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Boyko M, Chaturvedi S, Beland B, Najm M, Demchuk AM, Menon BK, Almekhlafi M. Prevalence of high-risk aortic arch atherosclerosis features on computed tomography angiography in embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2023; 32:107374. [PMID: 37813086 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107374] [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: 03/22/2023] [Revised: 07/17/2023] [Accepted: 09/14/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Embolic stroke of undetermined source (ESUS) comprises a heterogenous group. There is a need to further identify etiologies within this group to guide management strategies. We examined the prevalence of aortic arch atherosclerosis (AAA) on CT angiography (CTA) in patients with embolic stroke of undetermined source (ESUS) to characterize high-risk plaque features. METHODS All patients from two prospective multicenter acute ischemic stroke studies (INTERRSeCT and PRove-IT) were included if the CTA adequately imaged the proximal aortic arch and the stroke etiology was recorded. Three readers blinded to stroke etiology analyzed the following AAA plaque features on baseline CTA at the time of stroke: 1) thickness in millimetres (mm); 2) morphology (none, smooth, ulcerated, or protruding); 3) location within the aortic arch (proximal, transverse, or distal); and 4) calcification (none, single small, multiple small, single large, or diffuse extensive). RESULTS We included 1063 patients, of which 293 (27.6%) had ESUS (mean age 67.5 years; 46.4% men; median NIHSS 12; 80.6% large vessel occlusion). Mean AAA thickness was significantly larger in ESUS patients (3.8 mm) compared to non-ESUS patients (3.0 mm; p<0.0001) and to a subgroup of patients with large artery atherosclerosis (2.9 mm; p=0.003). ESUS patients had a significantly higher proportion of ulcerated or protruding plaques (17.4% vs 10.3%; risk ratio 1.7, 95% C.I. 1.2-2.4, p=0.002). The location of AAA in the ESUS group was the ascending aorta in 37.9%, transverse arch in 42.3%, and descending aorta in 84.6%. Although AAA was mostly located in the distal aortic arch, ulcerated or protruding plaques were least common in the distal arch (p=0.002). There was no difference between ESUS and non-ESUS patients in plaque location (p=0.23) or calcification grade (p=0.092). CONCLUSION ESUS patients in our study had thicker AAA and a higher prevalence of ulcerated or protruding plaques located more proximally within the aortic arch. High-risk plaque features may suggest a causal role of AAA in the ESUS population with visible intracranial occlusions.
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Affiliation(s)
- Matthew Boyko
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada.
| | - Surbhi Chaturvedi
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada
| | - Benjamin Beland
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada
| | - Mohamed Najm
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada
| | - Mohammed Almekhlafi
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Canada
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [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: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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53
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Luo N, Shang ZY, Yang BQ, Ntaios G, Chen HS. Age-dependent sex differences in non-stenotic intracranial plaque of embolic stroke of undetermined source. Sci Rep 2023; 13:20652. [PMID: 38001235 PMCID: PMC10673951 DOI: 10.1038/s41598-023-48091-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/22/2023] [Indexed: 11/26/2023] Open
Abstract
Age and sex have effect on atherosclerosis. This study aimed to investigate their effect on non-stenotic intracranial atherosclerotic plaque (NIAP) in embolic stroke of undetermined source (ESUS) using high-resolution magnetic resonance imaging (HR-MRI). We retrospectively recruited consecutive ESUS patients who underwent intracranial HR-MRI to assess the plaque characteristics (remodeling index [RI], plaque burden [PB], fibrous cap [FC], discontinuity of plaque surface [DPS], intraplaque hemorrhage [IPH] and complicated plaque [CP]). We divided patients into three groups (< 60 years, 60-74 years, ≥ 75 years). 155 patients with ipsilateral NIAP were found from 243 ESUS patients, with 106 men (68.39%) and 49 women (31.61%). In total population or age group under 60 years, there were no significant differences in plaque characteristics between men and women (all p > 0.05). In age group of 60-74 years, men were associated with higher PB (66.27 ± 9.17% vs 60.91 ± 8.86%, p = 0.017) and RI (1.174 vs 1.156, p = 0.019), higher prevalence of DPS (82.50% vs 60.00%, p = 0.036) and complicated plaque (85.00% vs 63.33%, p = 0.036). For subjects ≥ 75 years old, PB were significantly higher in twomen vs men (68.85 ± 6.14% vs 62.62 ± 7.36%, p = 0.040). In addition, the probability for PBupper (≥ median PB), RIupper (≥ median RI) and vulnerable plaque increased as age increased, and its predictive power for index ESUS was higher in men than women. This study identified age-dependent sex differences in NIAP characteristics of ESUS patients, which will help us clarify their etiology.
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Affiliation(s)
- Na Luo
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China
| | - Zi-Yang Shang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China
| | - Ben-Qiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China.
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Berdalin AB, Namestnikova DD, Cherkashova EA, Golovin DA, Gubskiy IL, Lelyuk VG. Arterial Hypertension and Its Consequences Are the Main Predictors of Embolic Stroke of Undetermined Source. DISEASE MARKERS 2023; 2023:3469755. [PMID: 38025665 PMCID: PMC10667056 DOI: 10.1155/2023/3469755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/09/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023]
Abstract
Methods We performed a hospital-based prospective cohort study with 1,317 enrolled participants. We compared patients and healthy volunteers according to the main demographic, anthropometric parameters, stroke risk factors, comorbidities, and data of clinical and instrumental examination. In order to balance the study and the control groups for age and sex, the propensity score matching was performed. In order to generate the overall predictive model, a multivariate analysis was performed using the binary logistic regression method. Results The following predictors of ESUS were identified in current study: arterial hypertension (AH); increased heart rate and pulmonary arterial systolic pressure (PASP); the presence of conduction disturbance; the enlargement of left, right atrium, and left ventricle end-systolic length; increased intima-media thickness (IMT) in right and left common carotid artery (CCA); lowered Montreal Cognitive Assessment (MoСA) cognitive scale score; the presence of subcortical microbleeds; central brain atrophy; the larger size of third ventricle; and the higher medial temporal lobe atrophy (MTA) score. The following risk factors were included in the final predictive model: the presence of AH (p < 0.0005; OR = 12.98 (95% CI: 4.53-37.21)) and PASP (p=0.018; OR = 1.13 (95% CI: 1.02-1.25)) and male sex (p=0.046; OR = 2.771 (95% CI: 1.017-7.555)). The Nagelkerke's pseudo-R-squared value was 0.404 and the significance of the Hosmer-Lemeshow test was 0.733, which indicate the goodness of the final logistic regression model. Conclusions We propose that AH and its consequences are the main predictors of ESUS. The results of this study emphasize the importance of AH control for primary and secondary prevention of ESUS.
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Affiliation(s)
- Alexander B. Berdalin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Daria D. Namestnikova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Elvira A. Cherkashova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Denis A. Golovin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Ilya L. Gubskiy
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Vladimir G. Lelyuk
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
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Simaan N, Shalabi F, Schwartzmann Y, Jubeh T, Parag Y, Honig A, Metanis I, Joubran H, Magadlla J, Gomori JM, Cohen JE, Leker RR. Impact of high-resolution intracranial vessel wall magnetic resonance imaging on diagnosis in patients with embolic stroke of unknown source. J Neurol Sci 2023; 454:120863. [PMID: 37931444 DOI: 10.1016/j.jns.2023.120863] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/05/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The mechanism responsible for stroke in patients with embolic stroke of unknown source (ESUS) often remains unknown despite extensive investigations. We aimed to test whether high-resolution intracranial vessel wall MR imaging (icVWI) can add to the diagnostic yield in these patients. PATIENTS AND METHODS Patients with ESUS were prospectively included into an ongoing registry. Patients that underwent icVWI as part of their diagnostic workup were compared to those that did not have an icVWI. Patients with icVWI positive for intracranial vulnerable plaques were than compared to those without evidence of plaque vulnerability on VWI. RESULTS A total of 179 patients with ESUS were included and 48 of them (27%) underwent icVWI. Patients that had an icVWI scan were significantly younger, had lower rates of ischemic heart disease and prior disability as well as significantly lower stroke severity. On regression analysis the only factor that remained associated with not obtaining an icVWI scan was increasing age (Odds ratio [OR] 0.97/year, 95% confidence intervals [CI] 0.95-0.97). Among patients that had an icVWI scan 28 (58%) had evidence of plaque enhancement on VWI in the same distribution of the stroke and the remaining 20 studies were negative. The relative proportion of stroke presumed to be secondary to intracranial non-stenotic atheromatous disease increased from 15% in patients without icVWI scans to 58% among patients with icVWI scans (p = 0.001). On regression analysis the only factor that was associated with vulnerable plaques on icVWI was smoking (OR 11.05 95% CI 1.88-65.17). CONCLUSIONS icVWI can add significant information relevant to stroke pathogenesis and treatment in patients with ESUS and a negative initial exhaustive diagnostic workup.
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Affiliation(s)
- Naaem Simaan
- Departments of Neurology, Ziv Medical Center, Zefat, Israel
| | - Fatma Shalabi
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoel Schwartzmann
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tamer Jubeh
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Parag
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asaf Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Issa Metanis
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hamza Joubran
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jad Magadlla
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - John M Gomori
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jose E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Jeon KH, Jang JH, Kang S, Lee HS, Lee MS, Son JM, Jo YY, Park TJ, Oh IY, Kwon JM, Lee JH. Identifying Atrial Fibrillation With Sinus Rhythm Electrocardiogram in Embolic Stroke of Undetermined Source: A Validation Study With Insertable Cardiac Monitors. Korean Circ J 2023; 53:758-771. [PMID: 37973386 PMCID: PMC10654409 DOI: 10.4070/kcj.2023.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Paroxysmal atrial fibrillation (AF) is a major potential cause of embolic stroke of undetermined source (ESUS). However, identifying AF remains challenging because it occurs sporadically. Deep learning could be used to identify hidden AF based on the sinus rhythm (SR) electrocardiogram (ECG). We combined known AF risk factors and developed a deep learning algorithm (DLA) for predicting AF to optimize diagnostic performance in ESUS patients. METHODS A DLA was developed to identify AF using SR 12-lead ECG with the database consisting of AF patients and non-AF patients. The accuracy of the DLA was validated in 221 ESUS patients who underwent insertable cardiac monitor (ICM) insertion to identify AF. RESULTS A total of 44,085 ECGs from 12,666 patient were used for developing the DLA. The internal validation of the DLA revealed 0.862 (95% confidence interval, 0.850-0.873) area under the curve (AUC) in the receiver operating curve analysis. In external validation data from 221 ESUS patients, the diagnostic accuracy of DLA and AUC were 0.811 and 0.827, respectively, and DLA outperformed conventional predictive models, including CHARGE-AF, C2HEST, and HATCH. The combined model, comprising atrial ectopic burden, left atrial diameter and the DLA, showed excellent performance in AF prediction with AUC of 0.906. CONCLUSIONS The DLA accurately identified paroxysmal AF using 12-lead SR ECG in patients with ESUS and outperformed the conventional models. The DLA model along with the traditional AF risk factors could be a useful tool to identify paroxysmal AF in ESUS patients.
