021; 2021:rjaa550. [PMID: 33569161 PMCID: PMC7852472 DOI: 10.1093/jscr/rjaa550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 12/03/2020] [Indexed: 11/23/2022] Open
Abstract
Ischaemic stroke is a rare manifestation of hypercoagulability induced by underlying malignancy. It is proposed that paraneoplastic non-bacterial thrombotic endocarditis (NBTE) is the most common cause, predisposing to the formation of friable valvular lesions composed of platelets and fibrin that embolize commonly. Pancreas, gallbladder, stomach, colon and gynaecological malignancies have all been associated with NBTE. We describe a female patient who presented to our facility with syncope and limb weakness. Magnetic resonance imaging of the brain revealed ischaemic strokes in both the anterior and posterior circulation. Further investigation revealed a pelvic mass that was biopsy proven to be ovarian malignancy. Prognosis is heavily reliant on disease stage, thus diagnostic clues suggesting the possibility of underlying malignancy in the presentation of stroke should prompt a thorough investigation to exclude malignancy.
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Affiliation(s)
- Jonathon N Holt
- General Surgical Department, Albury-Wodonga Health, Albury, NSW, Australia
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12
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Clery A, Bhalla A, Rudd AG, Wolfe CDA, Wang Y. Trends in prevalence of acute stroke impairments: A population-based cohort study using the South London Stroke Register. PLoS Med 2020; 17:e1003366. [PMID: 33035232 PMCID: PMC7546484 DOI: 10.1371/journal.pmed.1003366] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/31/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Acute stroke impairments often result in poor long-term outcome for stroke survivors. The aim of this study was to estimate the trends over time in the prevalence of these acute stroke impairments. METHODS AND FINDINGS All first-ever stroke patients recorded in the South London Stroke Register (SLSR) between 2001 and 2018 were included in this cohort study. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted prevalence of 8 acute impairments, across six 3-year time cohorts. Prevalence ratios comparing impairments over time were also calculated, stratified by age, sex, ethnicity, and aetiological classification (Trial of Org 10172 in Acute Stroke Treatment [TOAST]). A total of 4,683 patients had a stroke between 2001 and 2018. Mean age was 68.9 years, 48% were female, and 64% were White. After adjustment for demographic factors, pre-stroke risk factors, and stroke subtype, the prevalence of 3 out of the 8 acute impairments declined during the 18-year period, including limb motor deficit (from 77% [95% CI 74%-81%] to 62% [56%-68%], p < 0.001), dysphagia (37% [33%-41%] to 15% [12%-20%], p < 0.001), and urinary incontinence (43% [39%-47%) to 29% [24%-35%], p < 0.001). Declines in limb impairment over time were 2 times greater in men than women (prevalence ratio 0.73 [95% CI 0.64-0.84] and 0.87 [95% CI 0.77-0.98], respectively). Declines also tended to be greater in younger patients. Stratified by TOAST classification, the prevalence of all impairments was high for large artery atherosclerosis (LAA), cardioembolism (CE), and stroke of undetermined aetiology. Conversely, small vessel occlusions (SVOs) had low levels of all impairments except for limb motor impairment and dysarthria. While we have assessed 8 key acute stroke impairments, this study is limited by a focus on physical impairments, although cognitive impairments are equally important to understand. In addition, this is an inner-city cohort, which has unique characteristics compared to other populations. CONCLUSIONS In this study, we found that stroke patients in the SLSR had a complexity of acute impairments, of which limb motor deficit, dysphagia, and incontinence have declined between 2001 and 2018. These reductions have not been uniform across all patient groups, with women and the older population, in particular, seeing fewer reductions.
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Affiliation(s)
- Amanda Clery
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- * E-mail:
| | - Ajay Bhalla
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Anthony G. Rudd
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Charles D. A. Wolfe
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
| | - Yanzhong Wang
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
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13
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Siriratnam P, Godfrey A, O'Connor E, Pearce D, Hu CC, Low A, Hair C, Oqueli E, Sharma A, Kraemer T, Sahathevan R. Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective. Intern Med J 2019; 50:698-704. [PMID: 31211881 DOI: 10.1111/imj.14407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/26/2019] [Accepted: 06/08/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no universally accepted age cut-off for defining young strokes. AIMS We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes. METHODS A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria. RESULTS We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke. CONCLUSIONS The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.
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Affiliation(s)
- Pakeeran Siriratnam
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Amelia Godfrey
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Ellie O'Connor
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Dora Pearce
- School of Science, Engineering and Information Technology, Federation University, Ballarat, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Publication and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Chih-Chiang Hu
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Ashlea Low
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Casey Hair
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Ernesto Oqueli
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Anand Sharma
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Thomas Kraemer
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Ramesh Sahathevan
- Faculty of Medicine, Ballarat Health Services, Ballarat, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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14
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Gad MS, Zakaria NHED, Elgayar NHAAM. Evaluation of the role of ischemia modified albumin as a new biochemical marker for differentiation between ischemic and hemorrhagic stroke. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2014.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mohamed Samy Gad
- Geriatric Unit, Faculty of Medicine, Alexandria University, Egypt
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15
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Agasthi P, Kolla KR, Yerasi C, Tullah S, Pulivarthi VS, Louka B, Arsanjani R, Yang EH, Mookadam F, Fortuin FD. Are we there yet with patent foramen ovale closure for secondary prevention in cryptogenic stroke? A systematic review and meta-analysis of randomized trials. SAGE Open Med 2019; 7:2050312119828261. [PMID: 30783525 PMCID: PMC6365999 DOI: 10.1177/2050312119828261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/14/2019] [Indexed: 01/02/2023] Open
Abstract
Background: We performed a meta-analysis to evaluate the benefit of patent foramen ovale closure in stroke prevention. Methods: We searched Medline/PubMed, EMBASE, Web of Science and Cochrane central database for randomized control trials assessing the incidence of recurrent stroke after patent foramen ovale closure when compared to medical therapy. Pooled odds ratio and 95% confidence intervals were calculated using a random effects model. The heterogeneity among studies was tested using the χ2 test and inconsistency was quantified using the I2 statistic. Results: Our search strategy yielded 71 articles. We included five studies with a total of 3440 patients. Median age in the device group was 45 (43, 5.5) years and in the medical group was 45 (44.5, 46) years; 52% were male, 27.7% of patients had an atrial septal aneurysm, 25% had hypertension, and 20.5% had diabetes mellitus. The median follow-up time was 44 (34.5–50) months. The pooled odds ratio of recurrent stroke, transient ischemic attack and composite end point of stroke + transient ischemic attack + peripheral embolism in the patent foramen ovale closure versus medical therapy group were 0.4 (95% confidence interval 0.25–0.63, I2 = 57.5%), 0.93 (95% confidence interval 0.61–1.42, I2 = 0%), and 0.6 (95% confidence interval 0.44–0.82, I2 = 0%), respectively. The incidence of atrial fibrillation was found to be significantly higher in the patent foramen ovale closure group with odds ratio of 6 (95% confidence interval 3.13–11.4, I2 = 33.5%). On subgroup analysis, patent foramen ovale closure appeared to benefit males and patients with a large shunt. Number needed to treat to prevent one recurrent stroke with patent foramen ovale closure is 42. Number needed to harm to cause one atrial fibrillation with patent foramen ovale closure is 39. Conclusion: This meta-analysis of randomized trials concludes that percutaneous patent foramen ovale closure is effective in recurrent stroke prevention especially in males and in those with a large shunt.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | | | - Charan Yerasi
- Department of Cardiovascular Diseases, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sibghat Tullah
- Department of Cardiovascular Diseases, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Boshra Louka
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Eric H Yang
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - F David Fortuin
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
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16
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Henderson SJ, Weitz JI, Kim PY. Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke. J Thromb Haemost 2018; 16:1932-1940. [PMID: 29953716 DOI: 10.1111/jth.14215] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Indexed: 02/03/2023]
Abstract
Stroke is a major cause of disability worldwide, and is the second leading cause of death after ischemic heart disease. Until recently, tissue-type plasminogen activator (t-PA) was the only treatment for acute ischemic stroke. If administered within 4.5 h of symptom onset, t-PA improves the outcome in stroke patients. Mechanical thrombectomy is now the preferred treatment for patients with acute ischemic stroke resulting from a large-artery occlusion in the anterior circulation. However, the widespread use of mechanical thrombectomy is limited by two factors. First, only ⁓ 10% of patients with acute ischemic stroke have a proximal large-artery occlusion in the anterior circulation and present early enough to undergo mechanical thrombectomy within 6 h; an additional 9-10% of patients presenting within the 6-24-h time window may also qualify for the procedure. Second, not all stroke centers have the resources or expertise to perform mechanical thrombectomy. Nonetheless, patients who present to hospitals where thrombectomy is not an option can receive intravenous t-PA, and those with qualifying anterior circulation strokes can then be transferred to tertiary stroke centers where thrombectomy is available. Therefore, despite the advances afforded by mechanical thrombectomy, there remains a need for treatments that improve the efficacy and safety of thrombolytic therapy. In this review, we discuss: (i) current treatment options for acute ischemic stroke; (ii) the mechanism of action of fibrinolytic agents; and (iii) potential strategies to manipulate the fibrinolytic system to promote endogenous fibrinolysis or to enhance the efficacy of fibrinolytic therapy.
