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Perry JJ, Alsadoon A, Nemnom MJ, Sivilotti MLA, Émond M, Stiell IG, Stotts G, Lee JS, Worster A, Morris J, Cheung KW, Jin AY, Sahlas DJ, Murray HE, Mackey A, Verreault S, Camden MC, Yip S, Teal P, Gladstone DJ, Boulos MI, Chagnon N, Shouldice E, Atzema C, Slaoui T, Teitelbaum J, Giannakakis SM, Thiruganasambandamoorthy V, Dowlatshahi D, Wells GA, Sharma M. A Multicentre Prospective Cohort Study to Identify High-Risk Transient Ischemic Attack/Minor Stroke Patients Benefiting from Echocardiography. Can J Cardiol 2024:S0828-282X(24)00946-2. [PMID: 39277075 DOI: 10.1016/j.cjca.2024.09.008] [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: 07/17/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND We aimed to derive a clinical decision rule to identify transient ischemic attack (TIA)/minor stroke patients most likely to benefit from echocardiography. METHODS This multicentre prospective cohort study enrolled adults diagnosed with TIA/minor stroke in the emergency department who underwent a echocardiogram within 90 days, from 13 Canadian academic emergency departments from October 2006 to May 2017. Our outcome was clinically significant echocardiogram findings. RESULTS In 7,149 eligible patients, a clinically significant finding was found in 556 (7.8%). There were a further 2,421 (33.9%) with a potentially significant finding. History of heart failure (adjusted odds ratio [OR] 3.9) or coronary artery disease (OR 2.7) were the factors most strongly associated with clinically significant echocardiogram findings, while young age, male sex, valvular heart disease and infarct (any age) on neuroimaging were modestly associated (OR between 1.3 and 1.9). The model combining these predictors into a score (range 0 to 15), had a C-statistic of 0.67 (95%CI 0.65-0.70). A cut point of 6 points or more classified 6.6% of cases as high likelihood, defined as >15% for clinically significant echocardiogram findings. CONCLUSION Echocardiography is a very useful test in the investigations of TIA/minor stroke patients. We identified high risk clinical features, combined to create a clinical decision rule, to identify which TIA/minor stroke patients are likely to have clinically significant echocardiogram findings requiring an immediate change in management. These patients should have echocardiography prioritized while others may continue to have echocardiography conducted in a less urgent fashion.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Abdulaziz Alsadoon
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Founder SmartMed, SmartLab and Jiwar Freestanding ER, Saudi Arabia
| | | | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Marcel Émond
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacques S Lee
- Schwartz\\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Ka Wai Cheung
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Albert Y Jin
- Division of Neurology, Queen's University, Kingston, Ontario, Canada
| | - Demetrios J Sahlas
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Heather E Murray
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ariane Mackey
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Neurology, Laval University, Quebec City, Quebec, Canada
| | - Steve Verreault
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Neurology, Laval University, Quebec City, Quebec, Canada
| | - Marie-Christine Camden
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Neurology, Laval University, Quebec City, Quebec, Canada
| | - Samuel Yip
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philip Teal
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - David J Gladstone
- Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Mark I Boulos
- Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Nicolas Chagnon
- Department of Emergency Medicine, Montfort Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Elizabeth Shouldice
- Queensway Carleton Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Clare Atzema
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tarik Slaoui
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Jeanne Teitelbaum
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Sophia-Maria Giannakakis
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George A Wells
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mukul Sharma
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Ontario, Canada
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Lele AV, Liu J, Kunapaisal T, Chaikittisilpa N, Kiatchai T, Meno MK, Assad OR, Pham J, Fong CT, Walters AM, Nandate K, Chowdhury T, Krishnamoorthy V, Vavilala MS, Kwon Y. Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit. J Clin Med 2024; 13:2526. [PMID: 38731055 PMCID: PMC11084203 DOI: 10.3390/jcm13092526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.
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Affiliation(s)
- Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Jeffery Liu
- Department of Biosciences, Wiess School of Natural Sciences, Rice University, Houston, TX 77005, USA;
| | - Thitikan Kunapaisal
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai 90110, Thailand;
| | - Nophanan Chaikittisilpa
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 73170, Thailand; (N.C.); (T.K.)
| | - Taniga Kiatchai
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 73170, Thailand; (N.C.); (T.K.)
| | - Michael K. Meno
- Department of Medicine, University of Washington, Seattle, WA 98104, USA; (M.K.M.); (O.R.A.); (J.P.)
| | - Osayd R. Assad
- Department of Medicine, University of Washington, Seattle, WA 98104, USA; (M.K.M.); (O.R.A.); (J.P.)
| | - Julie Pham
- Department of Medicine, University of Washington, Seattle, WA 98104, USA; (M.K.M.); (O.R.A.); (J.P.)
| | - Christine T. Fong
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Koichiro Nandate
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Tumul Chowdhury
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | | | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Younghoon Kwon
- Department of Cardiology, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA;
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Inogés M, Arboix A, García-Eroles L, Sánchez-López MJ. Gender Predicts Differences in Acute Ischemic Cardioembolic Stroke Profile: Emphasis on Woman-Specific Clinical Data and Early Outcome-The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:101. [PMID: 38256361 PMCID: PMC10819324 DOI: 10.3390/medicina60010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Acute ischemic cardioembolic stroke (CS) is a clinical condition with a high risk of death, and can lead to dependence, recurrence, and dementia. Materials and Methods: In this study, we evaluated gender differences and female-specific clinical data and early outcomes in 602 women diagnosed with CS from a total of 4600 consecutive acute stroke patients in a single-center hospital stroke registry over 24 years. A comparative analysis was performed in women and men in terms of demographics, cerebrovascular risk factors, clinical data, and early outcomes. Results: In a multivariate analysis, age, hypertension, valvular heart disease, obesity, and internal capsule location were independent variables associated with CS in women. The overall in-hospital mortality rate was similar, but the group of women had a greater presence of neurological deficits and a higher percentage of severe limitation at hospital discharge. After the multivariate analysis, age, altered consciousness, limb weakness, and neurological, respiratory, gastrointestinal, renal, cardiac and peripheral vascular complications were independent predictors related to early mortality in women. Conclusions: Women with CS showed a differential demographic and clinical profile and worse early outcomes than men. Advanced age, impaired consciousness, and medical complications were predictors of stroke severity in women with CS.
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Affiliation(s)
- Marc Inogés
- Department of Neurology, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain; (M.I.); (L.G.-E.)
| | - Adrià Arboix
- Department of Neurology, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain; (M.I.); (L.G.-E.)
| | - Luís García-Eroles
- Department of Neurology, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain; (M.I.); (L.G.-E.)
| | - María José Sánchez-López
- Medical Library, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain;
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Villani LA, Guay M, DeDominicis M, Bharwani A, Xu R, Počuča N, Perera K. The Utility of Echocardiogram in the Workup of Ischemic Stroke Patients. Can J Neurol Sci 2024; 51:73-77. [PMID: 36691825 DOI: 10.1017/cjn.2023.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cardiac sources of emboli can be identified by transthoracic echocardiogram (TTE). The Canadian Best Practice Guidelines recommend routine use of TTE in the initial workup of ischemic stroke when an embolic source is suspected. However, TTEs are commonly ordered for all patients despite insufficient evidence to justify cost-effectiveness. We aim to evaluate the TTE ordering pattern in the initial workup of ischemic stroke at a regional Stroke Center in Central South Ontario and determine the proportion of studies which led to a change in management and affected length of stay (LOS). METHODS Hospital records of 520 patients with a discharge diagnosis of TIA or ischemic stroke between October 2016 and June 2017 were reviewed to gather information. RESULTS 477 patients admitted for TIA or ischemic stroke met inclusion criteria. 67.9% received TTE, out of which 6.0% had findings of cardiac sources of emboli including left ventricular thrombus, atrial septal aneurysm, PFO, atrial myxoma, and valvular vegetation. 2.5% of all TTE findings led to change in medical management. The median LOS of patients who underwent TTE was 2 days longer (p < 0.00001). CONCLUSION TTE in the initial workup of TIA or ischemic stroke remains common practice. The yield of TTEs is low, and the proportion of studies that lead to changes in medical management is minimal. TTE completion was associated with increased LOS and may result in increased healthcare spending; however, additional factors prolonging the LOS could not be excluded.