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Affiliation(s)
- Ki-Hyun Jeon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong-Hwan Jang
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Sora Kang
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Hak Seung Lee
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Min Sung Lee
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Jeong Min Son
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Yong-Yeon Jo
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Tae Jun Park
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Il-Young Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joon-Myoung Kwon
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
- Department of Critical Care and Emergency Medicine, Incheon Sejong Hospital, Incheon, Korea.
| | - Ji Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Lee HJ, Schwamm LH, Sansing L, Kamel H, de Havenon A, Turner AC, Sheth KN, Krishnaswamy S, Brandt C, Zhao H, Krumholz H, Sharma R. StrokeClassifier: Ischemic Stroke Etiology Classification by Ensemble Consensus Modeling Using Electronic Health Records. RESEARCH SQUARE 2023:rs.3.rs-3367169. [PMID: 37961532 PMCID: PMC10635373 DOI: 10.21203/rs.3.rs-3367169/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Determining the etiology of an acute ischemic stroke (AIS) is fundamental to secondary stroke prevention efforts but can be diagnostically challenging. We trained and validated an automated classification machine intelligence tool, StrokeClassifier, using electronic health record (EHR) text data from 2,039 non-cryptogenic AIS patients at 2 academic hospitals to predict the 4-level outcome of stroke etiology determined by agreement of at least 2 board-certified vascular neurologists' review of the stroke hospitalization EHR. StrokeClassifier is an ensemble consensus meta-model of 9 machine learning classifiers applied to features extracted from discharge summary texts by natural language processing. StrokeClassifier was externally validated in 406 discharge summaries from the MIMIC-III dataset reviewed by a vascular neurologist to ascertain stroke etiology. Compared with stroke etiologies adjudicated by vascular neurologists, StrokeClassifier achieved the mean cross-validated accuracy of 0.74 (±0.01) and weighted F1 of 0.74 (±0.01). In the MIMIC-III cohort, the accuracy and weighted F1 of StrokeClassifier were 0.70 and 0.71, respectively. SHapley Additive exPlanation analysis elucidated that the top 5 features contributing to stroke etiology prediction were atrial fibrillation, age, middle cerebral artery occlusion, internal carotid artery occlusion, and frontal stroke location. We then designed a certainty heuristic to deem a StrokeClassifier diagnosis as confidently non-cryptogenic by the degree of consensus among the 9 classifiers, and applied it to 788 cryptogenic patients. This reduced the percentage of the cryptogenic strokes from 25.2% to 7.2% of all ischemic strokes. StrokeClassifier is a validated artificial intelligence tool that rivals the performance of vascular neurologists in classifying ischemic stroke etiology for individual patients. With further training, StrokeClassifier may have downstream applications including its use as a clinical decision support system.
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Affiliation(s)
- Ho-Joon Lee
- Department of Genetics and Yale Center for Genome Analysis, Yale School of Medicine, New Haven, CT
| | - Lee H. Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School Boston, MA
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York City, NY
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Ashby C. Turner
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School Boston, MA
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Smita Krishnaswamy
- Departments of Genetics and Computer Science, Yale School of Medicine, New Haven, CT
| | - Cynthia Brandt
- Department of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT
| | - Hongyu Zhao
- Departments of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Harlan Krumholz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT
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Ingwersen T, Olma MC, Schlemm E, Mayer C, Cheng B, Tütüncü S, Kirchhof P, Veltkamp R, Röther J, Laufs U, Nabavi DG, Ntaios G, Endres M, Haeusler KG, Thomalla G. Independent external validation of a stroke recurrence score in patients with embolic stroke of undetermined source. Neurol Res Pract 2023; 5:51. [PMID: 37794453 PMCID: PMC10552210 DOI: 10.1186/s42466-023-00279-z] [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: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. A stroke recurrence score has been shown to predict the risk of recurrent stroke in patients with ESUS based on a combination of clinical and imaging features. This study aimed to externally validate the performance of the ESUS recurrence score using data from a randomized controlled trial. METHODS The validation dataset consisted of eligible stroke patients with available magnetic resonance imaging (MRI) data enrolled in the PreDAFIS sub-study of the MonDAFIS study. The score was calculated using three variables: age (1 point per decade after 35 years), presence of white matter hyperintensities (2 points), and multiterritorial ischaemic stroke (3 points). Patients were assigned to risk groups as described in the original publication. The model was evaluated using standard discrimination and calibration methods. RESULTS Of the 1054 patients, 241 (22.9%) were classified as ESUS. Owing to insufficient MRI quality, three patients were excluded, leaving 238 patients (median age 65.5 years [IQR 20.75], 39% female) for analysis. Of these, 30 (13%) patients experienced recurrent ischaemic stroke or transient ischemic attack (TIA) during a follow-up period of 383 patient-years, corresponding to an incidence rate of 7.8 per 100 patient-years (95% CI 5.3-11.2). Patients with an ESUS recurrence score value of ≥ 7 had a 2.46 (hazard ratio (HR), 95% CI 1.02-5.93) times higher risk of stroke recurrence than patients with a score of 0-4. The cumulative probability of stroke recurrence in the low-(0-4), intermediate-(5-6), and high-risk group (≥ 7) was 9%, 13%, and 23%, respectively (log-rank test, χ2 = 4.2, p = 0.1). CONCLUSIONS This external validation of a published scoring system supports a threshold of ≥ 7 for identifying ESUS patients at high-risk of stroke recurrence. However, further adjustments may be required to improve the model's performance in independent cohorts. The use of risk scores may be helpful in guiding extended diagnostics and further trials on secondary prevention in patients with ESUS. TRIAL REGISTRATION Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267 .
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Affiliation(s)
- Thies Ingwersen
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany.
| | - Manuel C Olma
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, BIH, Berlin, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Carola Mayer
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Hamburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Joachim Röther
- Department of Neurology, Asklepios Hospital Altona, Hamburg, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Hamburg, Germany
| | - Darius G Nabavi
- Department of Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, BIH, Berlin, Germany
- Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Hamburg, Germany
- Partner Site Berlin, German Centre for Neurodegenerative Diseases (DZNE), Berlin, Germany
- Excellence Cluster NeuroCure, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
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Chukwudelunzu FE, Demaerschalk B, Fugoso L, Amadi E, Dexter D, Gullicksrud A, Hagen C. In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center. Mayo Clin Proc Innov Qual Outcomes 2023; 7:402-410. [PMID: 37719772 PMCID: PMC10504462 DOI: 10.1016/j.mayocpiqo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Objective To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center. Patients and Methods Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05. Results The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group. Conclusions The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.
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Affiliation(s)
| | - Bart Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Sciences, Phoenix, AZ
| | - Leonardo Fugoso
- Department of Neurology, Mayo Clinic Health System Eau Claire, WI
| | - Emeka Amadi
- Department of Medicine, Section of Hospital Medicine, Mayo Clinic Health System Eau Claire, WI
| | - Donn Dexter
- Department of Neurology, Mayo Clinic Health System Eau Claire, WI
| | | | - Clinton Hagen
- Program for Hypoplastic Left Heart Syndrome, Mayo Clinic, Rochester, MN
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Wolfe J, Kamen S, Koneru M, Vigilante N, Rana A, Penckofer M, Hester T, Oak S, Patel K, Thau L, Sprankle K, Kim K, Thomas K, Zhang L, Siegler JE. Subcortical infarcts in patients with nonstenotic cervical atherosclerotic disease. J Stroke Cerebrovasc Dis 2023; 32:107264. [PMID: 37586218 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107264] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Prior studies have elucidated a relationship between nonstenotic plaque in patients with cryptogenic embolic infarcts with a largely cortical topology, however, it is unclear if nonstenotic cervical internal carotid artery (ICA) plaque is relevant in subcortical cryptogenic infarct patterns. METHODS A nested cohort of consecutive patients with anterior, unilateral, and subcortical infarcts without an identifiable embolic source were identified from a prospective stroke registry (September 2019 - June 2021). Patients with extracranial stenosis >50% or cardiac sources of embolism were excluded. Patients with computed tomography angiography were included and comparisons were made according to the infarct pattern being lacunar versus non-lacunar. Prevalence estimates for cervical internal carotid artery (ICA) plaque presence were estimated with 95% confidence intervals (CI), and differences in plaque thickness and features were compared between sides. RESULTS Of the 1684 who were screened, 141 met inclusion criteria (n=80 due to small vessel disease, n=61 cryptogenic). The median age was 66y (interquartile range, IQR 58-73) and the National Institutes of Health Stroke Scale score was 3 (IQR 1-5). There was a higher probability of finding excess plaque ipsilateral to the stroke (41.1%, 95% CI 33.3-49.3%) than finding excess contralateral plaque (29.1%, 95% CI 22.2-37.1%; p=0.03), but this was driven by patients with non-lacunar infarcts (excess ipsilateral vs. contralateral plaque frequency of 49.2% vs. 14.8%, p<0.001) rather than lacunar infarcts (35.0% vs. 40.0%, p=0.51). CONCLUSIONS The probability of finding ipsilateral, nonstenotic carotid plaque in patients with subcortical cryptogenic strokes exceeds the probability of contralateral plaque and is driven by larger subcortical infarcts, classically defined as being cryptogenic. Approximately 1 in 3 unilateral anterior subcortical infarcts may be due to nonstenotic ICA plaque.
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Affiliation(s)
- Jared Wolfe
- Cooper Medical School of Rowan University, Camden, NJ, United States.
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | | | - Ankit Rana
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Taryn Hester
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Kenyon Sprankle
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Kelly Kim
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Kavya Thomas
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Linda Zhang
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ, United States; Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
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Patel U, Dengri C, Pielykh D, Baskar A, Tar MI, Patel G, Patel N, Kothari N, Selvam SA, Sharma AM, Venkata VS, Shah S, Mahmood SN, Peela AS. Secondary Prevention of Cryptogenic Stroke and Outcomes Following Surgical Patent Foramen Ovale Closure Plus Medical Therapy vs. Medical Therapy Alone: An Umbrella Meta-Analysis of Eight Meta-Analyses Covering Seventeen Countries. Cardiol Res 2023; 14:342-350. [PMID: 37936625 PMCID: PMC10627369 DOI: 10.14740/cr1526] [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: 06/19/2023] [Accepted: 08/09/2023] [Indexed: 11/09/2023] Open
Abstract
Background Cryptogenic stroke (CS) is an exclusion diagnosis that accounts for 10-40% of all ischemic strokes. Patent foramen ovale (PFO) is found in 66% of patients with CS, while having a prevalence of 25-30% in the general population. The primary aim was to evaluate the risk of recurrent stroke following surgical PFO closure plus medical therapy vs. medical therapy alone amongst CS, an embolic stroke of undetermined source (ESUS), or transient ischemic attack (TIA). The secondary aim was to evaluate new-onset non-valvular atrial fibrillation, mortality, and major bleeding. Methods We conducted an umbrella meta-analysis using PRISMA guidelines on English studies comparing surgical PFO closure plus medical therapy versus medical therapy alone for managing CS. We extracted data on interventions and outcomes and used random-effects models with generic inverse variance to calculate relative risks (RRs) with 95% confidence intervals for outcome calculations. Results A comprehensive search yielded 54,729 articles on CS and 65,001 on surgical PFO closure, with 1,591 studies focusing on PFO closure and medical therapy for secondary CS, ESUS, or TIA prevention. After excluding non-meta-analyses, 52 eligible meta-analyses were identified, and eight studies were selected for outcome evaluation, excluding non-English, non-human, and studies before January 2019 as of August 31, 2021. Among a total of 41,880 patients, 14,942 received PFO closure + medical therapy, while 26,938 patients received medical therapy alone. Our umbrella meta-analysis showed that PFO closure plus medical therapy had a 64% lower risk of recurrent strokes than medical therapy alone (pooled RR: 0.36). PFO closure plus medical therapy was associated with 4.94 times higher risk of atrial fibrillation. There was no difference in the risk of death or bleeding between both groups. Conclusion In patients with CS, PFO closure, in addition to medical therapy, reduces the risk of recurrence. More research is needed to assess the efficacy of early closure as well as specific risk profiles that would benefit from early intervention to reduce the burden of stroke.
