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Plomaritis P, Theodorou A, Michalaki V, Stefanou MI, Palaiodimou L, Papagiannopoulou G, Kotsali-Peteinelli V, Bregianni M, Andreadou E, Paraskevas GP, Giannopoulos S, Tsivgoulis G, Bonakis A. Periodic Limb Movements during Sleep in Acute Stroke: Prevalence, Severity and Impact on Post-Stroke Recovery. J Clin Med 2023; 12:5881. [PMID: 37762823 PMCID: PMC10531709 DOI: 10.3390/jcm12185881] [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: 08/03/2023] [Revised: 08/25/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Periodic Limb Movements during Sleep (PLMS) have been described to be frequently present in stroke patients. We aimed to evaluate the prevalence and severity of PLMS in acute stroke patients and clarify the association between PLMS and coexisting Sleep Disordered Breathing (SDB). Additionally, we focused on identifying variables that could independently predict the presence of PLMS in patients with acute stroke. The potential impact of PLMS on stroke outcome at three months was investigated as well. METHODS In this study, we performed overnight polysomnography on consecutive stroke patients within 72 h from symptom onset. Data regarding clinical and imaging characteristics were prospectively collected. National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Epworth-Sleepiness Scale (ESS) were used to evaluate stroke severity on admission, stroke outcome at three months and history of daytime sleepiness, respectively. We documented PLMS and SDB using standard polysomnography criteria. RESULTS We prospectively assessed 126 patients with acute stroke [109 with ischemic and 17 with hemorrhagic stroke, mean age 60 ± 11 years, 68% men, median NIHSS score on admission: 3 (IQR: 2-7)]. The overall rate of PLMS in our cohort was 76%, and the rate of SDB among patients with PLMS was 83%. PLMS detection rates differed significantly (p-value: <0.001) according to SDB, with PLMS prevalence increasing with greater SDB severity. SDB could independently (OR:4.869, 95% CI: 1.884-12.784, p-value: 0.001) predict the presence of PLMS in the acute stroke phase in multivariable analyses adjusting for potential confounders. Moreover, baseline stroke severity (NIHSS-score increase in per-1 point: OR: 0.819, 95% CI: 0.737-0.895, p-value < 0.001) and PLMS (OR:0.099, 95% CI: 0.009-0.482, p-value = 0.015) were significantly associated with the likelihood of excellent functional outcome (mRS-scores: 0-1) at 3 months. CONCLUSION The common presence of mostly severe PLMS in patients with acute stroke and their negative effect on stroke outcomes point out the necessity for early PLMS detection and treatment.
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Affiliation(s)
- Panagiotis Plomaritis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Vasiliki Michalaki
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Georgia Papagiannopoulou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Vasiliki Kotsali-Peteinelli
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Marianna Bregianni
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Elissavet Andreadou
- First Department of Neurology, “Eginition” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Georgios P. Paraskevas
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Sotirios Giannopoulos
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Anastasios Bonakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Chaidari, Greece; (P.P.); (A.T.); (V.M.); (M.-I.S.); (L.P.); (G.P.); (V.K.-P.); (M.B.); (G.P.P.); (S.G.); (G.T.)
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Ekizoglu E, Atmaca M, Çinar-Balcıoglu Ç, Yesilot N, Çoban O. CHADS 2 and CHA 2DS 2-VASc Scores Can Guide the Evaluation of Cryptogenic Ischemic Stroke. Neurol India 2021; 69:1716-1721. [DOI: 10.4103/0028-3886.333477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Characteristics and outcomes of Embolic Stroke of Undetermined Source according to stroke severity. Int J Stroke 2020; 15:866-871. [DOI: 10.1177/1747493020909546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and aims Patients with embolic strokes of undetermined source (ESUS) usually present with mild symptoms. We aimed to compare the baseline characteristics between mild and severe ESUS, identify predictors for severe ESUS, and assess outcomes of patients with severe ESUS. Methods In the AF-ESUS (AF-ESUS) dataset, we stratified ESUS severity using the median National Institutes of Health Stroke Scale (NIHSS) score on admission as cut-off. We performed multivariable stepwise regression analyses to identify independent predictors of severe ESUS and to assess the association between ESUS severity and stroke recurrence, death, and new incident atrial fibrillation (AF) on follow-up. The 10-year cumulative probabilities of outcome incidence were estimated by the Kaplan–Meier product limit method. Results In 772 patients (median NIHSS: 6 (interquartile range: 3–12)), 414 (53.6%) patients had severe ESUS (i.e. NIHSS ≥6). Female sex was the only independent predictor for severe ESUS (odds ratio: 1.72 (1.27–2.33)). The rates of recurrence (3.3%/year vs. 3.4%/year, adjusted-hazard ratio: 1.09 (0.73–1.62)) and new incident AF (13.5% vs. 17.0%, adjusted odds ratio: 0.67 (0.44–1.03)) were similar between severe and mild ESUS, but mortality was higher (5.4%/year vs. 3.7%/year, adjusted-hazard ratio: 1.51 (1.05–2.16)) in severe ESUS. The 10-year cumulative probability for stroke recurrence was similar between severe and mild ESUS (38.1% (29.2–48.6) vs. 36.6% (27.8–47.0), log-rank test: 0.01, p = 0.920). The 10-year cumulative probability of death was higher in patients with severe ESUS compared with mild ESUS (40.5% (32.5–50.0) vs. 34.0% (26.0–43.6) respectively; log-rank test: 4.54, p = 0.033). Conclusions Women have more severe ESUS compared with men. Patients with severe ESUS have similar rates of stroke recurrence and new incident AF, but higher mortality compared with mild ESUS.