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Affiliation(s)
- Linda A Villani
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Meagan Guay
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | | | - Aadil Bharwani
- Temerty Faculty of Medicine, University of Toronto, Canada
| | - Richard Xu
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Nikola Počuča
- Faculty of Science, Department of Mathematics and Statistics, McMaster University, Canada
| | - Kanjana Perera
- Division of Neurology, Department of Medicine, McMaster University, Canada
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Liegey JS, Fawaz S, Ducos C, Pucheu Y, Boulestreau R, Sibon I, Couffinhal T. Predictive utility of stress tests in the detection of asymptomatic coronary artery disease in atherosclerotic stroke patients. J Stroke Cerebrovasc Dis 2023; 32:107290. [PMID: 37567133 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Whether and how atherosclerotic ischemic stroke patients should be investigated for asymptomatic coronary artery disease (CAD) is controversial. Our aim was to carry out a prospective observational study to determine the frequency and predictors of functionally significant coronary stenosis in these patients as well as the predictors of major adverse cardiovascular events (MACE) during post-stroke follow-up. MATERIAL AND METHODS From January 2014 to June 2018, patients with atherosclerotic ischemic stroke were referred from the stroke unit to our cardiovascular department 3+/- 1 months after the acute event where they benefited from evaluation of cardiovascular risk factors, vascular and myocardial disease. Main outcome was defined as the prevalence of myocardial ischemia defined by perfusion stress echography 3 months after stroke. Secondary outcome (MACE) was defined as the incidence of stroke, transient ischemic attack (TIA), acute coronary syndrome, cardiovascular (CV) death or coronary or peripheral revascularization during a 3 year follow-up. RESULTS Three hundred and twenty five patients (92% of strokes and 8% TIA) were included and median follow-up was 1075 days. At 3 months post-stroke, myocardial ischemia was found in 17 patients (5.2%). During the 3 year follow-up, 11 MACE occurred (3.4%, all in the non-ischemic group) of which 6 were recurrent strokes. In multivariate analysis, myocardial ischemia was significantly associated with the number of atheromatous vascular beds (OR 4.3; 95% CI, 1.7 to 10.6) and ECG signs of necrosis (OR 6.5; 95% CI, 1.9 to 21.9). MACE were also associated with ECG signs of necrosis (OR 3.5; 95% CI, 1.3 to 9.1), and unrelated to myocardial ischemia. CONCLUSION Myocardial ischemia and CV events were infrequent and both strongly associated with ECG signs of necrosis, suggesting a low yield of stress tests and the potential for a more straightforward algorithm in the choice of patients eligible to coronary angiogram or other coronary imaging in post-stroke setting.
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Affiliation(s)
- Jean-Sébastien Liegey
- CHU de Bordeaux, Service de Maladies Coronaires et Vasculaires, F-33600 Pessac, France.
| | - Sami Fawaz
- CHU de Bordeaux, Service de Maladies Coronaires et Vasculaires, F-33600 Pessac, France.
| | - Claire Ducos
- CHU de Bordeaux, Service de Maladies Coronaires et Vasculaires, F-33600 Pessac, France.
| | - Yann Pucheu
- CHU de Bordeaux, Service de Maladies Coronaires et Vasculaires, F-33600 Pessac, France.
| | - Romain Boulestreau
- CHU de Bordeaux, Service de Maladies Coronaires et Vasculaires, F-33600 Pessac, France.
| | - Igor Sibon
- CHU de Bordeaux, Service de Neurologie, Hopital Pellegrin, Rue de la Pelouse de Douet, Bordeaux, 33076, France.
| | - Thierry Couffinhal
- CHU de Bordeaux, Service de Maladies Coronaires et Vasculaires, F-33600 Pessac, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaires, U1034, F-33600 Pessac, France.
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Shah S, Malik P, Patel U, Wang Y, Gronseth GS. Diagnostic Yield of TEE in Patients with Cryptogenic Stroke and TIA with Normal TTE: A Systematic Review and Meta-Analysis. Neurol Int 2021; 13:659-670. [PMID: 34940749 PMCID: PMC8706810 DOI: 10.3390/neurolint13040063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/02/2021] [Accepted: 10/27/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The role of transesophageal echocardiography (TEE) in cryptogenic stroke and transient ischemic attack (TIA) with normal transthoracic echocardiography (TTE) remains controversial in the absence of definite guidelines. We aimed to perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal TTE. METHODS We performed a systematic review of cohort studies on PubMed using the keywords 'cryptogenic stroke', cryptogenic TIA', 'TEE', and 'TTE' with matching MeSH terms. We included studies with patients who had cryptogenic stroke or TIA and had normal TTE findings, where the study intended to obtain TEE on all patients and reported all TEE abnormalities. The studies containing patients with atrial fibrillation were excluded. All studies were evaluated for internal and external validity. Inverse variance random effects models were used to calculate the effect size, the number needed to diagnose, and the 95% confidence interval. RESULTS We included 15 studies with 2054 patients and found LA/LAA/aortic thrombus, valvular vegetation, PFO-ASA, valvular abnormalities, and complex aortic plaques on TEE. Of these, 37.5% (29.7%-45.1%) of patients had additional cardiac findings on TEE. Management of 13.6% (8.1%-19.1%) of patients had changed after TEE evaluation. Based on current guidelines, it should change management in 4.1% (2.1%-6.2%) of patients and could potentially change management in 30.4% (21.9%-38.9%) of patients. Sensitivity analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5%-48.3%), changed management in 20.2% (8.7%-31.8%), should change management in 4.7% (1.5%-7.9%), and could potentially change management in 30.4% (17.8%-43.0%) of patients. CONCLUSIONS The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is not only high, but it can also change management for certain cardiac abnormalities. TTE in cryptogenic stroke or TIA may mitigate future risks by tailoring the management of these patients.
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Affiliation(s)
- Shamik Shah
- Department of Neurology, Stormont Vail Health, Topeka, KS 66604, USA
| | - Preeti Malik
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (P.M.); (U.P.)
| | - Urvish Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (P.M.); (U.P.)
| | - Yunxia Wang
- Department of Neurology, The University of Kansas Health System, Kansas City, KS 66160, USA; (Y.W.); (G.S.G.)
| | - Gary S. Gronseth
- Department of Neurology, The University of Kansas Health System, Kansas City, KS 66160, USA; (Y.W.); (G.S.G.)
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Butt W, Dhillon PS, Lenthall R, Malik L, Izzath W, Krishnan K, George B, Pointon K. Left Atrial Enlargement on Non-Gated CT Is Associated with Large Vessel Occlusion in Acute Ischaemic Stroke. Cerebrovasc Dis Extra 2021; 11:87-91. [PMID: 34551410 PMCID: PMC8543283 DOI: 10.1159/000519121] [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: 05/11/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Recent reports have suggested that atrial fibrillation (AF) is more prevalent in the large vessel occlusion (LVO) subgroup of acute ischaemic stroke patients. Given the association between left atrial enlargement (LAE) and AF, we sought to evaluate the feasibility of assessing LAE on non-gated CT and its association with LVO in the hyperacute stroke setting. Methods We analysed our prospectively collected database that included all stroke patients referred for consideration of endovascular treatment between April 14, 2020, and May 21, 2020. During this period, a CT chest was included in our regional stroke protocol to aid triage of patients suspected for COVID-19 from which cardiac measurements were obtained. Patients were dichotomized into LVO and no-LVO groups, and LA measurements were trichotomized into normal, borderline, and enlarged. Univariate analyses were performed between groups. Results Of the included 38 patients, 21 were categorized as LVO and 17 as no LVO. There was a statistically significant association between LAE and LVO (p = 0.028). No significant difference was demonstrated between groups for the baseline AF and other clinical characteristics, except for baseline NIHSS (p = 0.0005). There was excellent inter- and intra-rater reliability (ICC = 0.969) for LA measurements. Conclusion Our study provides preliminary data to suggest LAE is more prevalent in the LVO stroke subgroup at presentation and can be reliably assessed on non-gated CT in the hyperacute setting. These findings have potential implications for stratifying secondary management and may prompt a more rigorous pursuit of occult AF or other cardiac causes of stroke.
