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Eichelmann A, Kubini R, Nachoski D, Kosinski C, Becker M, Aljalloud A. Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years. Clin Cardiol 2024; 47:e24251. [PMID: 38445759 PMCID: PMC10915992 DOI: 10.1002/clc.24251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The advantages of patent foramen ovale (PFO) closure as protection from a recurrence of stroke remains controversial compared to drug therapy, especially in patients over 60 years. HYPOTHESIS The aim of the study is to compare recurrence of stroke in patients over 60 years old with PFO closure versus drug therapy alone. METHODS We included 342 patients over 60 years who suffered a crytopgenic stroke, and were also accepted for a PFO closure. 199 patients refused a PFO closure and were treated with medical therapy alone, whereas 143 patients underwent a PFO closure procedure. RESULTS The mean follow up time was 5.5 ± 1.5 years. All patients in Group B showed persistent shunt in the follow-up period (n = 199, 100%). In Group A, seven patients were diagnosed with residual shunt during echocardiography examination (5%). A new onset of atrial fibrillation occurred in seven patients in Group A (5%) and six patients in Group B (3%), p = .117. Recurrent stroke occurred in 3 patients in Group A (2%) and 11 patients in Group B (6%), p = .021. One patient died of unknown reason (1%) and two patients were lost due to neurological death (1%) in Group B, whereas no patients in Group A died during the follow-up period. CONCLUSION Our results show that strict exclusion of patients over 60 years from PFO closure should be reconsidered. As life expectancies are increasing, patients should be considered for same treatment as younger patients, since the outcomes are improved compared to patients treated with medical therapy alone.
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Affiliation(s)
| | - Ralf Kubini
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Dejan Nachoski
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | | | - Michael Becker
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Ali Aljalloud
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
- Department of Cardiac SurgeryRWTH University Hospital AachenAachenGermany
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2
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Olma MC, Tütüncü S, Grittner U, Kunze C, Jawad-Ul-Qamar M, Kirchhof P, Röther J, Thomalla G, Veltkamp R, Laufs U, Nabavi DG, Heuschmann PU, Endres M, Haeusler KG. Extent of routine diagnostic cardiac work-up at certified German stroke units participating in the prospective MonDAFIS study. Neurol Res Pract 2023; 5:21. [PMID: 37259147 DOI: 10.1186/s42466-023-00246-8] [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: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND About 25% of all ischaemic strokes are related to cardio-embolism, most often due to atrial fibrillation (AF). Little is known about the extent and standardization of routine cardiac diagnostic work-up at certified stroke-units in Germany. METHODS The MonDAFIS study included non-AF patients with acute ischaemic stroke or transient ischaemic attack (TIA) at 38 certified stroke-units in Germany. Here, we analysed routine diagnostic work-up and disregarded study-related Holter-ECG monitoring. We compared duration of stroke-unit stay, number of 24-h Holter-ECGs, and echocardiography performed between university-based comprehensive stroke centres (UCSC, 12 hospitals, 1606 patients), non university-based comprehensive stroke centres (nUCSC, 14 hospitals, 892 patients), and primary stroke centres at non-university hospitals (PCS, 12 hospitals, 933 patients) using multivariable mixed regression analyses. Detection of a first AF episode in-hospital was also compared between hospitals of different stroke-unit levels. RESULTS In 3431 study patients (mean age 66.2 years, 39.5% female, median NIHSS = 2 on admission), median duration of the stroke-unit stay was 72 h (IQR 42-86). Stroke-unit stay was longer (categorised ≤ 24/ > 24- ≤ 72/ > 72 h) for patients with severe stroke (NIHSS score ≥ 5/ < 5: OR = 1.6, 95%CI 1.3-2.0) and for patients with ischaemic stroke vs. TIA (OR = 1.7, 95%CI 1.4-2.1). Overall, 2149/3396 (63.3%) patients underwent at least one additional 24-h Holter-ECG (median 1 [IQR 0-1], range 0-7). Holter-ECG rate was 47% in UCSC, 71% in nUCSC, and 84% in PCS. Compared to PCS, AF was less often detected in-hospital in UCSC (OR = 0.65, 95%CI 0.45-0.93) and nUCSC (OR = 0.69, 95%CI 0.46-1.04). Transoesophageal echocardiography (TEE) only was performed in 513/3391 (15.1%) study patients, transthoracic echocardiography (TTE) only in 1228/3391 (36.2%), and TEE combined with TTE in 1020/3391 (30.1%) patients. Patients younger than 60 years (vs. ≥ 60 years) underwent TEE more often than those older than 60 years (OR = 3.44, 95%CI 2.67-4.42). TEE (IQR 34-65%) and TTE rate (IQR 40-85%) varied substantially among study centres. Echocardiography rate (TTE and/or TEE) was 74.0% in UCSC, 85.4% in nUCSC, and 90.3% in PSC, respectively. CONCLUSIONS In the MonDAFIS study, the routine use of echocardiography and Holter-ECG monitoring varied in participating stroke centres and at stroke-unit level, if grouped according to stroke-unit certification grade and hospitals´ university status. Trial registration Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267 .