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Affiliation(s)
- S J Henderson
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - J I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - P Y Kim
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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17
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Gaowa S, Bao N, Da M, Qiburi Q, Ganbold T, Chen L, Altangerel A, Temuqile T, Baigude H. Traditional Mongolian medicine Eerdun Wurile improves stroke recovery through regulation of gene expression in rat brain. JOURNAL OF ETHNOPHARMACOLOGY 2018; 222:249-260. [PMID: 29758340 DOI: 10.1016/j.jep.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 04/28/2018] [Accepted: 05/10/2018] [Indexed: 06/08/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Eerdun Wurile (EW) is one of the key Mongolian medicines for treatment of neurological and cardiological disorders. EW is ranked most regularly used Mongolian medicine in clinic. Components of EW which mainly originate from natural products are well defined and are unique to Mongolian medicine. AIM OF THE STUDY Although the recipe of EW contains known neuroactive chemicals originated from plants, its mechanism of action has never been elucidated at molecular level. The objective of the present study is to explore the mechanism of neuroregenerative activity of EW by focusing on the regulation of gene expression in the brain of rat model of stroke. MATERIALS AND METHODS Rat middle cerebral artery occlusion (MCAO) models were treated with EW for 15 days. Then, total RNAs from the cerebral cortex of rat MCAO models treated with either EW or control (saline) were extracted and analyzed by transcriptome sequencing. Differentially expressed genes were analyzed for their functions during the recovery of ischemic stroke. The expression level of significantly differentially expressed genes such as growth factors, microglia markers and secretive enzymes in the lesion was further validated by RT-qPCR and immunohistochemistry. RESULTS Previously identified neuroactive compounds, such as geniposide (Yu et al., 2009), myristicin (Shin et al., 1988), costunolide (Okugawa et al., 1996), toosendanin (Shi and Chen, 1999) were detected in EW formulation. Bederson scale indicated that the treatment of rat MCAO models with EW showed significantly lowered neurological deficits (p < 0.01). The regional cerebral blood circulation was also remarkably higher in rat MCAO models treated with EW compared to the control group. A total of 186 genes were upregulated in the lesion of rat MCAO models treated with EW compared to control group. Among them, growth factors such as Igf1 (p < 0.05), Igf2 (p < 0.01), Grn (p < 0.01) were significantly upregulated in brain after treatment of rat MCAO models with EW. Meanwhile, greatly enhanced expression of microglia markers, as well as complementary components and secretive proteases were also detected. CONCLUSION Our data collectively indicated that EW enhances expression of growth factors including Igf1 and Igf2 in neurons and microglia, and may stimulate microglia polarization in the brain. The consequences of such activity include stimulation of neuron growth, hydrolysis and clearance of cell debris at the lesion, as well as the angiogenesis.
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Affiliation(s)
- Saren Gaowa
- School of Basic Medical Science, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, PR China; Inner Mongolia Medical University, Hohhot, Inner Mongolia 010020, PR China; International Hospital of Mongolian Medicine, Hohhot, Inner Mongolia 010021, PR China
| | - Narisi Bao
- School of Basic Medical Science, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, PR China; Inner Mongolia Medical University, Hohhot, Inner Mongolia 010020, PR China
| | - Man Da
- International Hospital of Mongolian Medicine, Hohhot, Inner Mongolia 010021, PR China
| | - Qiburi Qiburi
- Institute of Mongolian Medicinal Chemistry, School of Chemistry & Chemical Engineering, Inner Mongolia University, Hohhot, Inner Mongolia 010020, PR China
| | - Tsogzolmaa Ganbold
- Institute of Mongolian Medicinal Chemistry, School of Chemistry & Chemical Engineering, Inner Mongolia University, Hohhot, Inner Mongolia 010020, PR China
| | - Lu Chen
- Institute of Mongolian Medicinal Chemistry, School of Chemistry & Chemical Engineering, Inner Mongolia University, Hohhot, Inner Mongolia 010020, PR China
| | - Altanzul Altangerel
- Institute of Mongolian Medicinal Chemistry, School of Chemistry & Chemical Engineering, Inner Mongolia University, Hohhot, Inner Mongolia 010020, PR China
| | - Temuqile Temuqile
- Inner Mongolia Medical University, Hohhot, Inner Mongolia 010020, PR China; International Hospital of Mongolian Medicine, Hohhot, Inner Mongolia 010021, PR China
| | - Huricha Baigude
- Institute of Mongolian Medicinal Chemistry, School of Chemistry & Chemical Engineering, Inner Mongolia University, Hohhot, Inner Mongolia 010020, PR China.
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18
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Ahmad Y, Howard JP, Arnold A, Shin MS, Cook C, Petraco R, Demir O, Williams L, Iglesias JF, Sutaria N, Malik I, Davies J, Mayet J, Francis D, Sen S. Patent foramen ovale closure vs. medical therapy for cryptogenic stroke: a meta-analysis of randomized controlled trials. Eur Heart J 2018; 39:1638-1649. [PMID: 29590333 PMCID: PMC5946888 DOI: 10.1093/eurheartj/ehy121] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/09/2017] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
Aims The efficacy of patent foramen ovale (PFO) closure for cryptogenic stroke has been controversial. We undertook a meta-analysis of randomized controlled trials (RCTs) comparing device closure with medical therapy to prevent recurrent stroke for patients with PFO. Methods and results We systematically identified all RCTs comparing device closure to medical therapy for cryptogenic stroke in patients with PFO. The primary efficacy endpoint was recurrent stroke, analysed on an intention-to-treat basis. The primary safety endpoint was new onset atrial fibrillation (AF). Five studies (3440 patients) were included. In all, 1829 patients were randomized to device closure and 1611 to medical therapy. Across all patients, PFO closure was superior to medical therapy for prevention of stroke [hazard ratio (HR) 0.32, 95% confidence interval (95% CI) 0.13-0.82; P = 0.018, I2 = 73.4%]. The risk of AF was significantly increased with device closure [risk ratio (RR) 4.68, 95% CI 2.19-10.00, P<0.001, heterogeneity I2 = 27.5%)]. In patients with large shunts, PFO closure was associated with a significant reduction in stroke (HR 0.33, 95% CI 0.16-0.72; P = 0.005), whilst there was no significant reduction in stroke in patients with a small shunt (HR 0.90, 95% CI 0.50-1.60; P = 0.712). There was no effect from the presence or absence of an atrial septal aneurysm on outcomes (P = 0.994). Conclusion In selected patients with cryptogenic stroke, PFO closure is superior to medical therapy for the prevention of further stroke: this is particularly true for patients with moderate-to-large shunts. Guidelines should be updated to reflect this.