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Affiliation(s)
- Urvish Patel
- Department of Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- These authors contributed equally to the article
| | - Chetna Dengri
- Department of Neurology, Cleveland Clinic Florida, Weston, FL 33331, USA
- These authors contributed equally to the article
| | - David Pielykh
- Odessa National Medical University, Valikhovskiy Lane 2, Odessa 65000, Ukraine
| | - Aakash Baskar
- K.A.P. Viswanatham Government Medical College, Musiri, Trichy, Tamilnadu 621006, India
| | - Muhammad Imtiaz Tar
- Touro University Nevada College of Osteopathic Medicine, Henderson, NV 89014, USA
| | | | - Neel Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Nishel Kothari
- Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Renu
- Department of Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh 282003, India
| | - Sri Abirami Selvam
- Department of Internal Medicine, St Mary Medical Center, Langhorne, PA 19047, USA
| | - Amit Munshi Sharma
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA 18510, USA
| | | | - Shamik Shah
- Department of Neurology, Stormont Vail Health, Topeka, KS, USA
| | - Syed Nazeer Mahmood
- Department of Medicine, Section of Pulmonary/Critical Care, MedStar Washington Hospital Center, Washington, DC 5333, USA
| | - Appala Suman Peela
- Department of Family Medicine, UNC Health Southeastern, Lumberton, NC 28358, USA
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Weyland CS, Mutke MA, Zimmermann-Miotk A, Schmitt N, Chen M, Schönenberger S, Möhlenbruch M, Bendszus M, Jesser J. Clinical outcome and outcome prediction of octogenarians with acute basilar artery occlusion and endovascular stroke treatment compared to younger patients. Front Neurol 2023; 14:1266105. [PMID: 37840915 PMCID: PMC10570514 DOI: 10.3389/fneur.2023.1266105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Background and aims Octogenarians are underrepresented in recently published studies that showed the benefit of endovascular stroke treatment (EST) for patients with acute basilar artery occlusion (BAO). We aimed to compare the clinical outcome of octogenarians with BAO and EST compared to younger patients (YPs) and identify independent outcome predictors. Methods This is a retrospective, single-center analysis of patients treated for BAO with EST from January 2013 until June 2021 in a tertiary stroke center. Octogenarians (80-89 years) were compared to YPs. A study endpoint was a favorable clinical outcome as per the modified Rankin Scale (mRS 0-3), 90 days after stroke onset. The study groups were compared using univariate analysis, and a multivariable logistic regression analysis was performed to define independent predictors for favorable and unfavorable (mRS 5-6) clinical outcomes. Results In this study cohort, 74/191 (38.7%) octogenarians had a higher pre-stroke mRS [median, interquartile range (IQR): 2, 1-3 octogenarians vs. 0, 0-1 YP, p < 0.001] and a comparable National Institutes of Health Stroke Scale (NIHSS) before EST (median, IQR: 21, 10-38 vs. 20, 8-35 in YP, p = 0.487). They showed a comparable rate of favorable outcome (mRS 0-3, 90 days, 23.0 vs. 25.6% in YP, p = 0.725), but were less often functionally independent (mRS 0-2: 10.8% in octogenarians vs. 23.0% in YP, p = 0.049). The rate of unfavorable clinical outcome was comparable (mRS 5-6, n = 40, 54.1% in octogenarians vs. n = 64, 54.7% in YP, p = 0.831). A baseline NIHSS was an independent predictor for clinical outcome in YPs [e.g., for unfavorable clinical outcome: odds ratio (OR) 1.061, confidence interval (CI) 1.027-1.098, p = 0.005] and for favorable clinical outcome in octogenarians. Pre-stroke mRS predicted favorable outcomes in octogenarians (OR 0.54, CI 0.30-0.90, p = 0.0291), while age predicted unfavorable outcomes in YPs (OR 1.045, CI 1.011-1.086, p = 0.0137). Conclusion Octogenarians with acute BAO eligible for EST are as likely to achieve a favorable outcome as YPs, and the rate of death or severe disability is comparable. The admission NIHSS is an independent predictor for favorable and unfavorable outcomes in YP and for favorable outcomes in octogenarians. In this study cohort, pre-stroke mRS predicted favorable outcomes in octogenarians while age predicted an unfavorable outcome in YPs.
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Affiliation(s)
- Charlotte Sabine Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
- Department of Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Matthias Anthony Mutke
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
- Department of Neuroradiology, University Hospital of Basel, Basel, Switzerland
| | - Amanda Zimmermann-Miotk
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
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Kang DW, Jung KH, Yang W, Kim HM, Kim Y, Chung M, Ha J, Punsalan MT, Lee EJ, Jeong HY, Kim JM, Ko SB, Lee SH. Presence of Embolic Source and Outcome in Central Retinal Artery Occlusion. Neurology 2023; 101:e1364-e1369. [PMID: 37400246 PMCID: PMC10558162 DOI: 10.1212/wnl.0000000000207445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/07/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVES The etiology of central retinal artery occlusion (CRAO) is unclear in approximately 50% of patients, suggesting pathomechanical heterogeneity; moreover, little is known about outcomes according to etiology. This study investigated whether the presence of an embolic source affects outcome in CRAO. METHODS CRAO patients within 7 days of symptom onset were retrospectively enrolled. Clinical parameters, including initial and 1-month visual acuity, CRAO subtype, and brain images, were reviewed. CRAO etiology was categorized as CRAO with or without an embolic source (CRAO-E+ and CRAO-E-). Visual improvement was defined as a decrease in logarithm of the minimum angle of resolution ≥0.3 at 1 month. RESULTS A total of 114 patients with CRAO were included. Visual improvement was noted in 40.4% of patients. Embolic sources were identified in 55.3% of patients, and visual improvement group rather than no improvement group was more commonly associated with the presence of an embolic source. In multivariable logistic regression analysis, CRAO-E+ independently predicted visual improvement (odds ratio 3.00, 95% CI 1.15-7.81, p = 0.025). DISCUSSION CRAO-E+ was found to be associated with a better outcome. CRAO-E+ may be more prone to recanalization than that CRAO-E-.
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Affiliation(s)
- Dong-Wan Kang
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Keun-Hwa Jung
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea.
| | - Wookjin Yang
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Hyeong Min Kim
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Youngjoon Kim
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Matthew Chung
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Jiyeon Ha
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Monique Therese Punsalan
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Eung-Joon Lee
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea.
| | - Han-Yeong Jeong
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Jeong-Min Kim
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Sang-Bae Ko
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Seung-Hoon Lee
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea.
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Louka AM, Nagraj S, Adamou AT, Perlepe K, Godefroy O, Bugnicourt J, Palaiodimos L, Ntaios G. Risk Stratification Tools to Guide a Personalized Approach for Cardiac Monitoring in Embolic Stroke of Undetermined Source. J Am Heart Assoc 2023; 12:e030479. [PMID: 37681521 PMCID: PMC10547268 DOI: 10.1161/jaha.123.030479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Current recommendations support a personalized sequential approach for cardiac rhythm monitoring to detect atrial fibrillation after embolic stroke of undetermined source. Several risk stratification scores have been proposed to predict the likelihood of atrial fibrillation after embolic stroke of undetermined source. This systematic review aimed to provide a comprehensive overview of the field by identifying risk scores proposed for this purpose, assessing their characteristics and the cohorts in which they were developed and validated, and scrutinizing their predictive performance. We identified 11 risk scores, of which 4 were externally validated. The most frequent variables included were echocardiographic markers and demographics. The areas under the curve ranged between 0.70 and 0.94. The 3 scores with the highest area under the curve were the Decryptoring (0.94 [95% CI, 0.88-1.00]), newly diagnosed atrial fibrillation (0.87 [95% CI, 0.79-0.94]), and AF-ESUS (Atrial Fibrillation in Embolic Stroke of Undetermined Source) (0.85 [95% CI, 0.80-0.87]), of which only the latter was externally validated. Risk stratification scores can guide a personalized approach for cardiac rhythm monitoring after embolic stroke of undetermined source.
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Affiliation(s)
- Anna Maria Louka
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Sanjana Nagraj
- Department of Internal MedicineJacobi Medical Center/Albert Einstein College of MedicineNew YorkNY
| | - Anastasia T. Adamou
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Kalliopi Perlepe
- Department of CardiologyOnassis Cardiac Surgery CenterAthensGreece
| | - Olivier Godefroy
- Department of NeurologyUniversity of Picardie Jules VerneAmiensFrance
| | | | - Leonidas Palaiodimos
- Department of Internal MedicineJacobi Medical Center/Albert Einstein College of MedicineNew YorkNY
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
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Liu Q, Dai Y, Li X, Wang X, Ntaios G, Chen H. MRI-based risk stratification for recurrent ischemic stroke in embolic stroke of undetermined source. Ann Clin Transl Neurol 2023; 10:1533-1543. [PMID: 37401382 PMCID: PMC10502623 DOI: 10.1002/acn3.51843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/26/2023] [Accepted: 06/17/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Leukoaraiosis and other brain MRI-assessed parameters were shown to be associated with recurrent stroke in this population. We aimed to develop an MRI-based predictive tool for risk stratification of ESUS patients. METHODS We retrospectively assessed consecutive patients who were diagnosed with ESUS and underwent brain MRI and performed a multivariable analysis with the outcome of recurrent stroke/TIA. Based on the coefficient of each covariate, we generated an integer-based point scoring system. The discrimination and calibration of the score were assessed using the area under the receiver operator characteristic curve, net reclassification improvement, integrated discrimination improvement, calibration curve, and decision curve analysis. Also, we compared the new score with a previously published score (ALM score). RESULTS Among 176 patients followed for an overall period of 902.3 patient-years (median of 74 months), there were 39 recurrent ischemic stroke/TIAs (4.32 per 100 patient-years). Fazekas score (HR: 1.26, 95% CI: 1.03-1.54), enlarged perivascular space (EPVS) (HR: 2.76, 95% CI: 1.12-6.17), NIHSS at admission (HR: 1.11, 95% CI: 1.02-1.18), and infarct subtypes (HR: 2.88, 95% CI: 1.34-6.17) were associated with recurrent stroke/TIA. Accordingly, a score (FENS score) was developed with AUC-ROC values of 0.863, 0.788, and 0.858 for 1, 3, and 5 years, respectively. These were significantly better than the AUC-ROC of ALM score (0.635, 0.695, and 0.705, respectively). The FENS score exhibited better calibration and discrimination ability than the ALM score (Hosmer-Lemeshow test χ2 : 4.402, p = 0.819). CONCLUSION The MRI-based FENS score can provide excellent predictive performance for recurrent stroke/TIA and may assist in risk stratification of ESUS patients.