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Affiliation(s)
- Manuel C Olma
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Alexianer St. Josefs-Krankenhaus Potsdam, Potsdam, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Internal Medicine, Herz-Jesu- Hospital Dernbach, Dernbach, Germany
| | - Ulrike Grittner
- Institute for Biometry Und Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Muhammad Jawad-Ul-Qamar
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Birmingham, UK
- Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Birmingham, UK
- University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Hospital Altona, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Ulrich Laufs
- Department of Cardiology, University Hospital, Leipzig University, Leipzig, Germany
| | - Darius G Nabavi
- Department of Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Clinical Trial Center Würzburg, Institute of medical Data Science, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- German Center for Mental Health (DZPG), Partner Site Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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3
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Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
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Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
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4
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Brandt L, Albert S, Brandt KL. [Thalamic infarction following paradoxical embolism during total hip replacement : Case report and pathophysiological considerations]. Anaesthesist 2022; 71:535-540. [PMID: 35133444 DOI: 10.1007/s00101-022-01094-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/14/2022] [Indexed: 11/24/2022]
Abstract
Because of a painful right-sided coxarthrosis a 57-year-old female patient underwent a cementless total arthroplasty under general anesthesia. Except for Asperger's syndrome and an occlusion of a vein in her left eye she stated no other diseases or complaints, especially no cardiac problems. Postoperatively she developed neurological symptoms of left-sided hemiparesis and hemihypesthesia. A cranial computer tomography was performed and a right-sided infarction of the thalamic region was found. A patent foramen ovale (PFO) and atrial septal aneurysm were detected 5 days later. The incidence of a PFO is given as 25% of the population. A paradoxical air embolism in the presence of a PFO is a feared complication in neurosurgical interventions in a semi-sitting or sitting position. Corpuscular emboli, such as bone, cement, fat or wound debris may be the reason for paradoxical embolisms in combination especially with partial or total hip replacement. The kind of embolism in the case described could not be clarified. Deep vein thrombosis or cardiac arrhythmia could be excluded. Therefore, it can be considered most likely that the operation site was the source of the embolism. The trigger for a paradoxical embolism is a reversal of the pressure difference between the right and left atria: normally the left atrial pressure exceeds the right atrial pressure by ca. 2-4 mm Hg, resulting possibly in a small clinically irrelevant left-to-right shunt. If the pulmonary arterial circulation is compromised and pulmonary vascular resistance increases, the pressure gradient between the left and right atria reverses and a right-to-left shunt can occur causing a paradoxical embolism. Positive end-expiratory pressure (PEEP) ventilation during anesthesia could be an important reason for a shunt reversal between the right and left atria and therefore favoring a paradoxical embolism but the pathophysiological role of PEEP has not yet been finally clarified.
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Affiliation(s)
- L Brandt
- abcGbR, Oberschleißheim, Deutschland. .,, Ernst-Udet-Straße 9, 85764, Oberschleißheim, Deutschland.
| | - S Albert
- Fachbereich Neurologie, Kantonsspital Graubünden, Chur, Schweiz
| | - K L Brandt
- Faculty of Medicine, Vilnius University, Vilnius, Litauen
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5
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Wilfling S, Kilic M, Tsoneva B, Freyer M, Olmes D, Wendl C, Linker R, Schlachetzki F. Recurrent vertebrobasilar strokes and transient-ischemic attacks with challenging workup: Case report. Brain Circ 2022; 8:50-56. [PMID: 35372722 PMCID: PMC8973451 DOI: 10.4103/bc.bc_61_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Detecting the stroke etiology in young patients can be challenging. Among others, determining causality between ischemic stroke and patent foramen ovale (PFO) remains a complicated task for stroke neurologists, given the relatively high prevalence of PFOs. Thorough diagnostic workup to identify incidental vascular risk factors and rare embolic sources is crucial to avoid premature PFO closure suggesting successful secondary stroke prevention. In this paper, we report on a 38-year-old patient with recurrent vertebrobasilar territory, especially right posterior inferior cerebellar artery (PICA) territory strokes. After the initial suspicion of a left vertebral artery (VA) dissection was not confirmed by ultrasound and magnetic resonance imaging (MRI) and other major risk factors were excluded, a PFO was detected and closed. Successful PFO closure was confirmed by transesophageal echocardiography, yet recurrent transient-ischemic attacks and vertebrobasilar strokes, especially during nighttime and in the early morning, occurred despite various antiplatelet and antithrombotic regimes and a persistent right-to-left shunt was detected by bubble transcranial Doppler. Finally, MRI after another vertebrobasilar infarction detected a transient left VA occlusion that finally led to the diagnosis of a left VA pseudoaneurysm from an incident emboligenic dissection in the atlas segment. This pseudoaneurysm together with an anatomical variant of the right PICA originating with the right anterior inferior cerebellar artery from the basilar artery finally explained the recurrent ischemic events of the patient. After successful treatment with coil occlusion, the patient suffered no further stroke and recovered completely. In summary, stroke in the young remains a diagnostic challenge. The incidental finding of a PFO should not deter from thorough stroke workup and the follow-up of these patients including PFO closure verification should be performed under the guidance of vascular neurologists.