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Affiliation(s)
- Waleed Butt
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Robert Lenthall
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Luqman Malik
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Wazim Izzath
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Kailash Krishnan
- Stroke Medicine, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Bindu George
- Cardiothoracic Radiology Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Kate Pointon
- Cardiothoracic Radiology Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Cardiac Testing in Search for Occult Atrial Fibrillation after Ischemic Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00908-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Rodriguez-Granillo GA, Cirio JJ, Ciardi C, Caballero ML, Diluca P, Castrillon R, Ceron M, Scrivano E, Lylyk P. Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19. Minerva Cardiol Angiol 2021; 69:606-618. [PMID: 33703860 DOI: 10.23736/s2724-5683.21.05547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina - .,National Council of Scientific and Technical Investigations - Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina -
| | - Juan J Cirio
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Celina Ciardi
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Maria L Caballero
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pablo Diluca
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Ricardo Castrillon
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Marcos Ceron
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Esteban Scrivano
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
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10
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Pagola J, Pagola C, Juega J, González-Alujas T, Alvarez-Sabin J, Molina CA. The Role of Echocardiography Screening at the Stroke Unit. Front Neurol 2020; 11:1003. [PMID: 33013663 PMCID: PMC7516041 DOI: 10.3389/fneur.2020.01003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/30/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jorge Pagola
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Carlos Pagola
- Cardiology Department, Ciudad de Jaén University Hospital, Jaén, Spain
| | - Jesús Juega
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Teresa González-Alujas
- Echocardiography Lab Cardiology Department, Vall D'Hebrón Hospital, CIBER-CV, Barcelona, Spain
| | - José Alvarez-Sabin
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
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11
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Rajashekar D, Wilms M, Hecker KG, Hill MD, Dukelow S, Fiehler J, Forkert ND. The Impact of Covariates in Voxel-Wise Lesion-Symptom Mapping. Front Neurol 2020; 11:854. [PMID: 32922356 PMCID: PMC7456820 DOI: 10.3389/fneur.2020.00854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Voxel-wise lesion-symptom mapping (VLSM) is a statistical technique to infer the structure-function relationship in patients with cerebral strokes. Previous VLSM research suggests that it is important to adjust for various confounders such as lesion size to minimize the inflation of true effects. The aim of this work is to investigate the regional impact of covariates on true effects in VLSM. Methods: A total of 222 follow-up datasets of acute ischemic stroke patients with known NIH Stroke Scale (NIHSS) score at 48-h post-stroke were available for this study. Patient age, lesion volume, and follow-up imaging time were tested for multicollinearity using variance inflation factor analysis and used as covariates in VLSM analyses. Covariate importance maps were computed from the VLSM results by standardizing the beta coefficients of general linear models. Results: Covariates were found to have distinct regional importance with respect to lesion eloquence in the brain. Age has a relatively higher importance in the superior temporal gyrus, inferior parietal lobule, and in the pre- and post-central gyri. Volume explains more variability in the opercular area of the insula, inferior frontal gyrus, and caudate. Follow-up imaging time accounts for most of the variance in the globus pallidus, ventromedial- and dorsolateral putamen, dorsal caudate, pre-motor thalamus, and the dorsal insula. Conclusions: This is the first study investigating and revealing distinctive regional patterns of importance for covariates typically used in VLSM. These covariate importance maps can improve our understanding of the lesion-deficit relationships in patients and could prove valuable for patient-specific treatment and rehabilitation planning.
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Affiliation(s)
- Deepthi Rajashekar
- Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Matthias Wilms
- Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Kent G Hecker
- Departments of Community Health Sciences and Veterinary Clinical, and Diagnostic Sciences, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sean Dukelow
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D Forkert
- Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
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12
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Huang WY, Lee M, Sung SF, Tang SC, Chang KH, Huang YS, Lee JD, Lee TH, Jeng JS, Chung CM, Wu YL, Hsieh TT, Ovbiagele B. Atrial fibrillation trial to evaluate real-world procedures for their utility in helping to lower stroke events: A randomized clinical trial. Int J Stroke 2020; 16:300-310. [PMID: 32640882 PMCID: PMC8044652 DOI: 10.1177/1747493020938297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Enhancing detection of unrecognized atrial fibrillation among acute ischemic stroke patients is crucial for secondary stroke prevention. Aim To evaluate whether the detection rate of new atrial fibrillation in acute ischemic stroke patients without known atrial fibrillation could be improved by doing serial 12-lead electrocardiograms once daily for five days, compared with conventional 24-h Holter monitoring (24-h Holter). Methods We conducted a randomized clinical trial to compare the detection rates of paroxysmal atrial fibrillation between serial electrocardiograms versus 24-h Holter from October 2015 to October 2018 at six hospitals. Eligible participants were acute ischemic stroke patients with aged ≥65 years, with neither atrial fibrillation history nor any presence of atrial fibrillation on baseline electrocardiogram at admission. The primary outcome was newly detected electrocardiogram in the serial electrocardiograms and 24-h Holter group. Results Among 826 patients, baseline characteristics were similar between both groups. In the intention-to-treat analysis, there was no statistical difference between serial electrocardiograms versus 24-Holter to detect atrial fibrillation (8.4% vs. 6.9%; adjusted odds ratio 1.17, 95% confidence interval 0.69–2.01). Stepwise multivariate logistic regression revealed age ≥80 years and history of heart failure were associated with detection of paroxysmal atrial fibrillation whereas patients with lacunar infarction had lower odds for detection of paroxysmal atrial fibrillation. Conclusions Serial electrocardiograms had comparable detection rate of paroxysmal atrial fibrillation compared with 24-h Holter and might be a viable alternative to 24-h Holter as a first-line approach to survey for potential paroxysmal atrial fibrillation among elderly patients with acute ischemic stroke. Clinical Trial Registration: URL https://clinicaltrials.gov/ct2/show/NCT02578979 Unique Identifiers: NCT02578979
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Affiliation(s)
- Wen-Yi Huang
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meng Lee
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, 38006National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuo-Hsuan Chang
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Sung Huang
- Division of Neurology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, 38006National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chang-Min Chung
- Division of Cardiology, Department of Internal Medicine, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
| | - Yi-Ling Wu
- Institute of Population Health Sciences, 50115National Health Research Institutes, Miaoli County, Taiwan
| | - Tsung-Ta Hsieh
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, CA, USA
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13
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Fralick M, Goldberg N, Rohailla S, Guo Y, Burke MJ, Lapointe-Shaw L, Kwan JL, Weinerman AS, Rawal S, Tang T, Razak F, Verma AA. Value of routine echocardiography in the management of stroke. CMAJ 2020; 191:E853-E859. [PMID: 31387955 DOI: 10.1503/cmaj.190111] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention. METHODS We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression. RESULTS Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram. INTERPRETATION Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke.
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Affiliation(s)
- Mike Fralick
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont.
| | - Nicola Goldberg
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Sagar Rohailla
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Yishan Guo
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Matthew J Burke
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Janice L Kwan
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Adina S Weinerman
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Shail Rawal
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Terence Tang
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Fahad Razak
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Amol A Verma
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
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14
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Rosol ZP, Kopecky KF, Minehart BR, Tecson KM, Vasudevan A, McCullough PA, Grayburn PA, Schussler JM. Limitations of transoesophageal echocardiogram in acute ischaemic stroke. Open Heart 2020; 7:e001176. [PMID: 32257245 PMCID: PMC7103838 DOI: 10.1136/openhrt-2019-001176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/06/2020] [Accepted: 02/24/2020] [Indexed: 01/01/2023] Open
Abstract
Objective The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.