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Affiliation(s)
- Quan‐Ying Liu
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Ying‐Jie Dai
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Xiao‐Qiu Li
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Xin‐Hong Wang
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Hui‐Sheng Chen
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
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George J, Sylaja PN, Sreedharan SE. Recurrence of Cryptogenic (ESUS) Strokes in the First Year: Predictors and Outcome-A South Indian Study. Ann Indian Acad Neurol 2023; 26:728-732. [PMID: 38022488 PMCID: PMC10666862 DOI: 10.4103/aian.aian_282_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/09/2023] [Accepted: 06/24/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Around 9-25% of ischemic strokes are embolic stroke of undetermined source (ESUS) with an annual recurrence risk of 4.5-5%. Regarding ESUS, studies from India are limited. Here, we studied the prevalence of cryptogenic ESUS among stroke subtypes, recurrence risk and outcome at 1 year, and their predictors. Materials and Methods We performed a single-center study of ambispective nature. Patients above 18 years of age with a diagnosis of cryptogenic (ESUS) strokes from January 1, 2017, to December 31, 2020 (4 years), with a 1-year follow-up were recruited in our study. All the patients underwent neuroimaging computerised tomography/magnetic resonance tomography (CT/MRI) with angiography, electrocardiogram (ECG), transthoracic echo (TTE), and rhythm monitoring. Functional outcome was measured using the modified Rankin scale with scores 0-2 taken as good outcome. Results We had 234 (11.21% of total ischemic strokes) subjects satisfying the criteria for ESUS over the study period with a mean age of 58.2 ± 12.8 years. 46 patients had a history of stroke/transient ischemic attack (TIA) at admission. 9.4% had a recurrent event at 1 year. The most important neuroimaging predictor of recurrent strokes was multiple embolic followed by superficial watershed pattern. Around 10% had more than one marker of atrial cardiopathy positive. While the risk factors, coronary artery disease (CAD), and neuroimaging pattern showed an association with recurrent events at 1 year on bivariate analysis, only the latter two remained significant on multivariate analysis. Conclusions Our cohort of ESUS had a higher annual recurrence risk than reported before. Though vascular risk factors and ipsilateral vessel abnormalities were more in the recurrent ESUS group, it did not significantly affect the recurrence risk at 1 year. CAD and multiple embolic patterns on imaging showed an association with recurrent strokes, suggesting a possible cardiac substrate in our ESUS population as well.
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Affiliation(s)
- Jithin George
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - P. N. Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sapna E. Sreedharan
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Roopnarinesingh R, Leppert M, Mukherjee D. Evidence And Mechanisms For Embolic Stroke In Contralateral Hemispheres From Carotid Artery Sources. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.20.23288892. [PMID: 37162897 PMCID: PMC10168406 DOI: 10.1101/2023.04.20.23288892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Disambiguation of embolus etiology in embolic strokes is often a clinical challenge. One common source of embolic stroke is the carotid arteries, with emboli originating due to plaque build up, or perioperatively during revascularization procedures. While it is commonly thought that thromboemboli from carotid sources travel to cerebral arteries ipsilaterally, there are existing reports of contralateral embolic events which complicate embolus source destination relationship for carotid sources. Here, we hypothesize that emboli from carotid sources can travel to contralateral hemispheres, and that embolus interactions with collateral hemodynamics in the Circle of Willis influences this process. We use a patient-specific computational embolus-hemodynamics interaction model developed in prior works to conduct an in silico experiment spanning 4 patient vascular models, 6 Circle of Willis anastomosis variants, and 3 different thromboembolus sizes released from left and right carotid artery sites. This led to a total of 144 different experiments, estimating trajectories and distribution of approximately 1.728 million embolus samples. Across all cases considered, emboli from left and right carotid sources showed non-zero contralateral transport (p value < 0.05). Contralateral movement revealed a size-dependence, with smaller emboli traveling more contralaterally. Detailed analysis of embolus dynamics revealed that collateral flow routes in Circle of Willis played a role in routing emboli, and transhemispheric movement occurred through the anterior and posterior communicating arteries in the Circle of Willis. We generated quantitative data demonstrating the complex dynamics of finite size thromboembolus particles as they interact with pulsatile arterial hemodynamics, and traverse the vascular network of the Circle of Willis. This leads to a non-intuitive source-destination relationship for emboli originating from carotid artery sites, and emboli from carotid sources can potentially travel to cerebral arteries on contralateral hemispheres.
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Tan ESJ, de Leon J, Boey E, Chin HK, Ho KH, Aguirre S, Sim MG, Seow SC, Sharma VK, Kojodjojo P. Stroke Recurrence in Embolic Stroke of Undetermined Source Without Atrial Fibrillation on Invasive Cardiac Monitoring. Heart Lung Circ 2023; 32:1000-1009. [PMID: 37291002 DOI: 10.1016/j.hlc.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND More than half of patients with embolic stroke of undetermined source (ESUS) suffer from recurrent ischaemic stroke, despite the absence of atrial fibrillation (AF) on invasive cardiac monitoring (ICM). This study investigated the predictors and prognosis of recurrent stroke in ESUS without AF on ICM. METHOD This prospective study included patients with ESUS at two tertiary hospitals from 2015 to 2021 who underwent comprehensive neurological imaging, transthoracic echocardiography, and inpatient continuous electrographic monitoring for ≥48 hours prior to ICM for definitive exclusion of AF. Recurrent ischaemic stroke, all-cause mortality, and functional outcome by the modified Rankin scale (mRS) at 3 months were evaluated in patients without AF. RESULTS Of 185 consecutive patients with ESUS, AF was not detected in 163 (88%) patients (age 62±12 years, 76% men, 25% prior stroke, median time to ICM insertion 26 [7, 123] days), and stroke recurred in 24 (15%) patients. Stroke recurrences were predominantly ESUS (88%), within the first 2 years (75%), and involved a different vascular territory from qualifying ESUS (58%). Pre-existing cancer was the only independent predictor of recurrent stroke (adjusted hazard ratio [AHR] 5.43, 95% CI 1.43-20.64), recurrent ESUS (AHR 5.67, 95% CI 1.15-21.21), and higher mRS score at 3 months (ß 1.27, 95% CI 0.23-2.42). All-cause mortality occurred in 17 (10%) patients. Adjusting for age, cancer, and mRS category (≥3 vs <3), recurrent ESUS was independently associated with more than four times greater hazard of death (AHR 4.66, 95% CI 1.76-12.34). CONCLUSIONS Patients with recurrent ESUS are a high-risk subgroup. Studies elucidating optimal diagnostic and treatment strategies in non-AF-related ESUS are urgently required.
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Affiliation(s)
- Eugene S J Tan
- Department of Cardiology, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore.
| | - Jhobeleen de Leon
- Department of Cardiology, National University Heart Centre, Singapore
| | - Elaine Boey
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore
| | - Howe-Keat Chin
- Department of Neurology, National University Health System, Singapore
| | - Kian-Hui Ho
- Department of Cardiology, National University Heart Centre, Singapore
| | - Shana Aguirre
- Department of Cardiology, National University Heart Centre, Singapore
| | - Ming-Gin Sim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Swee-Chong Seow
- Department of Cardiology, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Neurology, National University Health System, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Cardiology, Ng Teng Fong General Hospital, Singapore
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Tan SM, Ho JS, Sia CH, Leow AS, Seet RC, Teoh HL, Yuen LZ, Tham CH, Chua CY, Yap ES, Chan BP, Lim MJ, Sharma VK, Yeo LL, Tu TM, Tan BY. Etiologies, mechanisms, and risk factors of ischemic stroke in a young Asian adult cohort. J Stroke Cerebrovasc Dis 2023; 32:107134. [PMID: 37172470 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107134] [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: 10/02/2022] [Revised: 03/18/2023] [Accepted: 04/09/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVES Risk factors and causes of acute ischemic stroke (AIS) are more diverse in young adults, and traditional stroke classifications may be inadequate. Precise characterisation of AIS is important for guiding management and prognostication. We describe stroke subtypes, risk factors and etiologies for AIS in a young Asian adult population. MATERIALS AND METHODS Young AIS patients aged 18-50 years admitted to two comprehensive stroke centres from 2020-2022 were included. Stroke etiologies and risk factors were adjudicated using Trial of Org 10172 in Acute Stroke Treatment (TOAST) and International Pediatric Stroke Study (IPSS) risk factors. Potential embolic sources (PES) were identified in a subgroup with embolic stroke of undetermined source (ESUS). These were compared across sex, ethnicities and age groups (18-39 years versus 40-50 years). RESULTS A total of 276 AIS patients were included, with mean age 43±5.7 years and 70.3% male. Median duration of follow-up was 5 months (IQR: 3-10). The most common TOAST subtypes were small-vessel disease (32.6%) and undetermined etiology (24.6%). IPSS risk factors were identified in 95% of all patients and 90% with undetermined etiology. IPSS risk factors included atherosclerosis (59.5%), cardiac disorders (18.7%), prothrombotic states (12.4%) and arteriopathy (7.7%). In this cohort, 20.3% had ESUS, of which 73.2% had at least one PES, which increased to 84.2% in those <40 years old. CONCLUSIONS Young adults have diverse risk factors and causes of AIS. IPSS risk factors and ESUS-PES construct are comprehensive classification systems that may better reflect heterogeneous risk factors and etiologies in young stroke patients.
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Affiliation(s)
- Sarah Ml Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Jamie Sy Ho
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Aloysius S Leow
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Raymond Cs Seet
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Linus Zh Yuen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, SingHealth, Singapore
| | - Christopher Yk Chua
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Bernard Pl Chan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Mervyn Jr Lim
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, SingHealth, Singapore
| | - Benjamin Yq Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore.
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Kamel H, Elkind MSV. Genetics and the Quest to Define Sources of Cardiac Embolism. Stroke 2023; 54:1786-1788. [PMID: 37363943 PMCID: PMC10313158 DOI: 10.1161/strokeaha.123.043488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Han M, Heo J, Lee IH, Kim JH, Lee H, Jung JW, Lim IH, Hong SH, Kim YD, Nam HS. Prognostic value of central blood pressure on the outcomes of embolic stroke of undetermined source. Sci Rep 2023; 13:9550. [PMID: 37308509 DOI: 10.1038/s41598-023-36151-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
We investigated the prognostic impact of central blood pressure (BP) on outcomes in patients with embolic stroke of undetermined source (ESUS). The prognostic value of central BP according to ESUS subtype was also evaluated. We recruited patients with ESUS and data on their central BP parameters (central systolic BP [SBP], central diastolic BP [DBP], central pulse pressure [PP], augmentation pressure [AP], and augmentation index [AIx]) during admission. ESUS subtype classification was arteriogenic embolism, minor cardioembolism, two or more causes, and no cause. Major adverse cardiovascular event (MACE) was defined as recurrent stroke, acute coronary syndrome, hospitalization for heart failure, or death. Over a median of 45.8 months, 746 patients with ESUS were enrolled and followed up. Patients had a mean age of 62.8 years, and 62.2% were male. Multivariable Cox regression analysis showed that central SBP and PP were associated with MACE. All-cause mortality was independently associated with AIx. In patients with no cause ESUS, central SBP and PP, AP, and AIx were independently associated with MACE. AP and AIx were independently associated with all-cause mortality (all p < 0.05). We demonstrated that central BP can predict poor long-term prognosis in patients with ESUS, especially those with the no cause ESUS subtype.
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Affiliation(s)
- Minho Han
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Joon Ho Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - In Hwan Lim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Soon-Ho Hong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea.
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea.