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6
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Retinal Vascular Events after mRNA and Adenoviral-Vectored COVID-19 Vaccines-A Case Series. Vaccines (Basel) 2021; 9:vaccines9111349. [PMID: 34835280 PMCID: PMC8625395 DOI: 10.3390/vaccines9111349] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 01/25/2023] Open
Abstract
Background: To describe cases of retinal vascular events shortly after administration of mRNA or adenoviral-vectored COVID-19 vaccines. Design: Retrospective, multicenter case series. Methods: Six cases of retinal vascular events shortly after receiving COVID-19 vaccines. Results: A 38-year-old, otherwise healthy male patient presented with branch retinal arterial occlusion four days after receiving his second dose of SARS-CoV-2 vaccination with Comirnaty® (BioNTech®, Mainz, Germany; Pfizer®, New York City, NY, USA). An 81-year-old female patient developed visual symptoms twelve days after the second dose of SARS-CoV-2 vaccination with Comirnaty® and was diagnosed with a combined arterial and venous occlusion in her right eye. A 40-year-old male patient noticed blurry vision five days after his first dose of SARS-CoV-2 vaccination with Comirnaty® and was diagnosed with venous stasis retinopathy in his left eye. A 67-year-old male was diagnosed with non-arteritic anterior ischemic optic neuropathy in his right eye four days after receiving the first dose of Vaxzevria® (AstraZeneca®, Cambridge, UK). A 32-year-old man presented with a sudden onset of a scotoma two days after receiving the second dose of SARS-CoV-2 vaccination with Spikevax® (Moderna, Cambridge, UK) and was diagnosed with a circumscribed nerve fiber infarction. A 21-year-old female patient developed an acute bilateral acute macular neuroretinopathy three days after receiving the first dose of SARS-CoV2-vaccine Vaxzevria® (AstraZeneca®, Cambridge, UK). Conclusion: This case series describes six cases of retinal vascular events shortly after receiving mRNA or adenoviral-vectored COVID-19 vaccines. The short time span between received vaccination and occurrence of the observed retinal vascular events raises the question of a direct correlation. Our case series adds to further reports of possible side effects with potential serious post-immunization complications of COVID-19 vaccinations.
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7
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
- Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
- Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany
- Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany
- Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
- University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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8
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Schnabel RB, Häusler KG. [Cardiac diagnostics after ischemic stroke or transitory ischemic attack]. Dtsch Med Wochenschr 2021; 146:801-808. [PMID: 34130322 DOI: 10.1055/a-1221-7095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Stroke is the most common cause of permanent disability and one of the most common causes of death. Cardio-embolic strokes are associated with a poor prognosis and a high risk of recurrence compared to other stroke etiologies. The most common source of cardiac embolism is atrial fibrillation which must be quickly identified to optimize secondary stroke prevention. A structured evaluation after ischemic stroke includes taking the medical history, a physical examination, 12-lead ECG recording, rhythm monitoring for 72 h, transthoracic echocardiography and transesophageal echocardiography, if an atrial embolic source of stroke is suspected. Extended cardiac work-up (e. g., MRI/CT, prolonged rhythm monitoring) should be performed in selected patients based on diagnostic findings.
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9
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Diener HC, Nickenig G. [Secondary stroke prevention after TIA or ischemic stroke]. Herz 2021; 46:293-302. [PMID: 33914089 DOI: 10.1007/s00059-021-05035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
Stroke is one of the main causes of mortality and permanent disability. Secondary prevention of stroke recurrence therefore has a high priority. Secondary prevention of ischemic stroke includes optimization of the lifestyle and diet, treatment of risk factors, such as hypertension, diabetes mellitus and hyperlipidemia, prophylaxis of recurrence with antiplatelet treatment in patients with high vascular risk and anticoagulation in atrial fibrillation. In addition, secondary prevention includes carotid surgery or stenting in selected symptomatic patients and closure of a patent foramen ovale after cryptogenic stroke.
