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Saglietto A, Bertello E, Barra M, Ferraro I, Rovera C, Orzan F, De Ferrari GM, Anselmino M. MRI pattern characterization of cerebral cardioembolic lesions following atrial fibrillation ablation. Front Cardiovasc Med 2024; 11:1327567. [PMID: 38327489 PMCID: PMC10847299 DOI: 10.3389/fcvm.2024.1327567] [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: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background Recognizing etiology is essential for treatment and secondary prevention of cerebral ischemic events. A magnetic resonance imaging (MRI) pattern suggestive of an embolic etiology has been described but, to date, there are no uniformly accepted criteria. Aim The purpose of the study is to describe MRI features of ischemic cerebral lesions occurring after transcatheter ablation of atrial fibrillation (AF). Methods A systematic review and meta-analysis of studies performing brain imaging investigations before and after AF transcatheter ablation was performed. The incidence of cerebral ischemic lesions after AF transcatheter ablation was the primary endpoint. The co-primary endpoints were the prevalence of the different neuroimaging features regarding the embolic cerebral ischemic lesions. Results A total of 25 studies, encompassing 3,304 patients, were included in the final analysis. The incidence of ischemic cerebral lesions following AF transcatheter ablation was 17.2% [95% confidence interval (CI) 12.2%-23.8%], of which a minimal fraction was symptomatic [0.60% (95% CI 0.09%-3.9%)]. Only 1.6% of the lesions (95% CI 0.9%-3.0%) had a diameter >10 mm, and in 20.5% of the cases the lesions were multiple (95% CI 17.1%-24.4%). Brain lesions were equally distributed across the two hemispheres and the different lobes; cortical location was more frequent [64.0% (95% CI 42.9%-80.8%)] while the middle cerebral artery territory was the most involved 37.0% (95% CI 27.3-48.0). Conclusions The prevailing MRI pattern comprises a predominance of small (<10 mm) cortical lesions, more prevalent in the territory of the middle cerebral artery.
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Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Eleonora Bertello
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Barra
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ilenia Ferraro
- Division of Cardiology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Chiara Rovera
- Department of Cardiology, Civic Hospital of Chivasso, Chivasso, Italy
| | - Fulvio Orzan
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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2
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Inogés M, Arboix A, García-Eroles L, Sánchez-López MJ. Gender Predicts Differences in Acute Ischemic Cardioembolic Stroke Profile: Emphasis on Woman-Specific Clinical Data and Early Outcome-The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:101. [PMID: 38256361 PMCID: PMC10819324 DOI: 10.3390/medicina60010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Acute ischemic cardioembolic stroke (CS) is a clinical condition with a high risk of death, and can lead to dependence, recurrence, and dementia. Materials and Methods: In this study, we evaluated gender differences and female-specific clinical data and early outcomes in 602 women diagnosed with CS from a total of 4600 consecutive acute stroke patients in a single-center hospital stroke registry over 24 years. A comparative analysis was performed in women and men in terms of demographics, cerebrovascular risk factors, clinical data, and early outcomes. Results: In a multivariate analysis, age, hypertension, valvular heart disease, obesity, and internal capsule location were independent variables associated with CS in women. The overall in-hospital mortality rate was similar, but the group of women had a greater presence of neurological deficits and a higher percentage of severe limitation at hospital discharge. After the multivariate analysis, age, altered consciousness, limb weakness, and neurological, respiratory, gastrointestinal, renal, cardiac and peripheral vascular complications were independent predictors related to early mortality in women. Conclusions: Women with CS showed a differential demographic and clinical profile and worse early outcomes than men. Advanced age, impaired consciousness, and medical complications were predictors of stroke severity in women with CS.