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Canali E, Serani M, Tarzia P, Ciampi P, Canestrelli S, Calò L. Echocardiography in cardioembolic stroke prevention. Eur Heart J Suppl 2023; 25:C212-C217. [PMID: 37125319 PMCID: PMC10132583 DOI: 10.1093/eurheartjsupp/suad022] [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] [Indexed: 05/02/2023]
Abstract
Stroke is a leading cause of mortality and disability, and cardiac embolism accounts for one-third of all ischaemic strokes. Thirty per cent of strokes are cryptogenic. In this setting, echocardiography is essential in the diagnosis, treatment, and prevention of embolic stroke of undetermined source since it is a widely available, safe, and inexpensive tool. Transthoracic echocardiography and transoesophageal echocardiography, furthermore, are proven to change therapeutic management leading to initiation of anti-coagulation, anti-microbial therapy, patent foramen ovale (PFO) closure, or cardiac tumour resection. The most common cardioembolic sources include left atrial appendage thrombus, left ventricular thrombus, vegetations in endocarditis, paradoxical embolization in PFO, prosthesis thrombosis, and intracardiac tumours. Although the presence of a cardioembolic source only represents a risk factor for an ischaemic stroke, it could not assure the certain or the unique cause of the event. The purpose of this review is to underline the importance of echocardiography and overview the main sources of cardiac embolism and the echocardiographic features.
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Affiliation(s)
- Emanuele Canali
- Corresponding author. Tel: +39 3473067059, Fax: +39 0623188305,
| | - Marco Serani
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Pierpaolo Tarzia
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Pellegrino Ciampi
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Stefano Canestrelli
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
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Chen A, Zhu J, Zhu L, Tang Y, Li Y, Zhang Q, Zhao Y, Ma C, Liu X. Neglected intrapulmonary arteriovenous anastomoses: A comparative study of pulmonary right-to-left shunts in patients with patent foramen ovale. Front Cardiovasc Med 2023; 10:1111818. [PMID: 37089892 PMCID: PMC10117845 DOI: 10.3389/fcvm.2023.1111818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/16/2023] [Indexed: 04/09/2023] Open
Abstract
ObjectivePulmonary right-to-left shunt (P-RLS) and patent foramen ovale right-to-left shunt (PFO-RLS) often appear in combination, and there are often differences and connections between them. Intrapulmonary arteriovenous anastomoses (IPAVAs), as part of P-RLS, are often overlooked because there are no technologies to detect and identify them. This study aimed to further clarify the incidence and characteristics of P-RLS with the help of contrast transesophageal echocardiography (c-TEE) and contrast transthoracic echocardiography (c-TTE), providing a reference for clinically relevant research and patent foramen ovale (PFO) management disposal decisions.MethodsWe retrospectively investigated 414 subjects who came to our hospital for c-TEE from October 2021 to July 2022, and all subjects completed c-TTE simultaneously. 7 Patients who were newly diagnosed with an atrial septal defect were excluded. Eventually, 407 patients were included in this study. Among them, 157 patients with PFO (58 patients were treated with PFO closure subsequently) and 250 patients without PFO confirmed by c-TEE were finally enrolled. In the process, we observed and analysed the presence of P-RLS.ResultsA total of 407 patients were included in the final analysis and divided into PFO group (N = 157) and non-PFO group (N = 250) according to the results of c-TEE. Whether at rest or after Valsalva maneuver, the incidence of P-RLS was significantly higher under c-TEE than under c-TTE in the two groups (P < 0.001). For both c-TTE and c-TEE, the incidence of P-RLS was slightly higher after Valsalva maneuver than at rest, but the difference was not significant (c-TTE: rest vs. Valsalva maneuver, P = 0.214; c-TEE: rest vs. Valsalva maneuver, P = 0.076). The Valsalva maneuver increased the incidence of P-RLS in the group without PFO, which was more significant in c-TEE (c-TTE: rest vs. Valsalva maneuver, P = 0.591; c-TEE: rest vs. Valsalva maneuver, P = 0.008). In both groups, the P-RLS semiquantitative grading was statistical significance under different states and examinations (P < 0.001).ConclusionThe vast majority of P-RLS are grade 1–2 and are derived from physiological IPAVAs. Even so, attention should be given to the differentiation between P-RLS and PFO-RLS. c-TEE is an effective method to detect P-RLS; however, the recruitments of c-TEE and Valsalva maneuver to P-RLS should be noted.
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Affiliation(s)
- Anni Chen
- Department of Ultrasound, The First Affiliated Hospital of Shaoxing University, Shaoxing, China
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Jianbo Zhu
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Lei Zhu
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Yunyi Tang
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Yun Li
- Department of Ultrasound, The First Affiliated Hospital of Shaoxing University, Shaoxing, China
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Qi Zhang
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Yeping Zhao
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Caiye Ma
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
- Correspondence: Xiatian Liu Caiye Ma
| | - Xiatian Liu
- Department of Ultrasound, The First Affiliated Hospital of Shaoxing University, Shaoxing, China
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
- Correspondence: Xiatian Liu Caiye Ma
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Johansen MC. The Future of Ischemic Stroke Diagnosis and a Review of Underrecognized Ischemic Stroke Etiologies. Neurotherapeutics 2023; 20:613-623. [PMID: 37157043 PMCID: PMC10275839 DOI: 10.1007/s13311-023-01383-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
Accurate ischemic stroke etiologic determination and diagnosis form the foundation of excellent cerebrovascular care as from it stems initiation of the appropriate secondary prevention strategy as well as appropriate patient education regarding specific risk factors for that subtype. Recurrent stroke rates are highest among those patients who receive an incorrect initial stroke diagnosis. Patient distrust and patient reported depression are also higher. The cause of the ischemic stroke also informs predicted patient outcomes and the anticipated recovery trajectory. Finally, determining the accurate cause of the ischemic stroke provides the patient the opportunity to enroll in appropriate research studies studying mechanism, or targeting treatment approaches for that particular disease process. Advances in ischemic stroke research, imaging techniques, biomarkers, and the ability to rapidly perform genetic sequencing over the past decade have shown that classifying patients into large etiologic buckets may not always be appropriate and may represent one reason why some patients are labeled as cryptogenic, or for whom an underlying etiology is never found. Aside from the more traditional stroke mechanisms, there is new research emerging regarding clinical findings that are not normative, but the contributions to ischemic stroke are unclear. In this article, we first review the essential steps to accurate ischemic stroke etiologic classification and then transition to a discussion of embolic stroke of undetermined source (ESUS) and other new entities that have been postulated as causal in ischemic stroke (i.e., genetics and subclinical atherosclerosis). We also discuss the limitations that are inherent in the current ischemic stroke diagnostic algorithms and finally review the most recent studies regarding more uncommon diagnoses and the future of stroke diagnostics and classification.
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Abstract
The health burden of ischemic stroke is high and will continue to increase with an aging population. Recurrent ischemic stroke is increasingly recognized as a major public health concern with potentially debilitating sequelae. Thus, it is imperative to develop and implement effective strategies for stroke prevention. When considering secondary ischemic stroke prevention, it is important to consider the mechanism of the first stroke and the related vascular risk factors. Secondary ischemic stroke prevention typically includes multiple medical and, potentially, surgical treatments, but with the shared goal of reducing the risk of recurrent ischemic stroke. Providers, health care systems, and insurers also need to consider the availability of treatments, their cost and patient burden, methods for improving adherence, and interventions that target lifestyle risk factors such as diet or activity. In this article, we discuss aspects from the 2021 AHA Guideline on Secondary Stroke Prevention as well as highlight additional information relevant to best practices for reducing recurrent stroke risk.
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Affiliation(s)
- Aaron Bangad
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Mehdi Abbasi
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Adam de Havenon
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA.
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Soni S, Duggal B, Upadhyay J, Basu-Ray I, Kumar N, Bhadoria AS. Does left atrial appendage morphology and dimension differ amongst etiological stroke subtypes in patients without known atrial fibrillation? Results from the left atrial appendage morphology and dimension assessment by TEE in patients with stroke without known atrial fibrillation (LAMDA-STROKE) study. Indian Heart J 2023; 75:133-138. [PMID: 36894122 PMCID: PMC10123447 DOI: 10.1016/j.ihj.2023.03.001] [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: 11/09/2022] [Revised: 02/05/2023] [Accepted: 03/05/2023] [Indexed: 03/09/2023] Open
Abstract
CONTEXT Complex left atrial appendage (LAA) morphology is increasingly associated with cryptogenic ischemic stroke as compared to cardioembolic stroke due to atrial fibrillation (AF). However, data on such an association in patients with other etiological stroke subtypes in the absence of AF is limited. AIM The study aimed to assess the LAA morphology, dimension and other echocardiographic parameters by transesophageal echocardiography (TEE) in patients with embolic stroke of undetermined source (ESUS) and compare it with other etiological stroke subtypes without known AF. METHODS This was a single-Centre, observational study involving comparison of echocardiographic parameters including LAA morphology and dimension in ESUS patients (group A; n = 30) with other etiological stroke subtypes i.e., TOAST (Trial of Org 10172 in Acute Stroke Treatment) class I-IV without AF (group B; n = 30). RESULTS Complex LAA morphology was predominant in group A (18 patients in group A versus 5 patients in group B, p-Value = 0.001). Mean LAA orifice diameter (15.3 + 3.5 mm in group A versus 17 + 2.0 mm in group B, p-Value = 0.027) and LAA depth were significantly lower in group A (28.4 + 6.6 mm in group A versus 31.7 + 4.3 mm in group B, p-Value = 0.026). Out of these three parameters only complex LAA morphology was found to be independently associated with ESUS [OR = 6.003, 95% CI {1.225-29.417}, p = 0.027]. CONCLUSION Complex LAA morphology is a predominant feature in ischemic stroke patients with ESUS and may contribute to an increased risk of stroke in these patients.
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Affiliation(s)
- Shishir Soni
- Department of Cardiology, Super-Speciality Hospital NSCB Medical College, Jabalpur, MP, India; Ex-Senior Resident, Department of Cardiology, AIIMS Rishikesh, India.
| | - Bhanu Duggal
- Department of Cardiology, AIIMS Rishikesh, India.
| | - Jaya Upadhyay
- Department of Neonatology, Super-Speciality Hospital NSCB Medical College, Jabalpur, MP, India.
| | - Indranill Basu-Ray
- Department of Cardiology, AIIMS Rishikesh, India; Department of Cardiology, Memphis VA Medical Center, Memphis, TN, USA.
| | - Niraj Kumar
- Department of Neurology, AIIMS Rishikesh, India.