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Affiliation(s)
- Hans Christoph Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Georg Nickenig
- Herzzentrum, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Deutschland
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Hochholzer W, Nührenberg T, Flierl U, Olivier CB, Landmesser U, Möllmann H, Dörr M, Mehilli J, Schäfer A, Dürschmied D, Sibbing D, El-Armouche A, Zeymer U, Neumann FJ, Ahrens I, Geisler T. Antithrombotische Therapie nach strukturellen kardialen Interventionen. DER KARDIOLOGE 2021. [DOI: 10.1007/s12181-020-00441-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Strecker C, Günther F, Harloff A. Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients? Front Neurol 2021; 11:588151. [PMID: 33391153 PMCID: PMC7775476 DOI: 10.3389/fneur.2020.588151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke. Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology. Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020. Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.
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Affiliation(s)
- Christoph Strecker
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Felix Günther
- Department of Internal Medicine, Staufenburg Klinik, Durbach, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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Abstract
Stroke has traditionally been classified according to the trial of ORG 10172 in acute stroke treatment (TOAST) criteria; however, the concept of cryptogenic stroke did not meet the operational criteria necessary to define patient populations eligible for randomized studies. Therefore, the concept of embolic stroke of undetermined etiology (ESUS) was developed. An underlying hypothesis was that most strokes in patients with ESUS are caused by embolic events, hence, anticoagulation may prevent secondary events. Therefore, two large randomized trials were conducted comparing dabigatran or rivaroxaban with acetylsalicylic acid. Both studies could not show superiority of the new oral anticoagulants (NOAC) compared to aspirin; however, subgroup analyses showed that there is a patient population that may benefit from oral anticoagulation.
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Affiliation(s)
- Hans-Christoph Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät der Universität Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Deutschland.
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charite - Universitätsmedizin Berlin, Berlin, Deutschland
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Abstract
About 20–25% of all ischemic strokes are of cardioembolic etiology, with atrial fibrillation and heart failure as the most common underlying pathologies. Diagnostic work-up by noninvasive cardiac imaging is essential since it may lead to changes in therapy, e.g., in—but not exclusively—secondary stroke prevention. Echocardiography remains the cornerstone of cardiac imaging after ischemic stroke, with the combination of transthoracic and transesophageal echocardiography as gold standard thanks to their high sensitivity for many common pathologies. Transesophageal echocardiography should be considered as the initial diagnostic tool when a cardioembolic source of stroke is suspected. However, to date, there is no proven benefit of transesophageal echocardiography-related therapy changes on the main outcomes after ischemic stroke. Based on the currently available data, cardiac computed tomography and magnetic resonance imaging should be regarded as complementary methods to echocardiography, providing additional information in specific situations; however, they cannot be recommended as first-line modalities.
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Affiliation(s)
- S Camen
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany. .,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany.
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[Heart and brain-two terms, one central problem : The stroke]. Herz 2019; 44:287-288. [PMID: 31041491 DOI: 10.1007/s00059-019-4810-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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[Closure of the patent foramen ovale (PFO) in cryptogenic stroke]. Herz 2019; 44:304-309. [PMID: 30941472 DOI: 10.1007/s00059-019-4800-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Autopsy studies and echocardiographic investigations have shown that around 20-25% of the healthy population have a patent foramen ovale (PFO). In patients younger than 55 years the risk of a cryptogenic stroke is increased in the presence of a PFO. The first three randomized studies could not demonstrate superiority of an interventional closure of a PFO compared to antithrombotic treatment in patients with cryptogenic stroke. The results of three recently published studies and the extension of an earlier study showed a superiority of an interventional closure of a PFO compared to stroke prevention with antiplatelet therapy in patients aged 18-60 years after a cryptogenic stroke; however, PFO closure was not superior to oral anticoagulation but anticoagulation is associated with an increased risk of bleeding. The implantation of a PFO occluder can be associated with transient atrial fibrillation in some patients. The collaboration of neurologists and cardiologists is essential in order to select patients who are most likely to benefit from a PFO closure.
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Küpper C, Heinrich J, Müller K, Feil K, Kellert L. [Acute stroke]. MMW Fortschr Med 2019; 161:22-31. [PMID: 30912060 DOI: 10.1007/s15006-019-0008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Clemens Küpper
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, D-81377, München, Deutschland
| | | | | | - Katharina Feil
- Ludwig-Maximilians-Universität München, München, Deutschland
| | - Lars Kellert
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, D-81377, München, Deutschland.
- Ludwig-Maximilians-Universität München, München, Deutschland.
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
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