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Affiliation(s)
- Zachary P Rosol
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Kathleen F Kopecky
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Bailey R Minehart
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anupama Vasudevan
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Peter A McCullough
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.,Department of Cardiology, The Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, TX, United States
| | - Paul A Grayburn
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.,Department of Cardiology, The Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, TX, United States
| | - Jeffrey M Schussler
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.,Department of Cardiology, The Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, TX, United States
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15
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Tan TC, Nunes MCP, Handschumacher M, Pontes-Neto O, Park YH, O'Brien C, Piro V, Kim GM, Helenius J, Zeng X, Padilha da Silva JL, Furie K, Ay H, Hung J. Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes. Heart 2020; 106:1176-1182. [PMID: 31980438 DOI: 10.1136/heartjnl-2019-315964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Cardioembolic (CE) stroke carries significant morbidity and mortality. Left atrial (LA) size has been associated with CE risk. We hypothesised that differential LA remodelling impacts on pathophysiological mechanism of major CE strokes. METHODS A cohort of consecutive patients hospitalised with ischaemic stroke, classified into CE versus non-CE strokes using the Causative Classification System for Ischaemic Stroke were enrolled. LA shape and remodelling was characterised by assessing differences in maximal LA cross-sectional area (LA-CSA) in a cohort of 40 prospectively recruited patients with ischaemic stroke using three-dimensional (3D) echocardiography. Flow velocity profiles were measured in spherical versus ellipsoidal in vitro models to determine if LA shape influences flow dynamics. Two-dimensional (2D) LA-CSA was subsequently derived from standard echocardiographic views and compared with 3D LA-CSA. RESULTS A total of 1023 patients with ischaemic stroke were included, 230 (22.5%) of them were classified as major CE. The mean age was 68±16 years, and 464 (45%) were women. The 2D calculated LA-CSA correlated strongly with the LA-CSA measured by 3D in both end-systole and end-diastole. In vitro flow models showed shape-related differences in mid-level flow velocity profiles. Increased LA-CSA was associated with major CE stroke (adjusted relative risk 1.10, 95% CI 1.04 to 1.16; p<0.001), independent of age, gender, atrial fibrillation, left ventricular ejection fraction and CHA2DS2-VASc score. Specifically, the inclusion of LA-CSA in a model with traditional risk factors for CE stroke resulted in significant improvement in model performance with the net reclassification improvement of 0.346 (95% CI 0.189 to 0.501; p=0.00001) and the integrated discrimination improvement of 0.013 (95% CI 0.003 to 0.024; p=0.0119). CONCLUSIONS LA-CSA is a marker of adverse LA shape associated with CE stroke, reflecting importance of differential LA remodelling, not simply LA size, in the mechanism of CE risk.
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Affiliation(s)
- Timothy C Tan
- Cardiology, Blacktown Hospital, Blacktown, New South Wales, Australia.,Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Carmo Pereira Nunes
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Internal Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Mark Handschumacher
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Octavio Pontes-Neto
- University of São Paulo Department of Neurosciences and Behaviour Sciences, Ribeirao Preto, São Paulo, Brazil.,Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yong-Hyun Park
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cardiovascular Center, Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea
| | - Cashel O'Brien
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria Piro
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Unidad de Imagen Cardiaca, Hospital Universitario San Roque, Las Palmas, España
| | - Gyeong-Moon Kim
- Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cardiovascular Center, Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea
| | - Johanna Helenius
- Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Lahey Hospital and Medical Center Burlington, Burlington, Massachusetts, USA
| | - Xin Zeng
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Karen Furie
- Brown University Division of Biology and Medicine, Providence, Rhode Island, USA
| | - Hakan Ay
- Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Hung
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Brandler ES, Baksh N. Emergency management of stroke in the era of mechanical thrombectomy. Clin Exp Emerg Med 2019; 6:273-287. [PMID: 31910498 PMCID: PMC6952636 DOI: 10.15441/ceem.18.065] [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: 08/03/2018] [Revised: 10/13/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023] Open
Abstract
Emergency management of stroke has been directed at the delivery of recombinant tissue plasminogen activator (tPA) in a timely fashion. Because of the many limitations attached to the delivery of tPA and the perceived benefits accrued to tPA, its use has been limited. Mechanical thrombectomy, a far superior therapy for the largest and most disabling strokes, large vessel occlusions (LVOs), has changed the way acute strokes are managed. Aside from the rush to deliver tPA, there is now a need to identify LVO and refer those patients with LVO to physicians and facilities capable of delivering urgent thrombectomy. Other parts of emergency department management of stroke are directed at identifying and mitigating risk factors for future strokes and at preventing further damage from occurring. We review here the most recent literature supporting these advances in stroke care and present a framework for understanding the role that emergency physicians play in acute stroke care.
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Affiliation(s)
- Ethan S. Brandler
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Nayeem Baksh
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
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17
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Amlie-Lefond C, Wainwright MS. Organizing for Acute Arterial Ischemic Stroke in Children. Stroke 2019; 50:3662-3668. [DOI: 10.1161/strokeaha.119.025497] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Mark S. Wainwright
- Division of Neurology, Seattle Children’s Hospital, University of Washington
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18
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Fernando RJ, Goeddel LA, Shah R, Ramakrishna H. Analysis of the 2019 ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS Appropriate Use Criteria for Multimodal Imaging in the Assessment of Structural Heart Disease. J Cardiothorac Vasc Anesth 2019; 34:805-818. [PMID: 31196720 DOI: 10.1053/j.jvca.2019.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Lee A Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ronak Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Philadelphia, PA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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19
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Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
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Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
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20
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Amlie-Lefond C. Evaluation and Acute Management of Ischemic Stroke in Infants and Children. Continuum (Minneap Minn) 2018; 24:150-170. [PMID: 29432241 DOI: 10.1212/con.0000000000000559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article provides an overview of stroke in neonates, infants, and children. RECENT FINDINGS Arterial ischemic stroke and cerebral venous sinus thrombosis are increasingly recognized in childhood as important causes of lifelong morbidity and mortality. Diagnosis of arterial ischemic stroke is frequently delayed, as acute neurologic deficits can be challenging to detect in the young child, and stroke is often not considered in the differential diagnosis. Neurologic sequelae following stroke are common, and strategies to minimize stroke size and optimize recovery are being developed. Recurrent arterial ischemic stroke is not uncommon, particularly in children with cerebral arteriopathy. Cerebral venous sinus thrombosis causes obstruction of venous outflow leading to venous infarcts. Complications include hemorrhagic conversion of infarcts and increased intracranial pressure. Without treatment, thrombus extension with increased symptoms is common. Robust guidelines of care that exist for adults do not exist for children, particularly for children with arterial ischemic stroke. SUMMARY The approach to stroke in infants and children can be informed by clinical experience in pediatric stroke and cerebral venous sinus thrombosis, the extensive literature on pediatric thrombosis, and extrapolation from data from adult patients.
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21
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Al-Khaled M, Scheef B, Brüning T. Is transesophageal echocardiography needed for evaluating tissue-based transient ischemic attack? Neural Regen Res 2018; 13:1212-1215. [PMID: 30028329 PMCID: PMC6065226 DOI: 10.4103/1673-5374.235058] [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] [Indexed: 11/04/2022] Open
Abstract
Transient ischemic attack (TIA) is a warning signal for stroke. A comprehensive evaluation of TIA may reduce the risk for subsequent stroke. Data on the findings of cardiac evaluation with transesophageal echocardiography (TEE) in patients with TIA are sparse. Our aims were to determine the frequency of TEE performance and to investigate the findings of TEE in patients with TIA based on the new definition of TIA (i.e., transient neurological symptoms without evidence of infarction). During a 4-year period (2011-2014), 1071 patients (mean age, 70 ± 13 years; female, 49.7%) with TIA were included in a prospective study and evaluated. Of 1071 consecutive patients suffering from TIA, 288 patients (27%) underwent TEE. The median time between admission and TEE was 6 days. Patients with TIA who were evaluated by TEE were younger (67 vs. 71 years, P < 0.001) than those who were not evaluated by TEE. They had a higher rate of sensibility disturbance as a TIA symptom (39% vs. 31%, P = 0.012) but a lower rate of previous stroke (15% vs. 25%, P = 0.001) and atrial fibrillation (2% vs. 21%, P < 0.001) than those who did not. Foramen ovale was detected in 71 patients (25.7%), atrial septal aneurysm in 13 patients (4.6%), and severe atherosclerotic plaques (grade 4 and 5) in the aortic arch in 25 patients (8.7%). One patient (0.3%) had a fibroma detected by TEE. In 17 of the 288 patients (6%) who underwent TEE, the indication for anticoagulation therapy was based on the TEE results, and 1 patient with fibroma underwent heart surgery. During hospitalization, 7 patients experienced a subsequent stroke, and 27 patients had a recurrent TIA. At 3 months following discharge, the rates of readmission, stroke, recurrent TIA, and death were 19%, 2.7%, 4.2%, and 1.6%, respectively. The rates of mortality (0.9% vs. 1.8%, P = 0.7), stroke risk (1.9% vs. 3.0%, P = 0.8), and recurrent TIA (5.0% vs. 3.9%, P = 0.8) were similar in patients who underwent TEE and in those who did not. Performing TEE in patients with tissue-based TIA is helpful in detecting cardiac sources for embolism and may indicate for anticoagulation.