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Affiliation(s)
- Yousif Ahmad
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Ahran Arnold
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Matthew Shun Shin
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Christopher Cook
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Ozan Demir
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Luke Williams
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Juan F Iglesias
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Nilesh Sutaria
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Iqbal Malik
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Justin Davies
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Jamil Mayet
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Darrel Francis
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
| | - Sayan Sen
- National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK
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Herm J, Hoppe B, Kasabov R, Malzahn U, Endres M, Koscielny J, Jungehulsing GJ, Haeusler KG. Thrombophilia screening in young patients with cryptogenic stroke. Hamostaseologie 2017; 32:147-52. [DOI: 10.5482/ha-1175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 12/02/2011] [Indexed: 11/05/2022] Open
Abstract
SummaryThe clinical relevance of thrombophilia screening in stroke patients is still a matter of debate, and descriptions of larger patterns of genetic variability are rare. We assessed the frequency of hereditary hypercoagulability in young patients with cryptogenic stroke (n = 44) and in healthy blood donors (n = 282) without prior cardiovascular event. Furthermore, we focused on the impact of thrombophilia screening on secondary stroke prevention. Results: Compared to the control group (19–67 years; median 38.5 years; 64% women), there was a lower prevalence of the FVII-R353Q mutation (p = 0.033) in stroke patients (17–52 years; median 36 years; 59.1% women). Of note, the FVII-R353Q mutation lowers FVII plasma levels, probably reducing the risk of cardiovascular events. The prevalence of the remaining 13 gene polymorphisms did not differ significantly. However, the prevalence of FV Leiden mutation tended to be higher among stroke patients. Conclusion: Overall, extended screening for inherited thrombophilia had an impact on medical stroke prevention in every sixth patient with cryptogenic stroke.
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20
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Roach P, Kose Dunn M, Fricker R. Tissue engineered organoids for neural network modelling. ACTA ACUST UNITED AC 2017. [DOI: 10.15406/atroa.2017.03.00066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
The development of new methods to image the onset and progression of thrombosis is an unmet need. Non-invasive molecular imaging techniques targeting specific key structures involved in the formation of thrombosis have demonstrated the ability to detect thrombus in different disease state models and in patients. Due to its high concentration in the thrombus and its essential role in thrombus formation, the detection of fibrin is an attractive strategy for identification of thrombosis. Herein we provide an overview of recent and selected fibrin-targeted probes for molecular imaging of thrombosis by magnetic resonance imaging (MRI), positron emission tomography (PET), single photon emission computed tomography (SPECT), and optical techniques. Emphasis is placed on work that our lab has explored over the last 15 years that has resulted in the progression of the fibrin-binding PET probe [64Cu]FBP8 from preclinical studies into human trials.
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Affiliation(s)
- Bruno L Oliveira
- Department of Chemistry, University of Cambridge, Lensfield Road, CB2 1EW, Cambridge, UK.
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22
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Abstract
Premature atrial and ventricular contractions, or ectopic beats, are frequently detected on routine electrocardiogram monitoring. They are often considered to be benign with no pathological significance; however, the literature suggests that higher ectopic burdens may have clinical importance. This paper reviews the current literature and provides the treating physician with an understanding of when ectopic beats should be deemed significant and when treatment may be appropriate.
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23
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Lambe J, Noone I, Lonergan R, Tubridy N. Auditing the frequency and the clinical and economic impact of testing for Fabry disease in patients under the age of 70 with a stroke admitted to Saint Vincent’s University Hospital over a 6-month period. Ir J Med Sci 2017; 187:189-192. [DOI: 10.1007/s11845-017-1625-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 04/26/2017] [Indexed: 10/19/2022]
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24
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Markl M, Semaan E, Stromberg L, Carr J, Prabhakaran S, Collins J. Importance of variants in cerebrovascular anatomy for potential retrograde embolization in cryptogenic stroke. Eur Radiol 2017; 27:4145-4152. [PMID: 28386716 DOI: 10.1007/s00330-017-4821-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To test the hypothesis that variants in cerebrovascular anatomy will affect the number of patients demonstrating a plausible retrograde embolization mechanism from plaques in the descending aorta (DAo). METHODS Thirty-five patients (aged 63 ± 17 years) with cryptogenic stroke underwent 4D flow MRI for the assessment of aortic 3D blood flow and MR angiography for the evaluation of circle of Willis, posterior circulation, and aortic arch architecture. In patients with proven DAo plaque, retrograde embolization was considered a potential mechanism if retrograde flow extended from the DAo to a supra-aortic vessel supplying the cerebral infarct territory. RESULTS Retrograde embolization with matching cerebral infarct territory was detected in six (17%) patients. Circle of Willis and aortic arch variant anatomy was found in 60% of patients, leading to reclassification of retrograde embolization risk as present in three (9%) additional patients, for a total 26% of cryptogenic stroke patients. CONCLUSION 4D flow MRI demonstrated 26% concordance with infarct location on imaging with retrograde diastolic flow into the feeding vessels of the affected cerebral area, identifying a potential etiology for cryptogenic stroke. Our findings further demonstrate the importance of cerebrovascular anatomy when determining concordance of retrograde flow pathways with vascular stroke territory from DAo plaques. KEY POINTS • Retrograde embolization from descending aortic plaques constitutes a plausible etiology in cryptogenic stroke. • Common variants of cerebrovascular anatomy are important in determining retrograde embolization mechanism. • Variant cerebrovascular anatomy can link retrograde flow pathways with vascular stroke territory.
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Affiliation(s)
- Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, IL, USA.
| | - Edouard Semaan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - LeRoy Stromberg
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Radiology, Edward Hospital, Naperville, IL, USA
| | - James Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shyam Prabhakaran
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeremy Collins
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Jorfida M, Antolini M, Cerrato E, Caprioli MG, Castagno D, Garrone P, Budano C, Cerrato P, Gaita F. Cryptogenic ischemic stroke and prevalence of asymptomatic atrial fibrillation: a prospective study. J Cardiovasc Med (Hagerstown) 2017; 17:863-869. [PMID: 25379716 DOI: 10.2459/jcm.0000000000000181] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Atrial fibrillation is responsible for up to one-third of ischemic strokes, and is also associated with silent cerebral infarctions and transient ischemic attacks (TIAs). The self-terminating and often asymptomatic nature of paroxysmal atrial fibrillation (PAF) may lead to its underdiagnosis. A continuous and long-term heart rhythm monitoring can be useful in unmasking PAF episodes. OBJECTIVE Prevalence of asymptomatic PAF in patients suffering a cryptogenic stroke, at risk for atrial fibrillation but without any history of arrhythmia or palpitations, using a continuous electrocardiographic monitoring. METHODS One hundred and forty-two consecutive patients were admitted to the Stroke Unit of 'Città della Salute e della Scienza' Hospital of Turin between June 2010 and March 2013 and discharged with the diagnosis of ischemic cryptogenic stroke. Sixty fulfilled predefined inclusion criteria. Follow-up was carried on and completed for the 54 patients who consented to implantable loop recorder (ILR) implantation. After ILR implantation, trans-telephonic data were collected monthly. RESULTS Atrial fibrillation episodes lasting more than 5 min were recorded in 25 patients (46%), median detection time was 5.4 months (range 1-18) and median duration of atrial fibrillation episodes was 20 h (range 7 min-8 days) with 19 patients (76%) remaining asymptomatic and the others experiencing weakness and dyspnoea but not palpitations. CONCLUSION Long-term heart rhythm monitoring is successful in unmasking silent atrial fibrillation in 46% of patients suffering a cryptogenic stroke with concomitant atrial fibrillation risk factors, but without history of arrhythmia or palpitations.