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von Falkenhausen AS, Feil K, Sinner MF, Schönecker S, Müller J, Wischmann J, Eiffener E, Clauss S, Poli S, Poli K, Zuern CS, Ziemann U, Berrouschot J, Kitsiou A, Schäbitz WR, Dieterich M, Massberg S, Kääb S, Kellert L. Atrial Fibrillation Risk Assessment after Embolic Stroke of Undetermined Source. Ann Neurol 2023; 93:479-488. [PMID: 36373166 DOI: 10.1002/ana.26545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Approximately 20% of strokes are embolic strokes of undetermined source (ESUS). Undetected atrial fibrillation (AF) remains an important cause. Yet, oral anticoagulation in unselected ESUS patients failed in secondary stroke prevention. Guidance on effective AF detection is lacking. Here, we introduce a novel, non-invasive AF risk assessment after ESUS. METHODS Catch-Up ESUS is an investigator-initiated, observational cohort study conducted between 2018 and 2019 at the Munich University Hospital. Besides clinical characteristics, patients received ≥72 h digital electrocardiogram recordings to generate the rhythm irregularity burden. Uni- and multivariable regression models predicted the primary endpoint of incident AF, ascertained by standardized follow-up including implantable cardiac monitors. Predictors included the novel rhythm irregularity burden constructed from digital electrocardiogram recordings. We independently validated our model in ESUS patients from the University Hospital Tübingen, Germany. RESULTS A total of 297 ESUS patients were followed for 15.6 ± 7.6 months. Incident AF (46 patients, 15.4%) occurred after a median of 105 days (25th to 75th percentile 31-33 days). Secondary outcomes were recurrent stroke in 7.7% and death in 6.1%. Multivariable-adjusted analyses identified the rhythm irregularity burden as the strongest AF-predictor (hazard ratio 3.12, 95% confidence interval 1.62-5.80, p < 0001) while accounting for the known risk factors age, CHA2 DS2 -VASc-Score, and NT-proBNP. Independent validation confirmed the rhythm irregularity burden as the most significant AF-predictor (hazard ratio 2.20, 95% confidence interval 1.45-3.33, p < 0001). INTERPRETATION The novel, non-invasive, electrocardiogram-based rhythm irregularity burden may help adjudicating AF risk after ESUS, and subsequently guide AF-detection after ESUS. Clinical trials need to clarify if high-AF risk patients benefit from tailored secondary stroke prevention. ANN NEUROL 2023;93:479-488.
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Affiliation(s)
- Aenne S von Falkenhausen
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany
| | - Moritz F Sinner
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johanna Müller
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Elodie Eiffener
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sebastian Clauss
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Center of Experimental Medicine, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christine S Zuern
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tübingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Jörg Berrouschot
- Department of Neurology, Klinikum Altenburger Land, Altenburg, Germany
| | - Alkisti Kitsiou
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Marianne Dieterich
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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78
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Dilemmas in hematology: consults in patients with arterial thrombosis. J Thromb Haemost 2023; 21:421-432. [PMID: 36696207 DOI: 10.1016/j.jtha.2023.01.002] [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: 10/21/2022] [Revised: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Arterial thrombotic events, particularly ischemic stroke and myocardial infarction, are common, and mostly occur due to atherosclerotic disease or arrhythmias. The diagnosis and management of the majority of such events occurs without the involvement of a hematologist, following established guidelines or pathways. In this review, we discuss 3 scenarios in which optimal management is less certain. These scenarios concern patients with a left ventricular thrombus, in whom the duration and choice of anticoagulant has been debated, patients with ischemic stroke and a patent foramen ovale, in whom the role of patent foramen ovale closure requires careful consideration, and the role of thrombophilia testing in young patients after a stroke or myocardial infarction, which remains an area of contention. We consider the available evidence and published guidelines in order to provide a practical, evidence-based approach to these 3 clinical scenarios.
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79
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Hague JP, Keelan J, Beishon L, Swienton D, Robinson TG, Chung EML. Three-dimensional simulations of embolic stroke and an equation for sizing emboli from imaging. Sci Rep 2023; 13:3021. [PMID: 36810427 PMCID: PMC9944911 DOI: 10.1038/s41598-023-29974-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 02/14/2023] [Indexed: 02/23/2023] Open
Abstract
Stroke simulations are needed to run in-silico trials, develop hypotheses for clinical studies and to interpret ultrasound monitoring and radiological imaging. We describe proof-of-concept three-dimensional stroke simulations, carrying out in silico trials to relate lesion volume to embolus diameter and calculate probabilistic lesion overlap maps, building on our previous Monte Carlo method. Simulated emboli were released into an in silico vasculature to simulate 1000 s of strokes. Infarct volume distributions and probabilistic lesion overlap maps were determined. Computer-generated lesions were assessed by clinicians and compared with radiological images. The key result of this study is development of a three-dimensional simulation for embolic stroke and its application to an in silico clinical trial. Probabilistic lesion overlap maps showed that the lesions from small emboli are homogeneously distributed throughout the cerebral vasculature. Mid-sized emboli were preferentially found in posterior cerebral artery (PCA) and posterior region of the middle cerebral artery (MCA) territories. For large emboli, MCA, PCA and anterior cerebral artery (ACA) lesions were comparable to clinical observations, with MCA, PCA then ACA territories identified as the most to least probable regions for lesions to occur. A power law relationship between lesion volume and embolus diameter was found. In conclusion, this article showed proof-of-concept for large in silico trials of embolic stroke including 3D information, identifying that embolus diameter could be determined from infarct volume and that embolus size is critically important to the resting place of emboli. We anticipate this work will form the basis of clinical applications including intraoperative monitoring, determining stroke origins, and in silico trials for complex situations such as multiple embolisation.
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Affiliation(s)
- James P. Hague
- grid.10837.3d0000 0000 9606 9301School of Physical Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
| | - Jonathan Keelan
- grid.10837.3d0000 0000 9606 9301School of Physical Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
| | - Lucy Beishon
- grid.9918.90000 0004 1936 8411Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 7RH UK
| | - David Swienton
- grid.269014.80000 0001 0435 9078Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW UK
| | - Thompson G. Robinson
- grid.511501.1NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Leicester, LE3 9QP UK
| | - Emma M. L. Chung
- grid.9918.90000 0004 1936 8411Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 7RH UK ,grid.269014.80000 0001 0435 9078Department of Medical Physics, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW UK ,grid.13097.3c0000 0001 2322 6764School of Life Course and Population Sciences, King’s College London, Guy’s Campus, London, SE1 1UL UK
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80
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Elsheikh S, Lip GYH, Abdul-Rahim AH. Potential Embolic Sources in Embolic Stroke of Undetermined Source in Patients with Patent Foramen Ovale: Look Harder. Cerebrovasc Dis 2023; 52:607-608. [PMID: 36750045 DOI: 10.1159/000529105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023] Open
Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK,
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK,
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK,
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK
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81
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Fan ZX, Liu RX, Liu GZ. Development and refinement of diagnostic and therapeutic strategies for managing patients with cardiogenic stroke: An arduous journey. World J Clin Cases 2023; 11:719-724. [PMID: 36818629 PMCID: PMC9928701 DOI: 10.12998/wjcc.v11.i4.719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
Cardioembolic stroke, referred to as cardiogenic stroke, is a clinical syndrome in which emboli from the heart pass through the circulatory system and cause cerebral artery embolism and corresponding brain dysfunction. Compared to other subtypes of ischemic stroke, cardiogenic stroke presents with more etiologies, greater severity, worse prognosis, and a higher recurrence rate. In this minireview, we provide new insights into the etiological classification, diagnostic methods, and interventions of cardiogenic stroke.
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Affiliation(s)
- Ze-Xin Fan
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
| | - Ri-Xia Liu
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
| | - Guang-Zhi Liu
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
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82
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Larson AS, Brinjikji W, Lekah A, Klaas JP, Lanzino G, Huston J, Saba L, Benson JC. Nonstenotic Carotid Plaques and Embolic Stroke of Undetermined Source: A Multimodality Review. AJNR Am J Neuroradiol 2023; 44:118-124. [PMID: 36549844 PMCID: PMC9891333 DOI: 10.3174/ajnr.a7750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 12/24/2022]
Abstract
Symptomatic nonstenotic carotid artery disease has been increasingly recognized as a thromboembolic source in patients who would otherwise be classified as having embolic stroke of undetermined source. Evidence suggests that certain plaque features seen on sonography, CT, and MR imaging in nonstenotic carotid artery disease may predispose to recurrent stroke in patients with embolic stroke of undetermined source. We performed a focused literature review to further study plaque features in the context of embolic stroke of undetermined source and to determine which plaque features may be associated with ipsilateral ischemic events in such patients. Plaque thickness as seen on both ultrasound and CT appears to have a consistent association with ipsilateral stroke in patients with embolic stroke of undetermined source across multiple studies. Intraplaque hemorrhage as seen on MR imaging is now understood to have a strong association with ipsilateral stroke in patients with embolic stroke of undetermined source. Continued study of various plaque features as seen on different modalities is warranted to uncover other potential associations.
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Affiliation(s)
- A S Larson
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - W Brinjikji
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
- Neurosurgery (W.B., G.L.)
| | - A Lekah
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - J P Klaas
- Neurology (J.P.K.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
- Neurosurgery (W.B., G.L.)
| | - J Huston
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
| | - L Saba
- Department of Medical Sciences (L.S.), University of Cagliari, Cagliari, Italy
| | - J C Benson
- From the Departments of Radiology (A.S.L., W.B., A.L., G.L., J.H., J.C.B.)
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83
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Field TS, Sposato LA, Hill MD, Healey JS, Andrade JG, Zhou LW. Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management. Can J Cardiol 2023; 39:172-186. [PMID: 36272633 DOI: 10.1016/j.cjca.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/07/2023] Open
Abstract
In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.
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Affiliation(s)
- Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Luciano A Sposato
- Schulich School of Medicine and Dentistry, Robarts Research Institute, Heart and Brain Laboratory, London, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lily W Zhou
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
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84
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Grosse GM, Leotescu A, Sieweke JT, Schneppenheim S, Budde U, Ziegler NL, Biber S, Gabriel MM, Ernst J, Schuppner R, Lichtinghagen R, Bavendiek U, Widder J, Weissenborn K. ADAMTS-13 activity in stroke of known and unknown cause: Relation to vascular risk factor burden. Front Neurol 2023; 13:1045478. [PMID: 36703637 PMCID: PMC9871749 DOI: 10.3389/fneur.2022.1045478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023] Open
Abstract
Background The identification of the underlying mechanism in ischemic stroke has important implications for secondary prevention. A disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS-13) has antithrombotic properties and was repeatedly implicated in the pathophysiology of stroke. In this study, we, therefore, aimed to investigate whether ADAMTS-13 is associated with stroke etiology and the burden of vascular risk factors. Methods We determined ADAMTS-13 activity in two prospectively recruited stroke cohorts in the long-term course after the event. Cohort 1 (n = 88) consisted of patients who suffered a stroke due to embolic stroke of undetermined source (ESUS), cardioembolic stroke due to atrial fibrillation (AF), large-artery atherosclerosis, or small vessel disease. In cohort 2, patients with cryptogenic stroke and patent foramen ovale (PFO) scheduled for PFO closure (n = 38) were enrolled. As measures of vascular risk factor burden, the CHA2DS2VASC score, the Essen Stroke Risk Score (ESRS), and the Risk of Paradoxical Embolism (RoPE) score were calculated, as appropriate. Results ADAMTS-13 activity was lower in patients with AF-related stroke compared to patients with ESUS (p = 0.0227), which was, however, due to confounding by vascular risk factors. ADAMTS-13 activity inversely correlated with the ESRS (r = -0.452, p < 0.001) and CHA2DS2VASC (r = -0.375, p < 0.001) in cohort 1. In accordance with these findings, we found a positive correlation between ADAMTS-13 activity and the RoPE score in cohort 2 (r = 0.413, p = 0.010). Conclusion ADAMTS-13 activity is inversely correlated with the number of vascular risk factors across different stroke etiologies. Further study is warranted to establish ADAMTS-13 as a mediator of cerebrovascular risk.