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Affiliation(s)
- Marc Inogés
- Department of Neurology, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain; (M.I.); (L.G.-E.)
| | - Adrià Arboix
- Department of Neurology, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain; (M.I.); (L.G.-E.)
| | - Luís García-Eroles
- Department of Neurology, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain; (M.I.); (L.G.-E.)
| | - María José Sánchez-López
- Medical Library, Hospital Universitari Sagrat Cor, Grupo Quirónsalud, Universitat de Barcelona, 08029 Barcelona, Catalonia, Spain;
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3
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Aerospace Medicine Clinic. Aerosp Med Hum Perform 2023; 94:864-867. [PMID: 37891716 DOI: 10.3357/amhp.6257.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
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4
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Wang Y, Mossa-Basha M, Zhu C. Spontaneously Ruptured Aortic Plaque: A Potential Cause for Frequently Observed Cerebral Infarct? JACC. ASIA 2022; 2:760-762. [PMID: 36444318 PMCID: PMC9699997 DOI: 10.1016/j.jacasi.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Mahmud Mossa-Basha
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, Washington, USA
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Higuchi Y, Hirayama A, Hamanaka Y, Kobayashi T, Sotomi Y, Komatsu S, Yutani C, Kodama K. Significant Contribution of Aortogenic Mechanism in Ischemic Stroke: Observation of Aortic Plaque Rupture by Angioscopy. JACC. ASIA 2022; 2:750-759. [PMID: 36444317 PMCID: PMC9700032 DOI: 10.1016/j.jacasi.2022.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Although embolic stroke accounts for most cerebral infarction, examinations to identify the embolic source have been insufficient. Nonobstructive general angioscopy (NOGA) has developed to allow the detailed observation of atheromatous changes of the aorta. OBJECTIVES The purpose of this study was to clarify the importance of the aortogenic mechanism in the development of ischemic stroke. METHODS We examined 114 consecutive patients whose aorta was observed by NOGA and who subsequently underwent brain magnetic resonance imaging to detect ischemic stroke lesions. In the evaluation of the aorta, the presence and location of spontaneously ruptured aortic plaque (SRAP) were determined. The aorta was observed from the origin to the arch (proximal aorta [PAo]) and the proximal descending aorta. RESULTS Forty-nine of 114 patients had SRAP observed by NOGA. Among these, 24 had SRAP in the PAo, and 43 had SRAP in the descending aorta. Thirty-three patients had ischemic stroke lesions, including 6 with a clinical neurologic deficit. The frequency at which SRAP was detected in these patients was significantly higher in comparison to 81 patients without ischemic stroke (69% vs 33%; P < 0.01). The sensitivity and specificity of the presence of SRAP for ischemic stroke were 0.70 and 0.68, respectively. The presence of SRAP in PAo was significantly correlated with ischemic stroke (odds ratio: 14.3; P < 0.001). CONCLUSIONS In the treatment of ischemic stroke, attention should be paid to SRAP, especially that in the PAo. (STROKE-NOGA [SponTaneously Ruptured aOrtic plaques as a potential cause of embolic stroKEs visualized by Non-Obstructive General Angioscopy] Study; UMIN000034588).