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Vinogradov O, Jablonskij M, Kuznecov A. Embolic stroke of undetermined source. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:42-48. [DOI: 10.17116/jnevro202012012242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Characteristics and Outcomes of Younger Adults with Embolic Stroke of Undetermined Source (ESUS): A Retrospective Study. Stroke Res Treat 2019; 2019:4360787. [PMID: 31885851 PMCID: PMC6914878 DOI: 10.1155/2019/4360787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/24/2019] [Accepted: 09/06/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Embolic stroke of undetermined source (ESUS) in younger adults may have different risk factors compared with ESUS in elderly, and the approach to ESUS in young adults may require new therapies. We aimed to investigate the characteristics and outcomes in younger adults with ESUS at a single centre in Saudi Arabia. Patients and Methods A retrospective study was conducted using the medical records of younger adults with ESUS according to the criteria of the Cryptogenic Stroke/ESUS International Working Group. Younger adults (aged ≤50 years) with ESUS were compared with older patients, on admission and discharge from hospital, using the modified Rankin scale (mRS) and the National Institute of Health Stroke Scale (NIHSS). Results Among 147 patients with ESUS, 39 (26.5%) were younger adults. Younger adults compared with older adults with ESUS had fewer vascular risk factors, including lower rates of hypertension (43.6% vs. 70.3%; P = 0.004), diabetes (35.9% vs. 57.4%; P = 0.03), and dyslipidaemia (12.8% vs. 28.7%; P = 0.05). There was no significant difference in poor outcome at discharge (defined as mRS > 2), which was observed in 17.9% of younger adults and 28.7% of older adults. Further, there were no significant differences in stroke severity at discharge (NIHSS score ≤5) or median length of stay. Discussion Although the outcomes of ESUS do not differ between younger and older patients, younger patients have fewer identified risk factors. Conclusion This study showed that 26.5% of patients with ESUS were aged ≤50 years. Although younger adults with ESUS had fewer risk factors, there were no significant differences in neurologic disability or mortality at discharge, stroke severity, or median length of stay.
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Blat A, Dybas J, Chrabaszcz K, Bulat K, Jasztal A, Kaczmarska M, Pulyk R, Popiela T, Slowik A, Malek K, Adamski MG, Marzec KM. FTIR, Raman and AFM characterization of the clinically valid biochemical parameters of the thrombi in acute ischemic stroke. Sci Rep 2019; 9:15475. [PMID: 31664105 PMCID: PMC6820737 DOI: 10.1038/s41598-019-51932-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
The significance and utility of innovative imaging techniques in arterial clot analysis, which enable far more detailed and automated analysis compared to standard methods, are presented. The examination of two types of human thrombi is shown, representing the main ischemic stroke etiologies: fibrin–predominant clot of large vessel origin and red blood cells–rich clot of cardioembolic origin. The synergy effect of Fourier–transform infrared spectroscopy (FTIR), Raman spectroscopy (RS) and atomic force microscopy (AFM) techniques supported by chemometrics in comparison with reference histological staining was presented. The main advantage of such approach refers to free–label and non–destructive quantitative imaging of clinically valid, biochemical parameters in whole sample (FTIR–low resolution) and selected regions (RS–ultra–high resolution). We may include here analysis of lipid content, its distribution and total degree of unsaturation as well as analysis of protein content (mainly fibrin and hemoproteins). The AFM studies enhanced the vibrational data, showed clearly shape and thickness of clot features as well as visualized the fibrin framework. The extraordinary sensitivity of FTIR and RS imaging toward detection and discrimination of clinically valid parameters in clot confirms its applicability in assessment of thrombi origin.