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Affiliation(s)
- Marcella Jorfida
- aDivision of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital and Department of Medical Sciences bStroke Unit, 'Città della Salute e della Scienza' Hospital and University of Turin, Turin, Italy
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Boeckh-Behrens T, Kleine JF, Zimmer C, Neff F, Scheipl F, Pelisek J, Schirmer L, Nguyen K, Karatas D, Poppert H. Thrombus Histology Suggests Cardioembolic Cause in Cryptogenic Stroke. Stroke 2016; 47:1864-71. [DOI: 10.1161/strokeaha.116.013105] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/29/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Tobias Boeckh-Behrens
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Justus F. Kleine
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Claus Zimmer
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Frauke Neff
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Fabian Scheipl
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Jaroslav Pelisek
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Lucas Schirmer
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Kim Nguyen
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Deniz Karatas
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
| | - Holger Poppert
- From the Department of Neuroradiology (T.B.-B., J.F.K., C.Z.), Department of Vascular and Endovascular Surgery (J.P.), and Department of Neurology (L.S., K.N., D.K., H.P.), University Hospital Rechts der Isar, Technical University Munich, Munich, Germany; Department of Pathology, German Research Centre for Environmental Health, Munich, Germany (F.N.); and Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany (F.S.)
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Prabhakar AM, Misono AS, Brinegar KN, Khademhosseini A, Oklu R. Use of Magnetic Resonance Venography in Screening Patients With Cryptogenic Stroke for May-Thurner Syndrome. Curr Probl Diagn Radiol 2016; 45:370-372. [PMID: 27338307 DOI: 10.1067/j.cpradiol.2016.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/26/2016] [Indexed: 12/16/2022]
Abstract
The purpose of this study was to determine the prevalence of May-Thurner syndrome (MTS) in patients with cryptogenic stroke and to determine the incidence of patent foramen ovale. Magnetic resonance venography of 214 patients with cryptogenic stroke and 50 control patients with abdominopelvic computed tomography scans were evaluated for MTS. Incidence of patent foramen ovale and MTS in the stroke group were significantly greater than the control group (P = 0.0001, P = 0.0023, respectively). In addition, there was significantly greater compression of the left common iliac vein in the stroke group (32%) compared with the control group (13%) (P < 0.00001). In conclusion, there is a significantly higher prevalence of MTS and left common iliac vein compression in patients with cryptogenic stroke. These results indicate that magnetic resonance venography of the pelvis may be appropriate in the evaluation of stroke.
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Affiliation(s)
- Anand M Prabhakar
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander S Misono
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Katelyn N Brinegar
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ali Khademhosseini
- Department of Medicine, Biomaterials Innovation Research Center, Brigham and Women׳s Hospital, Harvard Medical School, Cambridge, MA; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA; Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA
| | - Rahmi Oklu
- Department of Medicine, Biomaterials Innovation Research Center, Brigham and Women׳s Hospital, Harvard Medical School, Cambridge, MA; Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ.
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Koh SH, Park HH. Neurogenesis in Stroke Recovery. Transl Stroke Res 2016; 8:3-13. [PMID: 26987852 DOI: 10.1007/s12975-016-0460-z] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/01/2016] [Accepted: 03/09/2016] [Indexed: 12/19/2022]
Abstract
Stroke, resulting from limited blood flow to the brain, is one of the most important causes of morbidity and mortality worldwide. Stroke is classified as ischemic, due to lack of blood flow, or hemorrhagic, due to bleeding. Because 87 % of strokes are classified as ischemic, this type will be the predominant focus of this review. Except for thrombolytic therapy, there is no established treatment to reduce the neurological deficits caused by ischemic stroke. Therefore, it is necessary to develop new therapeutic strategies designed to improve neurological functions after ischemic stroke. Recently, therapies to enhance neurogenesis after ischemic stroke have been investigated. However, these approaches have not led to successful clinical outcomes. This review addresses the pathophysiology of stroke, neurogenesis after stroke, and how to stimulate these processes based on the current literature. Finally, ongoing clinical trials to improve neurological functions after stroke by enhancing neurogenesis are discussed in this review.
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Affiliation(s)
- Seong-Ho Koh
- Department of Neurology, Hanyang University College of Medicine, 249-1 Guri Hospital, Gyomun-dong, Guri-si, Gyeonggi-do, 471-701, Republic of Korea. .,Department of Translational Medicine, Hanyang University Graduate School of Biomedical Science & Engineering, Seoul, Republic of Korea.
| | - Hyun-Hee Park
- Department of Neurology, Hanyang University College of Medicine, 249-1 Guri Hospital, Gyomun-dong, Guri-si, Gyeonggi-do, 471-701, Republic of Korea
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Burkowitz J, Merzenich C, Grassme K, Brüggenjürgen B. Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 23:1261-72. [PMID: 26864396 DOI: 10.1177/2047487316632628] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Insertable or implantable cardiac monitors (ICMs) continuously monitor the heart rhythm and record irregularities over 3 years, enabling the diagnosis of infrequent rhythm abnormalities associated with syncope and stroke. The enhanced recognition capabilities of recent ICM models are able to accurately detect atrial fibrillation (AF) and have led to new applications of ICMs for the detection and monitoring of AF. METHODS AND RESULTS Based on a systematic literature search, two indications were identified for ICMs for which considerable evidence, including randomized studies, exists: diagnosing the underlying cardiac cause of unexplained recurrent syncope and detecting AF in patients after cryptogenic stroke (CS). Three randomized controlled trials (RCTs) were identified that compared the effectiveness of ICMs in diagnosing patients with unexplained syncope (n = 556) to standard of care. A meta-analysis was conducted in order to generate an overall effect size and confidence interval of the diagnostic yield of ICMs versus conventional monitoring. In the indication CS, one RCT and five observational studies were included in order to assess the performance of ICMs in diagnosing patients with AF (n = 1129). Based on these studies, there is strong evidence that ICMs provide a higher diagnostic yield for detecting arrhythmias in patients with unexplained syncope and for detection of AF in patients after CS compared to conventional monitoring. CONCLUSIONS Prolonged monitoring with ICMs is an effective tool for diagnosing the underlying cardiac cause of unexplained syncope and for detecting AF in patients with CS. In all RCTs, ICMs have a superior diagnostic yield compared to conventional monitoring.
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Affiliation(s)
- Jörg Burkowitz
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Carina Merzenich
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Kathrin Grassme
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Bernd Brüggenjürgen
- Charité University Medicine Berlin, Institute for Social Medicine, Epidemiology and Health Economy, Berlin, Germany
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Ueno Y, Tanaka R, Yamashiro K, Shimada Y, Kuroki T, Hira K, Urabe T, Hattori N. Impact of BNP on cryptogenic stroke without potential embolic sources on transesophageal echocardiography. J Neurol Sci 2015; 359:287-92. [PMID: 26671129 DOI: 10.1016/j.jns.2015.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/05/2015] [Accepted: 11/08/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Clinical characteristics are important for determining the etiologies of embolic stroke, including patent foramen ovale and complex aortic plaques demonstrated on transesophageal echocardiography (TEE). This study sought to analyze the clinical signs of cryptogenic stroke (CS) without such embolic etiologies and to examine the association between CS and brain natriuretic peptide (BNP), which is currently unknown. METHODS Patients with CS after routine examinations who underwent TEE were included in this single-center observational study. Patients were classified into the potential embolic sources (PES) group (patients having PES on TEE) and the no potential embolic source (NPES) group. Patients were also categorized according to the tertile of BNP. RESULTS A total of 158 patients (age, 64.0 ± 13.9 years; 119 males) with CS were enrolled. The PES group had 108 (68%) patients, and the NPES group had 50 (32%). Hypertension was more common, and glucose, D-dimer, and BNP were higher in the NPES than in the PES group (p<0.05). NPES was independently associated with high-BNP tertile (OR: 5.61; 95% CI: 1.91 to 16.44; p=0.002). CONCLUSIONS BNP, an indicator of cardioembolism, was closely associated with NPES. Cardiogenic mechanisms may be implicated in the etiology of CS without potential embolic etiologies on TEE.