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Key Words
- AF, atrial fibrillation
- DAo, proximal descending aorta
- DOAC, direct oral anticoagulant
- DWI, diffusion-weighted imaging
- FLAIR, fluid-attenuated inversion recovery
- MRA, magnetic resonance angiography
- MRI, magnetic resonance imaging
- NOGA, nonobstructive general angioscopy
- PAo, proximal aorta
- SRAP, spontaneously ruptured aortic plaque
- TEE, transesophageal echocardiography
- angioscopy
- aortic plaque
- embolic stroke
- ischemic stroke
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Affiliation(s)
| | | | - Yuma Hamanaka
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | | | - Yohei Sotomi
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Sei Komatsu
- Cardiovascular Center, Osaka Gyoumeikan Hospital, Osaka, Japan
| | - Chikao Yutani
- Morinomiya Academy of Medical Arts and Sciences, Osaka, Japan
| | - Kazuhisa Kodama
- Cardiovascular Center, Osaka Gyoumeikan Hospital, Osaka, Japan
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Paradoxical embolic stroke: giant coronary aneurysms, myxoma, and PFO. Neurol Sci 2022; 43:6101-6103. [DOI: 10.1007/s10072-022-06161-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/18/2022] [Indexed: 11/25/2022]
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Lee JW, Park CH, Im DJ, Lee KH, Kim TH, Han K, Hur J. CT-based radiomics signature for differentiation between cardiac tumors and a thrombi: a retrospective, multicenter study. Sci Rep 2022; 12:8173. [PMID: 35581366 PMCID: PMC9114026 DOI: 10.1038/s41598-022-12229-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 05/06/2022] [Indexed: 12/20/2022] Open
Abstract
The study aimed to develop and validate whether the computed tomography (CT) radiomics analysis is effective in differentiating cardiac tumors and thrombi. For this retrospective study, a radiomics model was developed on the basis of a training dataset of 192 patients (61.9 ± 13.3 years, 90 men) with cardiac masses detected in cardiac CT from January 2010 to September 2019. We constructed three models for discriminating between a cardiac tumor and a thrombus: a radiomics model, a clinical model, which included clinical and conventional CT variables, and a model that combined clinical and radiomics models. In the training dataset, the radiomics model and the combined model yielded significantly higher differentiation performance between cardiac tumors and cardiac thrombi than the clinical model (AUC 0.973 vs 0.870, p < 0.001 and AUC 0.983 vs 0.870, p < 0.001, respectively). In the external validation dataset with 63 patients (59.8 ± 13.2 years, 26 men), the combined model yielded a larger AUC compared to the clinical model (AUC 0.911 vs 0.802, p = 0.037). CT radiomics analysis is effective in differentiating cardiac tumors and thrombi. In conclusion, the combination of clinical, conventional CT, and radiomics features demonstrated an additional benefit in differentiating between cardiac tumor and thrombi compared to clinical data and conventional CT features alone.
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Affiliation(s)
- Ji Won Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Busan, South Korea
| | - Chul Hwan Park
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Jin Im
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Kye Ho Lee
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Tae Hoon Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
| | - Jin Hur
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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Diagnostic Yield of TEE in Patients with Cryptogenic Stroke and TIA with Normal TTE: A Systematic Review and Meta-Analysis. Neurol Int 2021; 13:659-670. [PMID: 34940749 PMCID: PMC8706810 DOI: 10.3390/neurolint13040063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/02/2021] [Accepted: 10/27/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The role of transesophageal echocardiography (TEE) in cryptogenic stroke and transient ischemic attack (TIA) with normal transthoracic echocardiography (TTE) remains controversial in the absence of definite guidelines. We aimed to perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal TTE. METHODS We performed a systematic review of cohort studies on PubMed using the keywords 'cryptogenic stroke', cryptogenic TIA', 'TEE', and 'TTE' with matching MeSH terms. We included studies with patients who had cryptogenic stroke or TIA and had normal TTE findings, where the study intended to obtain TEE on all patients and reported all TEE abnormalities. The studies containing patients with atrial fibrillation were excluded. All studies were evaluated for internal and external validity. Inverse variance random effects models were used to calculate the effect size, the number needed to diagnose, and the 95% confidence interval. RESULTS We included 15 studies with 2054 patients and found LA/LAA/aortic thrombus, valvular vegetation, PFO-ASA, valvular abnormalities, and complex aortic plaques on TEE. Of these, 37.5% (29.7%-45.1%) of patients had additional cardiac findings on TEE. Management of 13.6% (8.1%-19.1%) of patients had changed after TEE evaluation. Based on current guidelines, it should change management in 4.1% (2.1%-6.2%) of patients and could potentially change management in 30.4% (21.9%-38.9%) of patients. Sensitivity analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5%-48.3%), changed management in 20.2% (8.7%-31.8%), should change management in 4.7% (1.5%-7.9%), and could potentially change management in 30.4% (17.8%-43.0%) of patients. CONCLUSIONS The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is not only high, but it can also change management for certain cardiac abnormalities. TTE in cryptogenic stroke or TIA may mitigate future risks by tailoring the management of these patients.