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Affiliation(s)
- Aneta Blat
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland.,Faculty of Chemistry, Jagiellonian University, 2 Gronostajowa Str., Krakow, Poland
| | - Jakub Dybas
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland
| | - Karolina Chrabaszcz
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland.,Faculty of Chemistry, Jagiellonian University, 2 Gronostajowa Str., Krakow, Poland.,Center for Medical Genomics (OMICRON), Jagiellonian University Medical College, 7c Kopernika Str., 31-034, Krakow, Poland
| | - Katarzyna Bulat
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland
| | - Agnieszka Jasztal
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland
| | - Magdalena Kaczmarska
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland
| | - Roman Pulyk
- Department of Neurology, Jagiellonian University Medical College, 3 Botaniczna Str., 31-503, Krakow, Poland
| | - Tadeusz Popiela
- Department of Neuroradiology, Jagiellonian University Medical College, 3 Botaniczna Str., 31-503, Krakow, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, 3 Botaniczna Str., 31-503, Krakow, Poland
| | - Kamilla Malek
- Faculty of Chemistry, Jagiellonian University, 2 Gronostajowa Str., Krakow, Poland
| | - Mateusz G Adamski
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland
| | - Katarzyna M Marzec
- Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzynskiego Str., 30-348, Krakow, Poland. .,Center for Medical Genomics (OMICRON), Jagiellonian University Medical College, 7c Kopernika Str., 31-034, Krakow, Poland.
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Al Khathaami AM, Al Bdah B, Alnosair A, Alrebdi R, Alwayili S, Alhamzah S, Al Turki A, Alotaibi N. Embolic Stroke of Undetermined Source in Saudi Arabia: Prevalence, Patient Characteristics, and Outcomes. J Stroke Cerebrovasc Dis 2019; 28:104390. [PMID: 31607440 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 08/24/2019] [Accepted: 08/31/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) is a newly introduced clinical construct to better characterize cryptogenic stroke. It is associated with considerable morbidity and mortality and a high recurrence rate. It has not previously been investigated in Saudi stroke patients. We aimed to conduct a descriptive analysis of ESUS in Saudi Arabia, including its frequency among patients with acute stroke, characteristics, and outcomes. METHODS We reviewed all ischemic stroke patients admitted to the stroke unit at King Abdulaziz Medical City-Riyadh, Saudi Arabia, from February 2016 to July 2018. We applied the criteria proposed by the Cryptogenic Stroke/ESUS International Working Group, which defines ESUS as a radiologically confirmed nonlacunar brain infarct without (a) extracranial or intracranial atherosclerosis causing ≥50% stenosis in arteries supplying the ischemic area, (b) a major-risk cardioembolic source, (c) any other specific cause of stroke. We compared ESUS patients with the other stroke patients. Study was approved by local institutional review board. RESULTS Of the 736 patients admitted with ischemic stroke, 147 (20%) had ESUS. Patients with ESUS had fewer vascular risk factors compared to patients without ESUS. Nearly third were either dead or dependent at discharge. There were no significant differences between ESUS and other types of ischemic strokes in mortality rate and independence at discharge. CONCLUSION ESUS is common in Saudi stroke patients. Despite of the lack of definite etiology, it is associated with considerable morbidity and mortality.
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Affiliation(s)
- Ali M Al Khathaami
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Bayan Al Bdah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Rayan Alrebdi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Shorug Alwayili
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Sulaiman Alhamzah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Nasser Alotaibi
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Al Khathaami AM, Al Bdah B, Alnosair A, Alturki A, Alrebdi R, Alwayili S, Alhamzah S, Alotaibi ND. Predictors of poor outcome in embolic stroke of undetermined source. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2019; 24:164-167. [PMID: 31380814 PMCID: PMC8015519 DOI: 10.17712/nsj.2019.3.20190005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives: To identify the clinical predictors of death or disability at discharge. Methods: We retrospectively reviewed all ischemic stroke patients admitted to the stroke unit of King Abdulaziz Medical City, Riyadh, Saudi Arabia, from February 2016 - July 2018. We applied the Cryptogenic Stroke/ESUS International Working Group Embolic stroke of undetermined source (ESUS) criteria. We compared patients with poor outcomes (death or modified Rankin Scale [mRS] score >2) to those with favorable outcomes. Multivariate logistic regression was used to identify predictors of poor outcome. The regression model included age >60 years, gender, body mass index >25 kg/m2, smoking history, comorbidities, previous ischemic/transient ischemic attack, pre-stroke mRS score >1, National Institutes of Health Stroke Scale (NIHSS) score at admission >5, pre-stroke antiplatelet use, and thrombolysis treatment. Results: Out of 147 patients who met the ESUS criteria, 28.8% had poor outcomes. Predictors of poor outcome were NIHSS score >5 (odds ratio [OR] 11.1, 95% confidence interval [CI] 4.4–28.2), pre-stroke mRS score >1 (OR 3.7, 95% CI 1.14–11.59), and age >60 years (OR 2.4, 95% CI 1.14–5.22). Conclusion: A significant proportion of ESUS patients were dead or disabled at discharge. Poor outcome was more in older patients with pre-stroke functional disability and moderate to severe stroke.