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Affiliation(s)
| | - Björn Scheef
- Department of Neurology, University of Lübeck, Lübeck; Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Toralf Brüning
- Department of Neurology, University of Lübeck, Lübeck, Germany
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22
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Abstract
Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5–10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.
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Affiliation(s)
- Camilo R Gomez
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Jose Biller
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
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23
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Hsieh TT, Lee M, Huang WY, Tang SC, Sung SF, Chang KH, Lee JD, Lee TH, Huang YS, Jeng JS, Chung CM, Wu YL, Ovbiagele B. Atrial fibrillation trial to evaluate real-world procedures for their utility in helping to lower stroke events (AFTER-PULSE): Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2017; 6:127-130. [PMID: 29082335 PMCID: PMC5659320 DOI: 10.1016/j.conctc.2017.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Enhancing detection of undiagnosed atrial fibrillation (AF) in hospitalized patients with a recent ischemic stroke is important because of the treatment implications; especially since presence of paroxysmal AF may not be picked up in a single 12-lead electrocardiogram (ECG) test. While several trials have shown improved detection of AF with prolonged ECG monitoring, this strategy is associated with relatively high cost, labor intensity, and patient inconvenience, thereby making it challenging to routinely implement in all hospitals. Fortunately, conventional 24-h Holter monitoring and repeated 12-lead ECGs are readily available to detect paroxysmal AF in all hospitals, but is unclear which is the better strategy for evaluating undiagnosed AF. The objective of his study is to conduct a randomized trial of serial 12-lead ECGs vs. 24-hour Holter monitoring in the detection of AF in ischemic stroke patients without known AF. Methods and analysis We plan to enroll 1200 participants from six hospitals in Taiwan. Patients will be eligible for enrollment if they are admitted for an acute ischemic stroke within 2 days, are ≥65 years of age, and have no known AF by history or on baseline ECG at admission. We will randomly assign participants in a 1:1 ratio to undergo daily 12-lead ECG once daily for 5 days (intervention group) or 24-h Holter monitoring (control group). Primary outcome is newly detected AF on a 12-lead ECG or AF lasting ≥30 s on Holter monitoring. Trial registration number ClinicalTrials.gov Identifier: NCT02578979.
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Affiliation(s)
- Tsung-Ta Hsieh
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Wen-Yi Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Kuo-Husan Chang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Yung-Sung Huang
- Division of Neurology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chang-Min Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Yi-Ling Wu
- Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston, USA
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24
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Stöllberger C, Wegner C, Finsterer J. Revision of Echocardiographic Indications and Findings in Neurologically Ill Patients. Open Cardiovasc Med J 2017; 11:14-18. [PMID: 28400861 PMCID: PMC5362974 DOI: 10.2174/1874192401711010014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/29/2016] [Accepted: 01/13/2017] [Indexed: 01/19/2023] Open
Abstract
Background and Objective: Little is known about the general indications for echocardiography and the prevalence of abnormalities detected by echocardiography in patients who are referred from a neurological department. Left ventricular hypertrabeculation/noncompaction (LVHT) is associated with neuromuscular disorders and embolism. The aim of the study was to assess the indications for echocardiography in patients from a neurological department and to review the cine-loops of the examinations in order to assess the frequency of abnormal echocardiographic findings with special regard to LVHT. Methods and Results: Included were 126 patients, 58 females (mean age 65 years). Indications were stroke (84%), heart failure (6%), endocarditis (6%) and arrhythmia (3%). The most frequent abnormalities were impaired relaxation (71%) and left ventricular wall thickening (63%). Females were older (68 vs. 62 years, p = 0.0214) and more frequently had normally sized left ventricles than males (98 vs. 88%, p = 0.0376). Patients ≥66 years more frequently had stroke as an indication (91 vs. 77%, p = 0.05), showed a thickened myocardium (72 vs. 53%, p = 0.0272), valvular abnormalities (52 vs. 13%, p = 0.0000) and impaired relaxation (86 vs. 54%, p = 0.0001) than patients <66 years. LVHT was diagnosed in 3 patients; in one of them the diagnosis was already known. In 45% LVHT and in 38% left ventricular thrombus could neither be excluded nor established since the image quality was poor. Conclusion: Care should be taken to visualize the left ventricular apical regions when investigating patients referred from a neurologic department in order not to overlook LVHT and thrombi within the left ventricular apex.
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Affiliation(s)
| | - Christian Wegner
- Vienna Institute of Demography of the Austrian Academy of Sciences, Welthandelsplatz 2, Level 2, 1020 Wien, Austria
| | - Josef Finsterer
- Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien, Austria
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25
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Pallesen LP, Ragaller M, Kepplinger J, Barlinn K, Zerna C, Siepmann T, Wiedemann B, Braun S, Weise M, Bodechtel U, Puetz V. Diagnostic Impact of Transesophageal Echocardiography in Patients with Acute Cerebral Ischemia. Echocardiography 2017; 33:555-61. [PMID: 27103483 DOI: 10.1111/echo.13131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Transesophageal echocardiography (TEE) is the diagnostic gold standard for the detection of structural heart diseases as potential sources of cardiac emboli in patients with acute cerebral ischemia. We sought to determine the diagnostic yield of TEE in patients with acute ischemic stroke or transient ischemic attack (TIA). METHODS We retrospectively analyzed consecutive patients with acute cerebral ischemia who were admitted to our hospital between October 2008 and December 2011. TEE reports were screened for detection of cardiac source of embolism judged by the recommendation to change medical management. We performed univariate and multivariate analyses to identify predictors of clinically relevant TEE findings among baseline characteristics. RESULTS Of 3314 patients with ischemic stroke or TIA, TEE was performed in 791 (24%) patients (mean age 64 ± 13 years, 589 [74%] ischemic stroke, 202 [26%] TIA). A potential cardioembolic source was found in 71 (9%) patients with patent foramen ovale with atrial septal aneurysm being the most common finding (24/71 patients, 34%). In multivariate analysis, peripheral vascular disease (OR 2.57; 95%CI 1.00-6.61), imaging evidence of infarction in multiple locations (OR 4.13; 95%CI 1.36-12.58), and infarction in the posterior circulation (OR 2.11; 95%CI 1.01-4.42) were associated with the identification of a potential cardioembolic source with TEE. CONCLUSION TEE identified a potential structural cardioembolic source in nearly 10% of our selected patient population with acute ischemic stroke or TIA, thus underlining its diagnostic value. Our data suggest that patients with hitherto unknown stroke etiology should be considered for additional TEE.
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Affiliation(s)
- Lars-Peder Pallesen
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Margaretha Ragaller
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Jessica Kepplinger
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Kristian Barlinn
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Charlotte Zerna
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Timo Siepmann
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Baerbel Wiedemann
- Institute for Medical Informatics and Biometry, University of Technology, Dresden, Germany
| | - Silke Braun
- Medical Clinic I, University of Technology, Dresden, Germany
| | - Matthias Weise
- Medical Clinic III, University of Technology, Dresden, Germany
| | - Ulf Bodechtel
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
| | - Volker Puetz
- Dresden University Stroke Center, Department of Neurology, University of Technology, Dresden, Germany
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26
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Homma S, Messé SR, Rundek T, Sun YP, Franke J, Davidson K, Sievert H, Sacco RL, Di Tullio MR. Patent foramen ovale. Nat Rev Dis Primers 2016; 2:15086. [PMID: 27188965 DOI: 10.1038/nrdp.2015.86] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.