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Affiliation(s)
- Yuji Ueno
- Department of Neurology, Juntendo University, School of Medicine, Japan.
| | - Ryota Tanaka
- Department of Neurology, Juntendo University, School of Medicine, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University, School of Medicine, Japan
| | - Yoshiaki Shimada
- Department of Neurology, Juntendo University, School of Medicine, Japan
| | - Takuma Kuroki
- Department of Neurology, Juntendo University, School of Medicine, Japan
| | - Kenichiro Hira
- Department of Neurology, Juntendo University, School of Medicine, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University, School of Medicine, Japan; Department of Neurology, Juntendo University, Urayasu Hospital, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University, School of Medicine, Japan
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Petrovičová A, Kurča E, Brozman M, Hasilla J, Vahala P, Blaško P, Andrášová A, Hatala R, Urban L, Sivák Š. Detection of occult paroxysmal atrial fibrilation by implantable long-term electrocardiographic monitoring in cryptogenic stroke and transient ischemic attack population: a study protocol for prospective matched cohort study. BMC Cardiovasc Disord 2015; 15:160. [PMID: 26631084 PMCID: PMC4668651 DOI: 10.1186/s12872-015-0160-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/30/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cardio-embolic etiology is the most frequently predicted cause of cryptogenic stroke/TIA. Detection of occult paroxysmal atrial fibrillation is crucial for selection of appropriate medication. METHODS Enrolment of eligible cryptogenic stroke and TIA patients began in 2014 and will continue until 2018. The patients undergo long-term (12 months) ECG monitoring (implantable loop recorder) and testing for PITX2 (chromosome 4q25) and ZFHX3 (chromosome 16q22) gene mutations. There will be an appropriate control group of age- and sex-matched healthy volunteers. To analyse the results descriptive statistics, statistical tests for group differences, and correlation analyses will be used. DISCUSSION In our study we are focusing on a possible correlation between detection of atrial fibrillation by an implantable ECG recorder, and PITX2 and/or ZFHX3 gene mutations in cryptogenic stroke/TIA patients. A correlation could lead to implementation of this genomic approach to cryptogenic stroke/TIA diagnostics and management. The results will be published in 2018. TRIAL REGISTRATION ClinicalTrials.gov: NCT02216370 .
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Affiliation(s)
- Andrea Petrovičová
- Department of Neurology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Kollárova 2, 03659, Martin, Slovak Republic.
| | - Miroslav Brozman
- Department of Neurology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Jozef Hasilla
- Clinic of Cardiology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Pavel Vahala
- Clinic of Cardiology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Peter Blaško
- Kardiocentrum Nitra s.r.o, Špitálska 1, 94901, Nitra, Slovak Republic.
| | - Andrea Andrášová
- Kardiocentrum Nitra s.r.o, Špitálska 1, 94901, Nitra, Slovak Republic.
| | - Robert Hatala
- Department of Arrhythmias and Cardiac Pacing, The National Institute of Cardiovascular Diseases, Pod Krásnou hôrkou 1, 83348, Bratislava, Slovak Republic.
| | - Luboš Urban
- Department of Arrhythmias and Cardiac Pacing, The National Institute of Cardiovascular Diseases, Pod Krásnou hôrkou 1, 83348, Bratislava, Slovak Republic.
| | - Štefan Sivák
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Kollárova 2, 03659, Martin, Slovak Republic.
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Blasi F, Oliveira BL, Rietz TA, Rotile NJ, Naha PC, Cormode DP, Izquierdo-Garcia D, Catana C, Caravan P. Multisite Thrombus Imaging and Fibrin Content Estimation With a Single Whole-Body PET Scan in Rats. Arterioscler Thromb Vasc Biol 2015; 35:2114-21. [PMID: 26272938 DOI: 10.1161/atvbaha.115.306055] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/22/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Thrombosis is a leading cause of morbidity and mortality worldwide. Current diagnostic strategies rely on imaging modalities that are specific for distinct vascular territories, but a thrombus-specific whole-body imaging approach is still missing. Moreover, imaging techniques to assess thrombus composition are underdeveloped, although therapeutic strategies may benefit from such technology. Therefore, our goal was to test whether positron emission tomography (PET) with the fibrin-binding probe (64)Cu-FBP8 allows multisite thrombus detection and fibrin content estimation. APPROACH AND RESULTS Thrombosis was induced in Sprague-Dawley rats (n=32) by ferric chloride application on both carotid artery and femoral vein. (64)Cu-FBP8-PET/CT imaging was performed 1, 3, or 7 days after thrombosis to detect thrombus location and to evaluate age-dependent changes in target uptake. Ex vivo biodistribution, autoradiography, and histopathology were performed to validate imaging results. Arterial and venous thrombi were localized on fused PET/CT images with high accuracy (97.6%; 95% confidence interval, 92-100). A single whole-body PET/MR imaging session was sufficient to reveal the location of both arterial and venous thrombi after (64)Cu-FBP8 administration. PET imaging showed that probe uptake was greater in younger clots than in older ones for both arterial and venous thrombosis (P<0.0001). Quantitative histopathology revealed an age-dependent reduction of thrombus fibrin content (P<0.001), consistent with PET results. Biodistribution and autoradiography further confirmed the imaging findings. CONCLUSIONS We demonstrated that (64)Cu-FBP8-PET is a feasible approach for whole-body thrombus detection and that molecular imaging of fibrin can provide, noninvasively, insight into clot composition.
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Affiliation(s)
- Francesco Blasi
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - Bruno L Oliveira
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - Tyson A Rietz
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - Nicholas J Rotile
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - Pratap C Naha
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - David P Cormode
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - David Izquierdo-Garcia
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - Ciprian Catana
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.)
| | - Peter Caravan
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown (F.B., B.L.O., T.A.R., N.J.R., D.I.-G., C.C., P.C.); Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.C.N., D.P.C.); and Institute for Innovation in Imaging, Massachusetts General Hospital, Boston (P.C.).
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Maino A, Rosendaal FR, Algra A, Peyvandi F, Siegerink B. Hypercoagulability Is a Stronger Risk Factor for Ischaemic Stroke than for Myocardial Infarction: A Systematic Review. PLoS One 2015; 10:e0133523. [PMID: 26252207 PMCID: PMC4529149 DOI: 10.1371/journal.pone.0133523] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/29/2015] [Indexed: 12/05/2022] Open
Abstract
Background and Purpose Hypercoagulability increases the risk of arterial thrombosis; however, this effect may differ between various manifestations of arterial disease. Methods In this study, we compared the effect of coagulation factors as measures of hypercoagulability on the risk of ischaemic stroke (IS) and myocardial infarction (MI) by performing a systematic review of the literature. The effect of a risk factor on IS (relative risk for IS, RRIS) was compared with the effect on MI (RRMI) by calculating their ratio (RRR = RRIS/RRMI). A relevant differential effect was considered when RRR was >1+ its own standard error (SE) or <1−SE. Results We identified 70 publications, describing results from 31 study populations, accounting for 351 markers of hypercoagulability. The majority (203/351, 58%) had an RRR greater than 1. A larger effect on IS risk than MI risk (RRE>1+1SE) was found in 49/343 (14%) markers. Of these, 18/49 (37%) had an RRR greater than 1+2SE. On the opposite side, a larger effect on MI risk (RRR<1-1SE) was found in only 17/343 (5%) markers. Conclusions These results suggest that hypercoagulability has a more pronounced effect on the risk of IS than that of MI.