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Abstract
This article focuses on the inpatient evaluation and management of ischemic stroke and transient ischemic attack (TIA). We describe foundational principles including quality metrics, TIA, and stroke as emergencies, TIA/minor stroke management, and standard assessments before discussing tailored evaluation and management strategies by stroke type.
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Affiliation(s)
- Lauren Patrick
- Department of Neurology, Division of Neurovascular, University of California San Francisco, 505 Parnassus Avenue, M-830, San Francisco, CA 94143, USA; Weill Institute for Neuroscience, San Francisco, CA, USA
| | - Cathra Halabi
- Department of Neurology, Division of Neurovascular, University of California San Francisco, 505 Parnassus Avenue, M-830, San Francisco, CA 94143, USA; Weill Institute for Neuroscience, San Francisco, CA, USA.
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10
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Meinel TR, Eggimann A, Brignoli K, Wustmann K, Buffle E, Meinel FG, Scheitz JF, Nolte CH, Gräni C, Fischer U, Kaesmacher J, Seiffge DJ, Seiler C, Jung S. Cardiovascular MRI Compared to Echocardiography to Identify Cardioaortic Sources of Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:699838. [PMID: 34393979 PMCID: PMC8362907 DOI: 10.3389/fneur.2021.699838] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/30/2021] [Indexed: 01/21/2023] Open
Abstract
Background: To compare the diagnostic yield of echocardiography and cardiovascular MRI (CMR) to detect structural sources of embolism, in patients with ischemic stroke with a secondary analysis of non-stroke populations. Methods and Results: We searched MEDLINE/Embase (from 01.01.2000 to 24.04.2021) for studies including CMR to assess prespecified sources of embolism. Comparison included transthoracic and/or transesophageal echocardiography. Two authors independently screened studies, extracted data and assessed bias using the QUADAS-2 tool. Estimates of diagnostic yield were reported and pooled. Twenty-seven studies with 2,525 patients were included in a study-level analysis. Most studies had moderate to high risk of bias. Persistent foramen ovale, complex aortic plaques, left ventricular and left atrial thrombus were the most common pathologies. There was no difference in the yield of left ventricular thrombus detection between both modalities for stroke populations (4 studies), but an increased yield of CMR in non-stroke populations (28.1 vs. 16.0%, P < 0.001, 10 studies). The diagnostic yield in stroke patients for detection of persistent foramen ovale was lower in CMR compared to transoesophageal echocardiography (29.3 vs. 53.7%, P < 0.001, 5 studies). For both echocardiography and CMR the clinical impact of the management consequences derived from many of the diagnostic findings remained undetermined in the identified studies. Conclusions: Echocardiography and CMR seem to have similar diagnostic yield for most cardioaortic sources of embolism except persistent foramen ovale and left ventricular thrombus. Randomized controlled diagnostic trials are necessary to understand the impact on the management and potential clinical benefits of the assessment of structural cardioaortic stroke sources. Registration: PROSPERO: CRD42020158787.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Angela Eggimann
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Kristina Brignoli
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Kerstin Wustmann
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eric Buffle
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research, Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research, Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Christoph Gräni