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Affiliation(s)
- Shunichi Homma
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Yee-Ping Sun
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Karina Davidson
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
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27
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Katsanos AH, Patsouras D, Tsivgoulis G, Kosmidou M, Katsanos KH, Kyritsis AP, Giannopoulos S. The value of transesophageal echocardiography in the investigation and management of cryptogenic cerebral ischemia: a single-center experience. Neurol Sci 2015; 37:629-32. [PMID: 26705252 DOI: 10.1007/s10072-015-2448-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
Abstract
The diagnostic utility of transesophageal echocardiography (TEE) has often been challenged in patients with cryptogenic stroke (CS). We estimated the prevalence of different findings on TEE examination of CS patients, their impact on secondary stroke prevention and the presence of potential age or gender disparities. We reviewed all TEE examinations that were performed in a single echocardiography laboratory during a 7-year-old period to identify CS patients that underwent investigation with TEE. Of the 518 total TEE examinations, we identified 88 CS patients. TEE revealed abnormal findings in 69.3 % of them. Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were identified in 30.6 and 22.7 % of the patients. Ascending aorta and aortic arch atheromatosis was present in 26.1 % of the patients, with complex atheromatosis diagnosed in 14.7 % of them. Cardiac myxomas were uncovered in 2.3 %. Thrombi in the left atrium and in cardiac valves were reported in 3.4 and 2.3 % of the patients, respectively. Based on TEE findings, the therapeutic management would be very likely modified in 9.1 % of the patients. Subgroup analysis revealed no gender disparities on the prevalence of TEE findings and in secondary stroke prevention, while linear regression analyses revealed significant associations of age with the prevalence of PFO, ASA, aorta atheromatosis and complex aorta atheromatosis. TEE examination should be included in the diagnostic work-up of all CS patients, irrespective of age and gender status, since it can reveal potential sources of embolism and has a significant impact for secondary stroke prevention.
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Affiliation(s)
- Aristeidis H Katsanos
- Department of Neurology, University of Ioannina School of Medicine, University Campus, Ioannina, 45110, Greece. .,Neurosurgical Research Institute, University of Ioannina, Ioannina, Greece.
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,International Clinical Research Center, St. Anne's University Hospital in Brno, Brno, Czech Republic
| | - Maria Kosmidou
- First Division of Internal Medicine, University of Ioannina School of Medicine, Ioannina, Greece
| | | | - Athanassios P Kyritsis
- Department of Neurology, University of Ioannina School of Medicine, University Campus, Ioannina, 45110, Greece.,Neurosurgical Research Institute, University of Ioannina, Ioannina, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, University Campus, Ioannina, 45110, Greece.,Neurosurgical Research Institute, University of Ioannina, Ioannina, Greece
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28
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Katsanos AH, Giannopoulos S, Frogoudaki A, Vrettou A, Ikonomidis I, Paraskevaidis I, Zompola C, Vadikolias K, Boviatsis E, Parissis J, Voumvourakis K, Kyritsis AP, Tsivgoulis G. The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta‐analysis. Eur J Neurol 2015; 23:569-79. [DOI: 10.1111/ene.12897] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/01/2015] [Indexed: 01/11/2023]
Affiliation(s)
- A. H. Katsanos
- Department of Neurology School of Medicine University of Ioannina IoanninaGreece
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - S. Giannopoulos
- Department of Neurology School of Medicine University of Ioannina IoanninaGreece
| | - A. Frogoudaki
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - A.‐R. Vrettou
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - I. Ikonomidis
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - I. Paraskevaidis
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - C. Zompola
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - K. Vadikolias
- Department of Neurology Democritus University of Thrace AlexandroupolisGreece
| | - E. Boviatsis
- Second Department of Neurosurgery ‘Attikon University Hospital’ School of Medicine University of Athens Athens Greece
| | - J. Parissis
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - K. Voumvourakis
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - A. P. Kyritsis
- Department of Neurology School of Medicine University of Ioannina IoanninaGreece
| | - G. Tsivgoulis
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
- Department of Neurology Democritus University of Thrace AlexandroupolisGreece
- International Clinical Research Center Department of Neurology St Anne's University Hospital Brno Czech Republic
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29
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Nabavi D, Ossenbrink M, Schinkel M, Koennecke HC, Hamann G, Busse O. Aktualisierte Zertifizierungskriterien für regionale und überregionale Stroke-Units in Deutschland. DER NERVENARZT 2015. [DOI: 10.1007/s00115-015-4395-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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30
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Elbers J, Wainwright MS, Amlie-Lefond C. The Pediatric Stroke Code: Early Management of the Child with Stroke. J Pediatr 2015; 167:19-24.e1-4. [PMID: 25937428 DOI: 10.1016/j.jpeds.2015.03.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 03/09/2015] [Accepted: 03/26/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Jorina Elbers
- Division of Child Neurology, Stanford Children's Health, Stanford University, Stanford, CA.
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Northwestern University, Chicago, IL
| | - Catherine Amlie-Lefond
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
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Deipolyi AR, Hamberg LM, Gonzaléz RG, Hirsch JA, Hunter GJ. Diagnostic yield of emergency department arch-to-vertex CT angiography in patients with suspected acute stroke. AJNR Am J Neuroradiol 2015; 36:265-8. [PMID: 25258370 DOI: 10.3174/ajnr.a4112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to investigate how often relevant diagnostic findings in an arch-to-vertex CTA scan, obtained specifically as part of the acute stroke CT protocol, are located in the head, neck, and upper chest regions. MATERIALS AND METHODS Radiology reports were reviewed in 302 consecutive patients (170 men, 132 women; median ages, 66 and 73 years, respectively) who underwent emergency department investigation of suspected acute stroke between January and July 2010. Diagnostic CTA findings relevant to patient management were recorded for the head, neck, and chest regions individually. Additionally, the contributions to the total CTA scan effective dose were estimated from each of the 3 anatomic regions by using the ImPACT CT Dose Calculator. RESULTS Of the 302 patients, 161 (54%) had relevant diagnostic findings in the head; 94 (31%), in the neck; and 4 (1%), in the chest. The estimated contributions to the total CTA scan dose from each body region, head, neck, and upper chest, were 14 ± 2%, 33 ± 5%, and 53 ± 6%, respectively. CONCLUSIONS Most clinically relevant findings are in the head and neck, supporting inclusion of these regions in arch-to-vertex CTA performed specifically in patients with acute stroke in the emergency department. Further studies are required to investigate extending the scan to the upper chest because only 1% of patients in our study had clinically relevant findings in the mediastinum, yet half the CTA effective dose was due to scanning in this region.
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Affiliation(s)
- A R Deipolyi
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - L M Hamberg
- Department of Radiology (L.M.H.), Brigham and Women's Hospital, Boston, Massachusetts
| | - R G Gonzaléz
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - J A Hirsch
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - G J Hunter
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
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Abstract
OPINION STATEMENT Cardioembolic (CE) stroke mechanisms account for a significant number of ischemic strokes; however, the true burden is likely underestimated. It is critically important to identify patients with CE strokes because these individuals have high recurrence rates and represent a subgroup of patients who may benefit from targeted therapy in the form of anticoagulation or device based treatments. Current guidelines offer recommendations for diagnosis and treatment of these patients; however, important questions remain. First, appropriate cardiac testing in the setting of CE must be individualized and the optimal duration of electrocardiographic monitoring to rule out atrial fibrillation (AF) is unclear. Second, risk stratification tools for AF remain understudied, and there is controversy about which anticoagulant agents are most appropriate. Lastly, important potential CE sources of stroke such as patent foramen ovale have garnered significant attention recently, and debate regarding how to manage these patients persists. In this review, we discuss some of the important controversies in diagnosing and treating patients with possible CE stroke, pointing to areas where future research might be particularly valuable.