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Affiliation(s)
- Gerrit M. Grosse
- 1Department of Neurology, Hannover Medical School, Hannover, Germany,*Correspondence: Gerrit M. Grosse ✉
| | - Andrei Leotescu
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | | | - Ulrich Budde
- 3Medilys Laboratory, Asklepios Klinik Altona, Hamburg, Germany
| | - Nora L. Ziegler
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Saskia Biber
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ramona Schuppner
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- 4Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Udo Bavendiek
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany
| | - Julian Widder
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany,5Medizinische Klinik VI, Kardiologie, Angiologie und Internistische Intensivmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Karin Weissenborn
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
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85
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Grifoni E, Baldini G, Baldini M, Pinto G, Micheletti I, Madonia EM, Cosentino E, Bartolozzi ML, Bertini E, Dei A, Signorini I, Giannoni S, Del Rosso A, Prisco D, Guidi L, Masotti L. Post-Stroke Detection of Subclinical Paroxysmal Atrial Fibrillation in Patients With Embolic Stroke of Undetermined Source in the Real World Practice: The Empoli ESUS Atrial Fibrillation (E 2 AF) Study. Neurologist 2023; 28:25-31. [PMID: 35486903 DOI: 10.1097/nrl.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Subclinical paroxysmal atrial fibrillation (AF) is one of the main occult causative mechanisms of embolic stroke of undetermined source (ESUS). Aim of this study was to identify AF predictors, and to develop a score to predict the probability of AF detection in ESUS. METHODS We retrospectively analyzed ESUS patients undergoing 2-week external electrocardiographic monitoring. Patients with and without AF detection were compared. On the basis of multivariate analysis, predictors of AF were identified and used to develop a predictive score, which was then compared with other existing literature scores. RESULTS Eighty-two patients, 48 females, mean age±SD 72±10 years, were included. In 36 patients (43.9%) AF was detected. The frequency of age 75 years or above and arterial hypertension, and the median CHA 2 DS 2 -VASc score were significantly higher in patients with AF compared with those without. National Institutes of Health Stroke Scale (NIHSS) score ≥8 was the only independent variable associated with AF detection. We derived the Empoli ESUS-AF (E 2 AF) score (NIHSS ≥8 5 points, arterial hypertension 3 points, age 75 years or above 2 points, age 65 to 74 years 1 point, history of coronary/peripheral artery disease 1 point, left atrial enlargement 1 point, posterior lesion 1 point, cortical or cortical-subcortical lesion 1 point), whose predictive power in detecting AF was good (area under the curve: 0.746, 95% confidence interval: 0.638-0.836) and higher than that of CHA 2 DS 2 -VASc and other scores. CONCLUSIONS In our study NIHSS score ≥8 was the only independent predictor of post-ESUS-AF detection. The E 2 AF score appears to have a good predictive power for detecting AF. External validations are required.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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86
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Zamora C, Castillo M, Puac-Polanco P, Torres C. Oncologic Emergencies in the Head and Neck. Radiol Clin North Am 2023; 61:71-90. [DOI: 10.1016/j.rcl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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87
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Escudero-Martínez I, Morales-Caba L, Segura T. Atrial fibrillation and stroke: A review and new insights. Trends Cardiovasc Med 2023; 33:23-29. [PMID: 34890796 DOI: 10.1016/j.tcm.2021.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 02/01/2023]
Abstract
The link between heart and brain continues to be a matter of great interest for the scientific community. One of the most established associations between the two is that the heart is a significant source of emboli and is responsible for 20-25% of all ischemic strokes. The most frequent underlying cause of cardioembolic stroke is atrial fibrillation (AF), a disease that affects almost 3 million people in the USA and 4.5 million in Europe. AF increases the risk of ischemic stroke by a factor of 3 to 5 times. It is estimated that AF is responsible for 15% of all strokes worldwide. A more comprehensive understanding of this association and development of intensive stroke prevention measures are needed, as we know that AF incidence and prevalence will increase over the coming years, becoming one of the largest epidemics and public health challenges we face.
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Affiliation(s)
- Irene Escudero-Martínez
- Stroke Unit, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe - Universidad de Valencia, Valencia, Spain.
| | - Lluis Morales-Caba
- Stroke Unit, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe - Universidad de Valencia, Valencia, Spain
| | - Tomás Segura
- Department of Medical Sciences, Faculty of Medicine of Albacete, University of Castilla-La Mancha, Albacete, Spain; Stroke Unit, Department of Neurology, Hospital General Universitario de Albacete, Spain
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88
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Atrial cardiomyopathy: Diagnosis, clinical implications and unresolved issues in anticoagulation therapy. J Electrocardiol 2023; 76:1-10. [PMID: 36370545 DOI: 10.1016/j.jelectrocard.2022.10.012] [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: 04/19/2022] [Revised: 10/15/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
Atrial cardiomyopathy (AC) is an evolving pathophysiological entity that has expanded our understanding regarding the atrium and its role in arrhythmogenesis and cardiac thromboembolism. The pathological myocardium in AC promotes arrhythmogenesis through mechanical dysfunction (hypocontractility, fibrosis), adverse alterations of the endothelium and secretion of prothrombotic factors (IL-6, IL-8, TNF-a). 'Red flags', indicative of AC, can be recognized either non-invasively by electrocardiography, echocardiography and cardiac magnetic resonance imaging or invasively by high-density electroanatomical mapping as low bipolar voltage areas of the affected myocardium. Signs of AC have been strongly associated with an increased risk of ischemic stroke, even embolic strokes of undetermined source, regardless of the coexistence of atrial fibrillation (AF). The underlying existence of AC has been negatively correlated with the success rate of catheter ablation of AF. The clinical value of AC is the provision of a novel pathway regarding the potential mechanisms of cerebrovascular events of cardiac thromboembolic origin. In addition, AC may serve as a risk stratification tool to predict the long-term responders of AF catheter ablation.
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Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified. AREAS COVERED This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract). EXPERT OPINION The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
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90
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Patel P, Tiongson J, Chen A, Siegal T, Oak S, Golla A, Kamen S, Thon JM, Vigilante N, Rana A, Hester T, Siegler JE. Outcomes associated with antithrombotic strategies in heart failure with reduced ejection fraction and sinus rhythm following acute ischemic stroke. Front Neurol 2022; 13:1041806. [PMID: 36588887 PMCID: PMC9797677 DOI: 10.3389/fneur.2022.1041806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Insufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%. Methods We retrospectively analyzed single-center registry data (2015-2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching. Results Of 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56-2.17]. Non-White race (HR 2.26, 95% CI: 1.16-4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40-5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21-0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses. Conclusion In HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.
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Affiliation(s)
- Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Justin Tiongson
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Austin Chen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Taylor Siegal
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Akhil Golla
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Jesse M. Thon
- Cooper Medical School of Rowan University, Camden, NJ, United States,Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | | | - Ameena Rana
- Department of Neurology, Sinai Beth Israel Hospital, New York, NY, United States
| | - Taryn Hester
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - James E. Siegler
- Cooper Medical School of Rowan University, Camden, NJ, United States,Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States,*Correspondence: James E. Siegler
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91
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Shapiro SD, Vazquez S, Das A, Dominguez JF, Kamal H, Chong J, Mayer SA, Kaur G, Gandhi C, Al-Mufti F. Investigating Outcomes Post-Endovascular Thrombectomy in Acute Stroke Patients With Cancer. Neurology 2022; 99:e2583-e2592. [PMID: 36123128 DOI: 10.1212/wnl.0000000000201208] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cancer is a common comorbidity in patients with acute ischemic stroke (AIS). Randomized controlled trials that established endovascular thrombectomy (EVT) as the standard of care for large vessel occlusion generally excluded patients with cancer. As such, the clinical benefits of endovascular thrombectomy in the cancer population are currently poorly established. We examine clinical outcomes of patients with cancer who underwent EVT using a large inpatient database, the National Inpatient Sample (NIS). METHODS The NIS was queried for AIS admission between 2016 and 2019, and patients with cancer were identified. Baseline demographics, comorbidities, reperfusion therapies, and outcomes were compared between patients with AIS with and without cancer. For patients who underwent EVT, propensity score matching was used to study primary outcomes such as risk of intracranial hemorrhage, hospital length of stay, and discharge disposition. RESULTS During the study period, 2,677,200 patients were hospitalized with AIS, 228,800 (8.5%) of whom had a diagnosis of cancer. A total of 132,210 patients underwent EVT, of which 8,935 (6.8%) had cancer. Over 20% of patients with cancer who underwent EVT had a favorable outcome of a routine discharge home without services. On adjusted propensity score analysis, patients with cancer who underwent EVT had similar rates of intracranial hemorrhage (OR 1.03, CI 0.79-1.33, p = 0.90) and odds of a discharge home, with a significantly higher rate of prolonged hospitalization greater than 10 days (OR 1.34, CI 1.07-1.68, p = 0.01). Compared with patients without cancer, patients with metastatic cancer who underwent EVT also had similar rates of intracranial hemorrhage (OR 1.03, CI 0.64-1.67, p = 1.00) and likelihood of routine discharge (OR 0.83, CI 0.51-1.35, p = 0.54) but higher rates of in-hospital mortality (OR 2.72, CI 1.52-4.90, p < 0.01). DISCUSSION Our findings show that in contemporary medical practice, patients with acute stroke with comorbid cancer or metastatic cancer who undergo endovascular thrombectomy have similar rates of intracranial hemorrhage and favorable discharges as patients without cancer. This suggests that patients with AIS who meet the criteria for reperfusion therapy may be considered in the setting of a comorbid cancer diagnosis.
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Affiliation(s)
- Steven D Shapiro
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Sima Vazquez
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Ankita Das
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Jose F Dominguez
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Haris Kamal
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Ji Chong
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Stephan A Mayer
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Gurmeen Kaur
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Chirag Gandhi
- All authors contributed equally and significantly to the work
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla
| | - Fawaz Al-Mufti
- All authors contributed equally and significantly to the work.
- From the Departments of Neurosurgery (S.D.S., J.F.D., H.K., S.A.M., G.K., C.G., F.A.-M.) and Neurology (J.C., S.A.M., G.K., F.A.-M.), Westchester Medical Center, Valhalla; and School of Medicine (S.V., A.D., C.G., F.A.-M.), New York Medical College, Valhalla.
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Toh KZX, Koh MY, Ho JSY, Ong KHX, Lee YQ, Chen X, Fang JT, Chong EY, Lim ICZY, Teo YH, Teo YN, Chua CYK, Lim Y, Chan BPL, Sharma VK, Yeo LLL, Sia CH, Tan BYQ. Potential Embolic Sources in Embolic Stroke of Undetermined Source Patients with Patent Foramen Ovale. Cerebrovasc Dis 2022; 52:503-510. [PMID: 36455524 PMCID: PMC10627487 DOI: 10.1159/000527791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/24/2022] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs. METHODS A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup. RESULTS Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5-7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011). CONCLUSION A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.
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Affiliation(s)
- Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore,
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jamie S Y Ho
- Royal Free London NHS Foundation Trust, London, UK
| | - Kathleen Hui Xin Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yong Qin Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Xintong Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Elliot Yeung Chong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Isis Claire Z Y Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher Y K Chua
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ching Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
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Jumah A, Aboul Nour H, Fana M, Choudhury O, Eltous L, Zoghoul S, Jumah F, Alsrouji OK, Alhajala H, Intikhab O, Marin H, Chebl A, Miller D. The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature. Interv Neuroradiol 2022:15910199221143172. [PMID: 36451548 DOI: 10.1177/15910199221143172] [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: 02/17/2024] Open
Abstract
PURPOSE Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.