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Affiliation(s)
- Alberto Maino
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ale Algra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Brain Center Rudolph Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Bob Siegerink
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands; Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
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Excessive Atrial Ectopy and Short Atrial Runs Increase the Risk of Stroke Beyond Incident Atrial Fibrillation. J Am Coll Cardiol 2015; 66:232-241. [DOI: 10.1016/j.jacc.2015.05.018] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 05/06/2015] [Accepted: 05/11/2015] [Indexed: 11/22/2022]
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Krajcoviechova A, Wohlfahrt P, Mayer O, Vanek J, Hajkova J, Hlinovsky D, Kvasnicka T, Tremblay J, Hamet P, Filipovsky J, Kvasnicka J, Cifkova R. Tobacco smoking strongly modifies the association of prothrombin G20210A with undetermined stroke: Consecutive survivors and population-based controls. Atherosclerosis 2015; 240:446-52. [DOI: 10.1016/j.atherosclerosis.2015.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 11/29/2022]
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Llombart V, Antolin-Fontes A, Bustamante A, Giralt D, Rost NS, Furie K, Shibazaki K, Biteker M, Castillo J, Rodríguez-Yáñez M, Fonseca AC, Watanabe T, Purroy F, Zhixin W, Etgen T, Hosomi N, Jafarian Kerman SR, Sharma JC, Knauer C, Santamarina E, Giannakoulas G, García-Berrocoso T, Montaner J. B-Type Natriuretic Peptides Help in Cardioembolic Stroke Diagnosis. Stroke 2015; 46:1187-95. [DOI: 10.1161/strokeaha.114.008311] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/20/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Determining the underlying cause of stroke is important to optimize secondary prevention treatment. Increased blood levels of natriuretic peptides (B-type natriuretic peptide/N-terminal pro-BNP [BNP/NT-proBNP]) have been repeatedly associated with cardioembolic stroke. Here, we evaluate their clinical value as pathogenic biomarkers for stroke through a literature systematic review and individual participants’ data meta-analysis.
Methods—
We searched publications in PubMed database until November 2013 that compared BNP and NT-proBNP circulating levels among stroke causes. Standardized individual participants’ data were collected to estimate predictive values of BNP/NT-proBNP for cardioembolic stroke. Dichotomized BNP/NT-proBNP levels were included in logistic regression models together with clinical variables to assess the sensitivity and specificity to identify cardioembolic strokes and the additional value of biomarkers using area under the curve and integrated discrimination improvement index.
Results—
From 23 selected articles, we collected information of 2834 patients with a defined cause. BNP/NT-proBNP levels were significantly elevated in cardioembolic stroke until 72 hours from symptoms onset. Predictive models showed a sensitivity >90% and specificity >80% when BNP/NT-proBNP were added considering the lowest and the highest quartile, respectively. Both peptides also increased significantly the area under the curve and integrated discrimination improvement index compared with clinical models. Sensitivity, specificity, and precision of the models were validated in 197 patients with initially undetermined stroke with final pathogenic diagnosis after ancillary follow-up.
Conclusions—
Natriuretic peptides are strongly increased in cardioembolic strokes. Future multicentre prospective studies comparing BNP and NT-proBNP might aid in finding the optimal biomarker, the best time point, and the optimal cutoff points for cardioembolic stroke identification.
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Affiliation(s)
- Víctor Llombart
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Albert Antolin-Fontes
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Alejandro Bustamante
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Dolors Giralt
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Natalia S. Rost
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Karen Furie
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Kensaku Shibazaki
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Murat Biteker
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - José Castillo
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Manuel Rodríguez-Yáñez
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Ana Catarina Fonseca
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Tetsu Watanabe
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Francisco Purroy
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Wu Zhixin
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Thorleif Etgen
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Naohisa Hosomi
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Scott Reza Jafarian Kerman
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Jagdish C. Sharma
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Carolin Knauer
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Estevo Santamarina
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - George Giannakoulas
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Teresa García-Berrocoso
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
| | - Joan Montaner
- From the Neurovascular Research Laboratory, Institut de Recerca Vall d’Hebron, Neurovascular Unit, Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain (V.L., A.A.-F., A.B., D.G., T.G.-B., J.M.); Acute Stroke Services, Massachusetts General Hospital, J. Philip Kistler Stroke Research Center, Boston (N.S.R.); Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.F.); Department of Stroke Medicine, Kawasaki Medical School,
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P wave dispersion in cryptogenic stroke: A risk factor for cardioembolism? Int J Cardiol 2015; 190:202-4. [PMID: 25920025 DOI: 10.1016/j.ijcard.2015.04.185] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/21/2015] [Indexed: 11/22/2022]
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Muuronen AT, Taina M, Hedman M, Marttila J, Kuusisto J, Onatsu J, Vanninen R, Jäkälä P, Sipola P, Mustonen P. Increased visceral adipose tissue as a potential risk factor in patients with embolic stroke of undetermined source (ESUS). PLoS One 2015; 10:e0120598. [PMID: 25756793 PMCID: PMC4354901 DOI: 10.1371/journal.pone.0120598] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/24/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The etiology of an ischemic stroke remains undetermined in 20-35% of cases and many patients do not have any of the conventional risk factors. Increased visceral adipose tissue (VAT) is a suggested new risk factor for both carotid artery atherosclerosis (CAA) and atrial fibrillation (AF), but its role in the remaining stroke population is unknown. We assessed the amount of VAT in patients with embolic stroke of undetermined source (ESUS) after excluding major-risk cardioembolic sources, occlusive atherosclerosis, and lacunar stroke. METHODS Altogether 58 patients (mean age 57.7 ± 10.2 years, 44 men) with ischemic stroke of unknown etiology but without CAA, known AF or small vessel disease underwent computed tomography angiography and assessment of VAT. For comparison VAT values from three different reference populations were used. Conventional risk factors (smoking, hypertension, diabetes, increased total and LDL-cholesterol, decreased HDL-cholesterol) were also registered. RESULTS Mean VAT area was significantly higher in stroke patients (205 ± 103 cm2 for men and 168 ± 99 cm2 for women) compared to all reference populations (P < 0.01). 50% of male and 57% of female patients had an increased VAT area. In male patients, VAT was significantly higher despite similar body mass index (BMI). Increased VAT was more common than any of the conventional risk factors. CONCLUSION Increased VAT was found in over half of our patients with ESUS suggesting it may have a role in the pathogenesis of thromboembolism in this selected group of patients.