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Affiliation(s)
- Benjamin S. Wessler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston
- Division of Cardiology, Tufts Medical Center, Boston
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston
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Jansson D, Rustenhoven J, Feng S, Hurley D, Oldfield RL, Bergin PS, Mee EW, Faull RLM, Dragunow M. A role for human brain pericytes in neuroinflammation. J Neuroinflammation 2014; 11:104. [PMID: 24920309 PMCID: PMC4105169 DOI: 10.1186/1742-2094-11-104] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/19/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Brain inflammation plays a key role in neurological disease. Although much research has been conducted investigating inflammatory events in animal models, potential differences in human brain versus rodent models makes it imperative that we also study these phenomena in human cells and tissue. METHODS Primary human brain cell cultures were generated from biopsy tissue of patients undergoing surgery for drug-resistant epilepsy. Cells were treated with pro-inflammatory compounds IFNγ, TNFα, IL-1β, and LPS, and chemokines IP-10 and MCP-1 were measured by immunocytochemistry, western blot, and qRT-PCR. Microarray analysis was also performed on late passage cultures treated with vehicle or IFNγ and IL-1β. RESULTS Early passage human brain cell cultures were a mixture of microglia, astrocytes, fibroblasts and pericytes. Later passage cultures contained proliferating fibroblasts and pericytes only. Under basal culture conditions all cell types showed cytoplasmic NFκB indicating that they were in a non-activated state. Expression of IP-10 and MCP-1 were significantly increased in response to pro-inflammatory stimuli. The two chemokines were expressed in mixed cultures as well as cultures of fibroblasts and pericytes only. The expression of IP-10 and MCP-1 were regulated at the mRNA and protein level, and both were secreted into cell culture media. NFκB nuclear translocation was also detected in response to pro-inflammatory cues (except IFNγ) in all cell types. Microarray analysis of brain pericytes also revealed widespread changes in gene expression in response to the combination of IFNγ and IL-1β treatment including interleukins, chemokines, cellular adhesion molecules and much more. CONCLUSIONS Adult human brain cells are sensitive to cytokine challenge. As expected 'classical' brain immune cells, such as microglia and astrocytes, responded to cytokine challenge but of even more interest, brain pericytes also responded to such challenge with a rich repertoire of gene expression. Immune activation of brain pericytes may play an important role in communicating inflammatory signals to and within the brain interior and may also be involved in blood brain barrier (BBB) disruption . Targeting brain pericytes, as well as microglia and astrocytes, may provide novel opportunities for reducing brain inflammation and maintaining BBB function and brain homeostasis in human brain disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Mike Dragunow
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, 85 Park Road, Auckland 1023, New Zealand.
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Purroy F, Jiménez Caballero PE, Gorospe A, Torres MJ, Alvarez-Sabin J, Martínez-Sánchez P, Cánovas D, Freijo M, Egido JA, Ramírez-Moreno JM, Alonso-Arias A, Rodríguez-Campello A, Casado-Naranjo I, Martí-Fàbregas J, Silva Y, Cardona P, Morales A, García-Pastor A, Arenillas JF, Segura T, Jiménez C, Masjuán J. How predictors and patterns of stroke recurrence after a TIA differ during the first year of follow-up. J Neurol 2014; 261:1614-21. [PMID: 24912470 DOI: 10.1007/s00415-014-7390-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/24/2014] [Accepted: 05/26/2014] [Indexed: 01/31/2023]
Abstract
The highest risk of subsequent stroke after a TIA occurs within the first week after the index event. However, the risk of stroke recurrence (SR) remains high during the first year of follow-up. We studied the temporal pattern and predictors of SR (at 7 days and from 7 days to 1-year follow-up). Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We determined the short-term (at 7 days) and long-term (from 8 days to 1 year) risk of SR. Patients who underwent short-term recurrence and long-term recurrence were compared with regard to clinical findings, vascular territories, and etiology. Enough information (clinical variables and extracranial vascular imaging) was assessed in 1,137 (90.6 %) patients. The 7-day stroke risk was 2.6 %. 32 (3.0 %) patients had an SR after 7-day follow-up. Multiple TIA (HR 3.50, 1.67-7.35, p = 0.001) and large artery atherosclerosis (HR 2.51, 1.17-5.37, p = 0.018) were independent predictors of early SR, whereas previous stroke (HR 1.40, 1.03-1.92, p = 0.034) and coronary heart disease (2.65, 1.28-5.50, p = 0.009) were independent predictors of late SR. Notoriously, 80 % of SR happened in the same territory of the index TIA at 7-day follow-up, whereas only 38 % during the long-term follow-up (p < 0.001). Different predictors of SR were identified throughout the follow-up period. Moreover, the ischemic mechanism differed in early and late stroke recurrences.
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Affiliation(s)
- F Purroy
- Stroke Unit, Department of Neurology, IRBLLEIDA Research Institute, Hospital Universitari Arnau de Vilanova de Lleida, Universitat de Lleida, Avda Rovira Roure, 80, 25198, Lleida, Spain,
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Prevalence of Fabry Disease in Stroke Patients—A Systematic Review and Meta-analysis. J Stroke Cerebrovasc Dis 2014; 23:985-92. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/06/2013] [Accepted: 08/14/2013] [Indexed: 01/15/2023] Open
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Fernández LB, Campo DL, Santos MR, Prieto MP, Lahoz CH, Puerta SC. Yield of Holter and echocardiography in the screening of TIA. Int J Cardiol 2014; 172:483-5. [PMID: 24529825 DOI: 10.1016/j.ijcard.2014.01.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/07/2014] [Indexed: 01/04/2023]
Affiliation(s)
| | | | - María Rico Santos
- Hospital Universitario Central de Asturias, Neurology Department, Spain
| | - Marta Para Prieto
- Hospital Universitario Central de Asturias, Neurology Department, Spain
| | - Carlos H Lahoz
- Hospital Universitario Central de Asturias, Neurology Department, Spain
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Secades-González S, Martín-Fernández M, de la Hera-Galarza JM, Calleja-Puerta S. Atrial fibrillation in cryptogenic stroke: new tools needed for diagnosis? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2014; 67:160-161. [PMID: 24795137 DOI: 10.1016/j.rec.2013.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 10/08/2013] [Indexed: 06/03/2023]
Affiliation(s)
- Sandra Secades-González
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
| | - María Martín-Fernández
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | | | - Sergio Calleja-Puerta
- Servicio de Neurología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Secades-González S, Martín-Fernández M, de la Hera-Galarza JM, Calleja–Puerta S. Fibrilación auricular en el ictus criptogénico: ¿son necesarias nuevas herramientas para su diagnóstico? Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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40
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Amlie-Lefond C, Gill JC. Approach to acute ischemic stroke in childhood. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:276. [PMID: 24390791 DOI: 10.1007/s11936-013-0276-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Acute ischemic stroke in childhood is a medical emergency. Prompt recognition and intervention is necessary to rescue potentially viable brain tissue, prevent complications, and minimize the risk of recurrent stroke. Conditions that could result in recurrent stroke such as cardiac thrombus or cervical artery dissection need to be identified and treated promptly. Although the care of childhood stroke is based largely on extrapolation from adults, an organized approach to the care of these children is critical to optimize outcome.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, MB 7.462, Seattle, WA, 98105, USA,
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41
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Flemming KD. Diagnosis of Stroke Mechanisms and Secondary Prevention. Stroke 2013. [DOI: 10.1002/9781118560730.ch4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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42
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Arboix A, Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev 2013; 8:54-67. [PMID: 22845816 PMCID: PMC3394108 DOI: 10.2174/157340312801215791] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/02/2012] [Accepted: 05/03/2012] [Indexed: 01/15/2023] Open
Abstract
Cardioembolic cerebral infarction (CI) is the most severe subtype of ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific cardiac disorders and prognosis of CI. CI accounts for 14-30% of ischemic strokes; patients with CI are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy and mitral rheumatic stenosis. Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic infarction. Mitral annular calcification can be a marker of complex aortic atheroma in stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhythmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. Dabigatran has been shown to be non-inferior to warfarin in the prevention of stroke or systemic embolism. All significant structural defects, such as atrial septal defects, vegetations on valve or severe aortic disease should be treated. Aspirin is recommended in stroke patients with a patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.