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Affiliation(s)
- Ammar Jumah
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Michael Fana
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Lara Eltous
- 37251Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, 36977Hamad Medical Corporation, Doha, Qatar
| | - Fareed Jumah
- Department of Neurosurgery, University of Missouri Hospital, Columbia, MO, USA
| | - Owais K Alsrouji
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | - Osama Intikhab
- Department of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Horia Marin
- Department of Neuroradiology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
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Tian B, Tian X, Zhu C. Editorial: Advances in imaging and treatment of embolic stroke of undetermined source. Front Neurol 2022; 13:1073545. [DOI: 10.3389/fneur.2022.1073545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/31/2022] [Indexed: 12/05/2022] Open
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Moustafa B, Testai FD. Navigating Antiplatelet Treatment Options for Stroke: Evidence-Based and Pragmatic Strategies. Curr Neurol Neurosci Rep 2022; 22:789-802. [PMID: 36227497 DOI: 10.1007/s11910-022-01237-z] [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] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The benefit of using antiplatelet monotherapy in acute ischemic stroke and secondary stroke prevention is well established. In the last few years, several large randomized trials showed that the use of short-term dual antiplatelet therapy in particular stroke subtypes may reduce the risk of recurrent ischemic events. The aim of this article is to provide a critical analysis of the current evidence and recommendations for the use of antiplatelet agents for stroke prevention. RECENT FINDINGS Long-term therapy with aspirin, clopidogrel, or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention in patients with noncardioembolic ischemic stroke. Short-term dual antiplatelet therapy with aspirin and clopidogrel is superior to antiplatelet monotherapy in secondary stroke prevention when used in patients with mild noncardioembolic stroke or high-risk transient ischemic attack. Dual therapy, however, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days. Similarly, aspirin plus ticagrelor is superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, although this combination is associated with a higher risk of hemorrhagic complications when compared to other dual antiplatelet regimens. Among patients who carry CYP2C19 genetic polymorphisms associated with a slow bioactivation of clopidogrel, short-term treatment with aspirin plus ticagrelor is superior to aspirin plus clopidogrel for the reduction of recurrent stroke; however, the use of ticagrelor is associated with a higher risk of any bleeding. In patients with symptomatic intracranial stenosis, aggressive medical management in addition to dual antiplatelet therapy up to 90 days is recommended. Antiplatelet therapy has an essential role in the management of ischemic stroke. The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications.
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Affiliation(s)
- Bayan Moustafa
- Mayo Clinic College of Medicine and Science, 1221 Whipple St, Eau Claire, WI, 54703, USA.
| | - Fernando D Testai
- College of Medicine, University of Illinois at Chicago, 912 S Wood St, Chicago, IL, 60612, USA
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Luo N, Shang Z, Tao L, Yang B, Chen H. Atherosclerosis as a Potential Cause of Deep Embolic Stroke of Undetermined Source: A 3T High‐Resolution Magnetic Resonance Imaging Study. J Am Heart Assoc 2022; 11:e026737. [DOI: 10.1161/jaha.122.026737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
The potential causes or sources of embolic stroke of undetermined source (ESUS) vary. This study aimed to investigate the main cause of deep ESUS by evaluating nonstenotic intracranial atherosclerotic plaque.
Methods and Results
We retrospectively screened consecutive patients with unilateral anterior circulation ESUS. After excluding the patients with possible embolism from an extracranial artery such as aortic arch plaque, carotid plaque, and so on, the enrolled patients with ESUS were categorized into 2 groups: deep ESUS and cortical with/without deep ESUS. All patients underwent intracranial high‐resolution magnetic resonance imaging to assess the characteristics of nonstenotic intracranial atherosclerotic plaque. Biomarkers of atrial cardiopathy (ie, P‐wave terminal force in lead V1 on ECG, NT‐proBNP [N‐terminal pro–brain natriuretic peptide] and left atrial diameter) were collected. A total of 155 patients with ipsilateral nonstenotic intracranial atherosclerotic plaque were found, with 76 (49.0%) in deep ESUS and 79 (51.0%) in cortical with/without deep ESUS. We found more prevalent plaque in the M1 segment of the middle cerebral artery and the ostia of the perforator, with a smaller remodeling index plaque burden, and less frequent occurrence of complicated plaque in deep ESUS versus cortical with/without deep ESUS. Higher BNP (brain natriuretic peptide) levels and a higher prevalence of atrial cardiopathy in cortical with/without deep ESUS versus deep ESUS. Moreover, the discrimination of vulnerable plaque for predicting ESUS was significantly enhanced after adjusting for or further excluding patients with deep ESUS.
Conclusions
The current study provides the first high‐resolution magnetic resonance imaging evidence that cortical with/without deep ESUS and deep ESUS should be 2 distinct entities and that atherosclerosis, not embolism, might be the main cause of deep ESUS.
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Affiliation(s)
- Na Luo
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Zi‐Yang Shang
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Lin Tao
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Ben‐Qiang Yang
- Department of Radiology General Hospital of Northern Theater Command Shenyang China
| | - Hui‐Sheng Chen
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
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Komarov AL, Krivosheeva EN, Makeev MI, Merkulov EV, Tripoten MI, Panchenko EP. [Patent foramen ovale as the cause of recurrent embolic strokes. Case report]. TERAPEVT ARKH 2022; 94:1109-1114. [PMID: 36286763 DOI: 10.26442/00403660.2022.09.201842] [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: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 06/16/2023]
Abstract
А clinical case of a young patient with recurrent ischemic strokes is presented. The problems of diagnostic embolic strokes are discussed. We set out the algorithm for identifying patients, in whom patent foramen ovale is the most probable cause of embolic stroke. Detailed consideration of imaging diagnostic methods possibility is included. Hypothesis of probable source of cardioembolism from patent foramen ovale is presented. Recommendations for the secondary prevention of recurrent ischemic stroke, associated with patent foramen ovale, are provided. We also considered the issues of antithrombotic treatment.
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Affiliation(s)
- A L Komarov
- Chazov National Medical Research Center of Cardiology
| | | | - M I Makeev
- Chazov National Medical Research Center of Cardiology
| | - E V Merkulov
- Chazov National Medical Research Center of Cardiology
| | - M I Tripoten
- Chazov National Medical Research Center of Cardiology
| | - E P Panchenko
- Chazov National Medical Research Center of Cardiology
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98
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Del Buono MG, Sanna T. Atrial fibrillation: focus on monitoring strategies after cryptogenic stroke. Minerva Cardiol Angiol 2022; 70:606-615. [PMID: 35080356 DOI: 10.23736/s2724-5683.21.05851-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes, with stroke potentially being the first manifestation of a previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic events, searching for unknown AF after stroke requires a comprehensive diagnostic workup. Prospective data have demonstrated the benefits of long-term cardiac monitoring to identify AF in association with cryptogenic stroke, as most strokes are presumed to result from AF. However, strategies of empirical anticoagulation using oral anticoagulants following cryptogenic stroke failed to improve outcomes. We herein summarize contemporary evidence and knowledge gaps on searching for AF after a stroke and the potential secondary prevention strategies to prevent further recurrences.
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Affiliation(s)
| | - Tommaso Sanna
- Sacred Heart Catholic University, Rome, Italy -
- IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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99
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Snyman S, Seder E, David-Muller M, Klein V, Doche E, Suissa L, Deharo JC, Robinet-Borgomano E, Maille B. Atrial Fibrillation Detected by Implantable Monitor in Embolic Stroke of Undetermined Source: A New Clinical Entity. J Clin Med 2022; 11:jcm11195740. [PMID: 36233608 PMCID: PMC9571950 DOI: 10.3390/jcm11195740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: High incidence of covert paroxysmal atrial fibrillation (CPAF) detected by an implantable cardiac monitor (ICM) is expected in embolic stroke of undetermined source (ESUS) patients. This study aimed to determine the CPAF rate in an ESUS cohort using ICMs and compare stroke characteristics of patients with CPAF to those with known or inpatient-diagnosed AF (KIDAF). Methods: ESUS patients with ICMs were enrolled. ESUS diagnosis was defined as a non-lacunar stroke in the absence of symptomatic atherosclerotic stenosis (≥50%), no major-risk cardioembolic source, and no other specific cause. ESUS characteristics of patients with CPAF were compared to ESUS patients without CPAF and to KIDAF stroke patients. Results: During the median follow-up of 476 (371–615) days, CPAF was newly detected in 38/163 (23.31%) patients within 236 (115.50–510.75) days after the stroke. CPAF was independently associated to older age, coronaropathy, left atrial dilation, and atrial hyperexcitability, but not to stroke severity. Compared to KIDAF strokes, ESUS with CPAF had lower rates of proximal occlusion leading to milder clinical severity (NIHSS: 3.00 (1.00–8.25) vs. 14.50 (6.00–21.00)). Conclusions: Our study revealed a high proportion of CPAF in ESUS. We highlight that CPAF is a distinct clinical entity compared to KIDAF based on differences in stroke characteristics and AF diagnosis temporality.
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Affiliation(s)
- Salomé Snyman
- Stroke Unit, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Elena Seder
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Marc David-Muller
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Victor Klein
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Emilie Doche
- Stroke Unit, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
| | - Laurent Suissa
- Stroke Unit, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
- Marseille School of Medicine, 27, Bd Jean-Moulin, 13005 Marseille, France
| | - Jean-Claude Deharo
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
- Marseille School of Medicine, 27, Bd Jean-Moulin, 13005 Marseille, France
| | | | - Baptiste Maille
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
- Correspondence:
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100
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Prevalence of Symptomatic Nonstenotic Carotid Disease Using Simultaneous Non-Contrast Angiography and Intraplaque Hemorrhage Imaging for MR Screen Protocol. Diagnostics (Basel) 2022; 12:diagnostics12102321. [PMID: 36292010 PMCID: PMC9600452 DOI: 10.3390/diagnostics12102321] [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: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background: To determine the prevalence of symptomatic nonstenotic carotid disease (SyNC) using simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP) imaging for patients with acute stroke as an MR screen protocol and to assess imaging findings of carotid plaques. Patients and Methods: From May 2020 to October 2021, 2459 patients with suspected acute neurological symptoms were evaluated with brain diffusion-weighted imaging (DWI) and carotid SNAP imaging. We analyzed the degree of stenosis and intraplaque hemorrhage (IPH) using SNAP imaging. Prevalence of SyNC and risk factors for stroke in patients with SyNC were determined. We performed subgroup multivariate analysis between SyNC and other etiologies of stroke (non-SyNC). Results: Of 4608 carotid arteries in 2304 patients enrolled in this study, 454 (9.9%) plaques (both lesions in 128 patients) were found on SNAP imaging. Of these plaques, 353 (77.8%) showed stenosis of <50%. Of plaques with <50% stenosis, 47 (13.3%) patients had a territorial acute focal infarction. Seventeen (36.2%) were classified with embolic stroke of undetermined source (ESUS) and SyNC. High maximal wall thickness and carotid IPH were identified as influencing factors for SyNC. Conclusion: For patients with <50% stenosis and territorial infarction, SyNC is a relatively important source of stroke. Especially, high maximal wall thickness and carotid IPH are important risk factors for SyNC.
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