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Affiliation(s)
- Antti T. Muuronen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- * E-mail:
| | - Mikko Taina
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
| | - Marja Hedman
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- Kuopio University Hospital, Heart Center, Kuopio, Finland
| | - Jarkko Marttila
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
| | - Johanna Kuusisto
- Kuopio University Hospital, Department of Medicine, Kuopio, Finland
| | - Juha Onatsu
- Kuopio University Hospital, Neuro Center, Kuopio, Finland
| | - Ritva Vanninen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Pekka Jäkälä
- Kuopio University Hospital, Neuro Center, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Neurology, Kuopio, Finland
| | - Petri Sipola
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
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Yevtushenko SK, Filimonov DA, Yevtushenko IS. New risk factors of stroke in young adults. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-12. [DOI: 10.17116/jnevro20151151223-12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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McGrath ER, Paikin JS, Motlagh B, Salehian O, Kapral MK, O'Donnell MJ. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review. Am Heart J 2014; 168:706-12. [PMID: 25440799 DOI: 10.1016/j.ahj.2014.07.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 07/18/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND The clinical utility of routine transesophageal echocardiography (TEE) for patients with unexplained ischemic stroke is controversial. We performed a systematic review to determine the frequency of detection of new cardiac findings in patients with cryptogenic ischemic stroke (IS) undergoing transesophageal echocardiography (TEE). METHODS Systematic review and meta-analysis of cohort studies of consecutive patients with "cryptogenic" IS undergoing TEE after routine etiologic workup. Patients were categorized into 2 groups: A (< 55 years) and B (≥ 55 years). Outcomes included proportion of patients with new TEE-detected cardiac findings and proportion of patients commenced on oral anticoagulation after TEE. RESULTS Twenty-seven studies were included (n = 5,653). We identified significant heterogeneity among studies and report a range of prevalence rates and I2 statistic as our primary analysis. Prevalence of individual cardiac findings on TEE varied significantly among studies; patent foramen ovale (A: 12.0%-57.8%, I2 = 89.9%; B: 3.9%-43.5%, I2 = 86.7%), atrial septal aneurysm (A: 0-48.9%, I2 = 91.9%; B: 3.5%-25.0%, I2 = 84.5%), left atrial thrombus (A: 0-10.9%, I2 = 61.1%; B: 0-21.2%, I2 = 91.7%), spontaneous echo contrast (A: 0-11.9%, I2 = 57.2%; B: 0-21.3%, I2 = 89.8%), and aortic atheroma (A: 0-9.6%, I2 = 53.8%; B: 2.8%-44.4%, I2 = 89.7%). Definitions of common findings were not provided for many studies. Five studies (n = 591) reported on the proportion of patients who were commenced on anticoagulant therapy after TEE (range 0-30.7%). CONCLUSIONS Routine TEE in patients with cryptogenic IS identifies cardiac findings in a large proportion. However, there is marked interstudy variation in the definition and prevalence of common findings. Transesophageal echocardiography-detected findings prompted the introduction of anticoagulant therapy in up to one-third of patients. However, these were mostly not for established guideline-based indications based on randomized controlled trial evidence. It is unclear if routine use of TEE in patients with cryptogenic IS is indicated.
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Affiliation(s)
- Emer R McGrath
- HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Department of Neurology, Massachusetts General Hospital, Boston MA.
| | - Jeremy S Paikin
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Bahareh Motlagh
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Omid Salehian
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Moira K Kapral
- Department of Internal Medicine and Clinical Epidemiology, University of Toronto, Ontario, Canada
| | - Martin J O'Donnell
- HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
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Barbarossa A, Guerra F, Capucci A. Silent Atrial Fibrillation: A Critical Review. J Atr Fibrillation 2014; 7:1138. [PMID: 27957123 DOI: 10.4022/jafib.1138] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/25/2014] [Accepted: 09/25/2014] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) in the most common cardiac arrhythmia, and is associated with an increased risk of thromboembolic events. Silent AF is an asymptomatic form of AF incidentally diagnosed during a routine test or manifesting as an arrhythmia-related complication. Although recent trials have clearly demonstrated that patients with sub-clinical AF are at increased risk of stroke, the real incidence of this form of AF is still unknown. In fact, studies about silent AF had been performed only in specific subgroups of patients such as those with implantable cardiac devices, with recent cryptogenic stroke or transient ischemic attack, and recently undergoing AF ablation. Continuous ECG-monitoring in patients without implantable cardiac devices may improve silent AF detection but its cost-effectiveness actually is not well established in all kind of patients. Moreover, recent data have revealed that only a small number of these patients may have sub-clinical AF within the month prior to their stroke suggesting a lack of temporal relationship between the stroke and the AF episode. This paper will review available data on different diagnostic tools for silent AF detection with a focus on their cost-effectiveness, analyzing the direct correlation between the arrhythmia and embolic events, and discussing areas of uncertainty where further research is required.
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Affiliation(s)
- Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
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Vayá A, Hernández V, Rivera L, Hernández JL, Lago A, España F, Bautista D. Red blood cell distribution width in patients with cryptogenic stroke. Clin Appl Thromb Hemost 2014; 21:241-5. [PMID: 25155500 DOI: 10.1177/1076029614547262] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is no information about a possible association of red blood cell distribution width (RDW) with cryptogenic stroke (CS). We aimed to analyze the association of RDW with CS. PATIENTS AND METHODS One hundred and sixty-three patients with CS were included along with 186 healthy controls. Fibrinogen, leukocytes, hemoglobin, and erythrocyte indices were evaluated. RESULTS Patients showed higher RDW, leukocyte count, and body mass index (BMI) than controls (P < .05). No differences were observed in the erythrocyte indices or in glucose, cholesterol, and triglycerides levels (P > .05). When patients with anemia were excluded from the study (6 controls and 5 cases), the differences between cases and controls persisted (P = .005). Multivariate logistic regression revealed that, after adjusting for potential confounders (anemia, age > 40 years, gender, and fibrinogen >382 mg/dL, total cholesterol >240 mg/dL, and BMI > 28.7 kg/m(2)), RDW >14% was the only parameter that independently increased the risk of CS. CONCLUSION The RDW >14% increased the risk of CS by 2.5-fold, irrespectively of anemia, inflammation, and lipidic profile.
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Affiliation(s)
- Amparo Vayá
- Department of Clinical Pathology, Hemorheology and Haemostasis Unit, La Fe University Hospital, Valencia, Spain
| | - Victoriano Hernández
- Department of Clinical Pathology, Hemorheology and Haemostasis Unit, La Fe University Hospital, Valencia, Spain
| | - Leonor Rivera
- Department of Clinical Pathology, Hemorheology and Haemostasis Unit, La Fe University Hospital, Valencia, Spain
| | - José Luis Hernández
- Department of Clinical Pathology, Hemorheology and Haemostasis Unit, La Fe University Hospital, Valencia, Spain
| | - Aída Lago
- Neurology Service, La Fe University Hospital, Valencia, Spain
| | | | - Daniel Bautista
- Epidemiology Service, Doctor Peset University Hospital, Valencia, Spain
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Seo JY, Lee KB, Lee JG, Kim JS, Roh H, Ahn MY, Park BW, Hyon MS. Implication of left ventricular diastolic dysfunction in cryptogenic ischemic stroke. Stroke 2014; 45:2757-61. [PMID: 25074516 DOI: 10.1161/strokeaha.114.006108] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Left ventricular diastolic dysfunction (LVDD) is a predictor for atrial fibrillation (AF). This study was aimed to investigate whether LVDD in cryptogenic ischemic stroke (CS) could be a clue to stroke mechanism. METHODS The clinical and echocardiographic findings of 1589 consecutive patients with acute ischemic stroke or transient ischemic attack between 2004 and 2013 were reviewed. LVDDs among stroke subtypes were graded by transthoracic echocardiography into 4 groups by severity: normal, abnormal relaxation (grade I), pseudonormal (grade II), and restrictive diastolic filling (grade III), whereas severe LVDD was defined as grade III. We classified the lesion pattern of CS into cardioembolism-mimic or non-cardioembolism-mimic and determined whether cardioembolism-mimic lesions were associated with severe LVDD. RESULTS The fraction of severe LVDD in CS was not different from that of stroke with AF (27.3% versus 37.1%; P=0.173) but was significantly higher than that of stroke without AF (27.3% versus 13.4%; P=0.008). Cardioembolism-mimic CS had more severe LVDD than non-cardioembolism-mimic CS (41.4% versus 11.5%; P=0.013). LVDD of grade II (odds ratio, 4.37; 95% confidence interval, 2.99-6.41) and grade III (odds ratio, 5.60; 95% confidence interval, 3.42-9.17) were independently related to stroke with AF after adjusting covariates. CONCLUSIONS The severe LVDD could be a predictor of stroke with AF, and its frequency was similar between CS and stroke with AF. Cardioembolism-mimic CS had significantly more severe LVDD than non-cardioembolism-mimic CS. LVDD could be helpful to discriminate the stroke mechanism in the patients with acute CS.