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Affiliation(s)
- Adria Arboix
- Cerebrovascular Division, Department of Neurology, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Spain.
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43
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Secades S, Martín M, Corros C, Rodríguez M, García-Campos A, de la Hera Galarza J, Lambert J. Rendimiento diagnóstico del estudio ecocardiográfico en el accidente cerebrovascular: ¿debemos mejorar la selección de los pacientes? Neurologia 2013; 28:15-8. [DOI: 10.1016/j.nrl.2012.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 02/14/2012] [Accepted: 03/01/2012] [Indexed: 10/28/2022] Open
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Diagnostic yield of echocardiography in stroke: Should we improve patient selection? NEUROLOGÍA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.nrleng.2012.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Faber T, Rippy A, Hyslop WB, Hinderliter A, Sen S. Cardiovascular MRI in Detection and Measurement of Aortic Atheroma in Stroke/TIA patients. ACTA ACUST UNITED AC 2013; 1:139. [PMID: 24851233 PMCID: PMC4025943 DOI: 10.4172/2329-6895.1000139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Aortic Atheroma (AoA) is an independent risk factor for new and recurrent stroke. AoA ulceration and mobility are associated with an increased risk for brain embolism. Transesophageal echocardiography (TEE) is the gold standard for detection and measurement of AoA in stroke/TIA patients. Cardiovascular MRI (cMRI) could be an alternative, non-invasive imaging modality for stroke/TIA patients. The objective of this study was to assess the accuracy and correlation of AoA detected and measured by cMRI versus TEE in patients with recent stroke/TIA. Methods and results Twenty-two stroke/TIA patients undergoing TEE as a part of their stroke workup consented to a protocol-mandated cMRI performed on a 1.5 T magnet. The protocol included an axial non-breathhold EKG-gated dual-echo spin echo MRI of the thoracic aorta (TR/TE1/TE2=900/29/69) and a contrast-enhanced breathhold 3D gradient-echo image of the thorax (flip/TR/TE=12/4.0/1.71). Maximum plaque thickness, ulceration (≥ 2 mm) and mobility of AoA were assessed in the proximal (ascending and proximal arch) and distal (distal arch and descending) segments of thoracic aorta by a cardiologist to interpret the TEE and a radiologist to interpret the cMRI. There was good correlation between cMRI and TEE in measurement of plaque thickness in the proximal segments (R=0.73, p<0.0001) and the distal segments (R=0.81, p<0.0001) of the aortic arch (AA). cMRI had a high degree of accuracy in detecting measurable AoA (≥ 1 mm) in the proximal segments (sensitivity 90%, specificity 100%), as well as the distal segments (sensitivity 67%, specificity 100%). cMRI also had a high degree of accuracy in detecting significant AoA (≥ 4 mm) in proximal segments (sensitivity 71%, specificity 93%), as well as distal segments (sensitivity 71%, specificity 100%). Conclusion The study showed a high degree of accuracy and correlation of AoA detected and measured by cMRI as compared to TEE in patients with recent stroke/TIA. This technique has limitations in detection of AoA ulceration, and protocols assessing AoA mobility need to be developed.
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Affiliation(s)
- Theodore Faber
- University of South Carolina School of Medicine, Department of Neurology, Columbia, South Carolina, USA
| | - Ashley Rippy
- University of South Carolina School of Medicine, Department of Neurology, Columbia, South Carolina, USA
| | - W Brian Hyslop
- University of North Carolina School of Medicine, Department of Radiology and Cardiology, Chapel Hill, North Carolina, USA
| | - Alan Hinderliter
- University of North Carolina School of Medicine, Department of Radiology and Cardiology, Chapel Hill, North Carolina, USA
| | - Souvik Sen
- University of South Carolina School of Medicine, Department of Neurology, Columbia, South Carolina, USA
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Bugnicourt JM, Flament M, Guillaumont MP, Chillon JM, Leclercq C, Canaple S, Lamy C, Godefroy O. Predictors of newly diagnosed atrial fibrillation in cryptogenic stroke: a cohort study. Eur J Neurol 2012; 20:1352-9. [DOI: 10.1111/ene.12017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 09/06/2012] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - M.-P. Guillaumont
- Department of Cardiology; Amiens University Hospital; Amiens; France
| | | | | | - S. Canaple
- Department of Neurology; Amiens University Hospital; Amiens; France
| | - C. Lamy
- Department of Neurology; Amiens University Hospital; Amiens; France
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Affiliation(s)
- Gustavo Saposnik
- From the Stroke Outcomes Research Unit, Stroke Outcomes Research Canada (SORCan), Division of Neurology, Department of Medicine, St Michael’s Hospital, University of Toronto, Toronto, Canada; the Institute for Clinical Evaluative Sciences & Li Ka Shing Knowledge Institute, Toronto, Canada; and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Rizos T, Güntner J, Jenetzky E, Marquardt L, Reichardt C, Becker R, Reinhardt R, Hepp T, Kirchhof P, Aleynichenko E, Ringleb P, Hacke W, Veltkamp R. Continuous Stroke Unit Electrocardiographic Monitoring Versus 24-Hour Holter Electrocardiography for Detection of Paroxysmal Atrial Fibrillation After Stroke. Stroke 2012; 43:2689-94. [DOI: 10.1161/strokeaha.112.654954] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timolaos Rizos
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Janina Güntner
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Ekkehart Jenetzky
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Lars Marquardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Christine Reichardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Rüdiger Becker
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Roland Reinhardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Thomas Hepp
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Paulus Kirchhof
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Elena Aleynichenko
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Peter Ringleb
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Werner Hacke
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Roland Veltkamp
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
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Kallmünzer B, Breuer L, Hering C, Raaz-Schrauder D, Kollmar R, Huttner HB, Schwab S, Köhrmann M. A Structured Reading Algorithm Improves Telemetric Detection of Atrial Fibrillation After Acute Ischemic Stroke. Stroke 2012; 43:994-9. [DOI: 10.1161/strokeaha.111.642199] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bernd Kallmünzer
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Lorenz Breuer
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Christiane Hering
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Dorette Raaz-Schrauder
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Rainer Kollmar
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Hagen B. Huttner
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Stefan Schwab
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Martin Köhrmann
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
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Ustrell X, Pellisé A. Cardiac workup of ischemic stroke. Curr Cardiol Rev 2011; 6:175-83. [PMID: 21804776 PMCID: PMC2994109 DOI: 10.2174/157340310791658721] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 12/31/2022] Open
Abstract
Stroke is the leading cause of disability in developed countries and the third cause of mortality. Up to 15-30% of ischemic strokes are caused by cardiac sources of emboli being associated with poor prognosis and high index of fatal recurrence. In order to establish an adequate preventive strategy it is crucial to identify the cause of the embolism. After a complete diagnostic workup up to 30% of strokes remain with an undetermined cause, and most of them are attributed to an embolic mechanism suggesting a cardiac origin.There is no consensus in the extent and optimal approach of cardiac workup of ischemic stroke. Clinical features along with brain imaging and the study of the cerebral vessels with ultrasonography or MRI/CT based angiography can identify other causes or lead to think about a possible cardioembolic origin.Atrial fibrillation is the most common cause of cardioembolic stroke. Identification of occult atrial fibrillation is essential. Baseline ECG, serial ECG('s), cardiac monitoring during the first 48 hours, and Holter monitoring have detection rates varying from 4 to 8% each separately. Extended cardiac monitoring with event loop recorders has shown higher rates of detection of paroxysmal atrial fibrillation.Cardiac imaging with echocardiography is necessary to identify structural sources of emboli. There is insufficient data to determine which is the optimal approach. Transthoracic echocardiography has an acceptable diagnostic yield in patients with heart disease but transesophageal echocardiography has a higher diagnostic yield and is necessary if no cardiac sources have been identified in patients with cryptogenic stroke with embolic mechanism.
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Affiliation(s)
- Xavier Ustrell
- Stroke Unit, Neurology Department, Joan XXIII University Hospital, Tarragona, Catalonia, Spain
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