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Affiliation(s)
- Ali M Al Khathaami
- Division of Neurology, Department of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. E-mail:
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Septal total atrial conduction time for prediction of atrial fibrillation in embolic stroke of unknown source: a pilot study. Clin Res Cardiol 2019; 109:205-214. [PMID: 31236691 PMCID: PMC6989646 DOI: 10.1007/s00392-019-01501-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/03/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Subclinical atrial fibrillation (AF) is the underlying cause in a relevant part of patients with embolic stroke of unknown source (ESUS). This pilot study aims to identify novel echocardiographic parameters predicting AF subsequently detected in patients originally hospitalized with ESUS. METHODS AND RESULTS Patients with acute ischemic stroke [baseline diagnosis of ESUS (n = 69), stroke of macro- or microvascular cause (n = 16/25), stroke caused by AF (n = 5)] and controls with paroxysmal AF without acute ischemic stroke (n = 22) as well as healthy controls of young and old age (n = 21/17) in sinus rhythm were included (overall n = 175). Echocardiography was performed in all participants. Prolonged Holter-ECG-monitoring was performed in all stroke patients. In the overall cohort, septal total atrial conduction time (sPA-TDI), left atrial (LA) volume index to tissue Doppler velocity (LAVI/a`) and second negative peak strain rate during LA contraction (SRa), representing echocardiographic parameters of LA remodelling and function, were statistically significant different in patients with and without AF and predictive for subclinical AF (multivariate regression analysis: sPA-TDI: HR 1.06 [1.04-1.08], p < 0.001; LAVI/a`: HR 0.85, [0.74-0.97], p = 0.02; SRa: HR 2.35 [0.9-5.5], p = 0.05). Multivariate Cox regression analysis revealed sPA-TDI as an independent predictor of AF in ESUS patients (sPA-TDI: HR 1.10 [1.04-1.17], p = 0.001). A sPA-TDI of 126 ms strictly discriminated between presence and absence of subclinical AF within 48 h after initiation of Holter-ECG-monitoring in ESUS patients. CONCLUSIONS sPA-TDI seems to be a strong independent predictor of subclinical AF in patients hospitalized for ESUS and might support risk-stratified clinical decision making in these patients. Septal Total Atrial Conduction Time (sPA-TDI) determined by echocardiography for prediction of Atrial Fibrillation in Embolic Stroke of Unknown Source (ESUS).
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Ntaios G, Perlepe K, Sirimarco G, Strambo D, Eskandari A, Karagkiozi E, Vemmou A, Koroboki E, Manios E, Makaritsis K, Michel P, Vemmos K. Carotid plaques and detection of atrial fibrillation in embolic stroke of undetermined source. Neurology 2019; 92:e2644-e2652. [DOI: 10.1212/wnl.0000000000007611] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/01/2019] [Indexed: 12/20/2022] Open
Abstract
ObjectiveTo investigate the association between the presence of ipsilateral nonstenotic carotid plaques and the rate of detection of atrial fibrillation (AF) during follow-up in patients with embolic strokes of undetermined source (ESUS).MethodsWe pooled data of all consecutive ESUS patients from 3 prospective stroke registries. Multivariate stepwise regression assessed the association between the presence of nonstenotic carotid plaques and AF detection. The 10-year cumulative probabilities of AF detection were estimated by the Kaplan-Meier product limit method.ResultsAmong 777 patients followed for 2,642 patient-years, 341 (38.6%) patients had an ipsilateral nonstenotic carotid plaque. AF was detected in 112 (14.4%) patients in the overall population during follow-up. The overall rate of AF detection was 8.5% in patients with nonstenotic carotid plaques (2.9% per 100 patient-years) and 19.0% in patients without (5.0% per 100 patient-years) (unadjusted hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.37–0.84). The presence of ipsilateral nonstenotic carotid plaques was associated with lower probability for AF detection (adjusted HR 0.57, 95% CI 0.34–0.96, p = 0.03). The 10-year cumulative probability of AF detection was lower in patients with ipsilateral nonstenotic carotid plaques compared to those without (34.5%, 95% CI 21.8–47.2 vs 49.0%, 95% CI 40.4–57.6 respectively, log-rank-test: 11.8, p = 0.001).ConclusionsAF is less frequently detected in ESUS patients with nonstenotic carotid plaques compared to those without.Clinicaltrials.gov identifierNCT02766205.
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