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Affiliation(s)
- Jae-Young Seo
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
| | - Kyung Bok Lee
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea.
| | - Jung-Gon Lee
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
| | - Ji-Sun Kim
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
| | - Hakjae Roh
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
| | - Moo-Young Ahn
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
| | - Byoung Won Park
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
| | - Min Su Hyon
- From the Departments of Neurology (J.-Y.S., K.B.L., J.-G.L., J.-S.K., H.R., M.-Y.A.) and Cardiology (B.W.P., M.S.H.), Soonchunhyang University School of Medicine, Seoul, Korea
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Kim J, Choi SI, Park KH, Chun EJ, Lim C. Clinical significance of intraluminal atheroma in patients with ascending and arch aneurysm. Ann Thorac Surg 2014; 97:2034-40. [PMID: 24793690 DOI: 10.1016/j.athoracsur.2014.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 02/22/2014] [Accepted: 03/05/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little is known about the clinical significance of intraluminal atheroma (ILA) in ascending and arch aneurysm (Asc-ArcA) regarding aneurysm expansion and associated cardiovascular events. METHODS We retrospectively investigated 70 consecutive patients with Asc-ArcA who underwent serial multidetector computed tomography between 2004 and 2011. We evaluated the diameter of the aneurysm, as well as the presence and characteristics of ILA. We also evaluated the characteristics of atheroma in terms of the presence of high-risk plaque (>4 mm in plaque thickness), vulnerable plaque (<60 HU in density), ulcerated plaque (extension of the contrast medium beyond the vascular lumen into the surrounding plaque with >3 mm orifice), and complex plaque (having all three characteristics). The annual expansion rate of Asc-ArcA and factors associated with cardiovascular events were evaluated. RESULTS During a median of 47 months of follow-up, cryptogenic stroke occurred in 13 patients (18.6%). Univariate and multivariate logistic regression analyses revealed the presence of ILA as an independent predictor for cryptogenic stroke. Cryptogenic stroke occurred in all 5 patients with complex atheroma. The annual expansion rate of Asc-ArcA was not significantly associated with the occurrence of cryptogenic stroke. CONCLUSIONS In patients with low to intermediate risk sized Asc-ArcA, ILA, especially complex atheroma, is strongly associated with cryptogenic stroke. Thus, the presence and characteristics of ILA within Asc-ArcA should be carefully evaluated for the prevention of adverse events.
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Affiliation(s)
- Jihang Kim
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggido, Korea
| | - Sang Il Choi
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggido, Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggido, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggido, Korea.
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggido, Korea
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45
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Ay I, Blasi F, Rietz TA, Rotile NJ, Kura S, Brownell AL, Day H, Oliveira BL, Looby RJ, Caravan P. In vivo molecular imaging of thrombosis and thrombolysis using a fibrin-binding positron emission tomographic probe. Circ Cardiovasc Imaging 2014; 7:697-705. [PMID: 24777937 DOI: 10.1161/circimaging.113.001806] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fibrin is a major component of arterial and venous thrombi and represents an ideal candidate for molecular imaging of thrombosis. Here, we describe imaging properties and target uptake of a new fibrin-specific positron emission tomographic probe for thrombus detection and therapy monitoring in 2 rat thrombosis models. METHODS AND RESULTS The fibrin-binding probe FBP7 was synthesized by conjugation of a known short cyclic peptide to a cross-bridged chelator (CB-TE2A), followed by labeling with copper-64. Adult male Wistar rats (n=26) underwent either carotid crush injury (mural thrombosis model) or embolic stroke (occlusive thrombosis model) followed by recombinant tissue-type plasminogen activator treatment (10 mg/kg, IV). FBP7 detected thrombus location in both animal models with a high positron emission tomographic target-to-background ratio that increased over time (>5-fold at 30-90 minutes, >15-fold at 240-285 minutes). In the carotid crush injury animals, biodistribution analysis confirmed high probe uptake in the thrombotic artery (≈0.5%ID/g; >5-fold greater than blood and other tissues of the head and thorax). Similar results were obtained from ex vivo autoradiography of the ipsilateral versus contralateral carotid arteries. In embolic stroke animals, positron emission tomographic-computed tomographic imaging localized the clot in the internal carotid/middle cerebral artery segment of all rats. Time-dependent reduction of activity at the level of the thrombus was detected in recombinant tissue-type plasminogen activator-treated rats but not in vehicle-injected animals. Brain autoradiography confirmed clot dissolution in recombinant tissue-type plasminogen activator-treated animals, but enduring high thrombus activity in control rats. CONCLUSIONS We demonstrated that FBP7 is suitable for molecular imaging of thrombosis and thrombolysis in vivo and represents a promising candidate for bench-to-bedside translation.
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Affiliation(s)
- Ilknur Ay
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Francesco Blasi
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Tyson A Rietz
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Nicholas J Rotile
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Sreekanth Kura
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Anna Liisa Brownell
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Helen Day
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Bruno L Oliveira
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Richard J Looby
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Peter Caravan
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA.
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Rudolph V, Augustin J, Hofmann T, Hamm CW, Meinertz T, Köster R, Baldus S, Franzen O. Predictors of recurrent stroke after percutaneous closure of patent foramen ovale. EUROINTERVENTION 2014; 9:1418-22. [DOI: 10.4244/eijv9i12a239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Manina G, Agnelli G, Becattini C, Zingarini G, Paciaroni M. 96 hours ECG monitoring for patients with ischemic cryptogenic stroke or transient ischaemic attack. Intern Emerg Med 2014; 9:65-7. [PMID: 22249917 DOI: 10.1007/s11739-012-0755-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/04/2012] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) is intermittent in 30% of patients with cardioembolic stroke and, therefore, might not be seen in a single standard ECG recording. The aim of this study was to evaluate if prolonged ECG monitoring (96 h) finds episodes of intermittent AF beyond the 24 h ECG monitoring in patients with cryptogenic stroke or transient ischemic attack (TIA). We prospectively evaluated consecutive patients affected by cryptogenic stroke or TIA who had sinus rhythm on a 12-lead ECG on admission, and during ECG monitoring performed in the acute phase (for at least 24 h). Patients had continuous 96 h Holter ECG monitoring within 30 days from stroke onset. 114 patients were included in the study (mean age 63.1 ± 15.1, 59 males). AF was found in 29 patients (24.3%). In 20 patients, AF was found in the first 24 h of recording, and in nine patients after 24 h. In addition, several other dysrhythmias such as supraventricular ectopic activity (33), ventricular tachycardia (10), sinus pause (4) and sinus-atrial block (1) were found. In patients with cryptogenic stroke or TIA, 96 h ECG monitoring detected a high rate of AF. One-third of AF was seen beyond 24 h of ECG monitoring.
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Affiliation(s)
- Giorgia Manina
- Division of Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy,
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48
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Amin H, Greer DM. Cryptogenic Stroke—The Appropriate Diagnostic Evaluation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:280. [DOI: 10.1007/s11936-013-0280-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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49
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Cox C, Sharp FR. RNA-based blood genomics as an investigative tool and prospective biomarker for ischemic stroke. Neurol Res 2013; 35:457-64. [DOI: 10.1179/1743132813y.0000000212] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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50
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Kwong JS, Lam YY, Yu CM. Percutaneous closure of patent foramen ovale for cryptogenic stroke: A meta-analysis of randomized controlled trials. Int J Cardiol 2013; 168:4132-8. [DOI: 10.1016/j.ijcard.2013.07.077] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/03/2013] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
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