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Predictive Value of Cardiac CTA, Cardiac MRI, and Transthoracic Echocardiography for Cardioembolic Stroke Recurrence. AJR Am J Roentgenol 2021; 217:336-346. [PMID: 32936016 DOI: 10.2214/ajr.20.23903] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Transthoracic echocardiography (TTE) is the standard of care for initial evaluation of patients with suspected cardioembolic stroke. Although TTE is useful for assessing certain sources of cardiac emboli, its diagnostic capability is limited in the detection of other sources, including left atrial thrombus and aortic plaques. OBJECTIVE. The purpose of this article was to investigate sensitivity, specificity, and predictive value of cardiac CTA (CCTA), cardiac MRI (CMRI), and TTE for recurrence in patients with suspected cardioembolic stroke. METHODS. We retrospectively included 151 patients with suspected cardioembolic stroke who underwent TTE and either CMRI (n = 75) or CCTA (n = 76) between January 2013 and May 2017. We evaluated for the presence of left atrial thrombus, left ventricular thrombus, vulnerable aortic plaque, cardiac tumors, and valvular vegetation as causes of cardioembolic stroke. The end point was stroke recurrence. Sensitivity, specificity, PPV, and NPV for recurrent stroke were calculated; the diagnostic accuracy of CMRI, CCTA, and TTE was compared between and within groups using AUC. RESULTS. Twelve and 14 recurrent strokes occurred in the CCTA and CMRI groups, respectively. Sensitivity, specificity, PPV, and NPV were 33.3%, 93.7%, 50.0%, and 88.2% for CCTA; 14.3%, 80.3%, 14.3%, and 80.3% for CMRI; 14.3%, 83.6%, 16.7%, and 80.9% for TTE in the CMRI group; and 8.3%, 93.7%, 20.0%, and 84.5% for TTE in the CCTA group. Accuracy was not different (p > .05) between CCTA (AUC = 0.63; 95% CI, 0.49-0.77), CMRI (0.53; 95% CI, 0.42-0.63), TTE in the CMRI group (0.51; 95% CI, 0.40-0.61), and TTE in the CCTA group (0.51; 95% CI, 0.42-0.59). In the CCTA group, atrial and ventricular thrombus were detected by CCTA in three patients and TTE in one patient; in the CMRI group, thrombus was detected by CMRI in one patient and TTE in two patients. CONCLUSION. CCTA, CMRI, and TTE showed comparably high specificity and NPV for cardioembolic stroke recurrence. CCTA and CMRI may be valid alternatives to TTE. CCTA may be preferred given potentially better detection of atrial and ventricular thrombus. CLINICAL IMPACT. CCTA and CMRI have similar clinical performance as TTE for predicting cardioembolic stroke recurrence. This observation may be especially important when TTE provides equivocal findings.
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12
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Lu X, Chen T, Liu G, Guo Y, Shi X, Chen Y, Li Y, Guo J. Relations between left atrial appendage contrast retention and thromboembolic risk in patients with atrial fibrillation. J Thromb Thrombolysis 2021; 53:191-201. [PMID: 34128199 DOI: 10.1007/s11239-021-02490-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
Left atrial appendage (LAA), a blind pouch, accounts for more than 90% of the source of cardiac thrombus formation. Contrast retention (CR) in the LAA has been frequently observed during left atrial appendage occlusion (LAAO) procedures, especially in patients with stroke history. This study was designed to assess the relations between LAA contrast retention and thrombogenesis risk of the LAA in patients with non-valvular atrial fibrillation. A total of 132 consecutive patients who underwent LAAO were enrolled. The data collected from computed tomography (CT), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and blood samples were analyzed. Univariate and multivariate logistic regression models were constructed to assess the association between CR, left atrial appendage thrombus (LAAT) and other factors. Contrast retention was observed in 33 patients, accounting for 25% of the population. Compared to the non-CR group, patients in the CR group had a larger left atrium anteroposterior diameter (49.64 ± 11.57 vs. 42.42 ± 7.04, P = 0.002), higher CHADS2 (3.88 ± 0.99 vs. 2.97 ± 1.35, P = 0.001) and CHA2DS2-VASc scores (5.79 ± 1.14 vs. 4.89 ± 1.56, P = 0.003), a higher rate of prior stroke (90.9% vs. 66.7%, P = 0.007), more LAA lobes (3.13 ± 1.18 vs. 2.64 ± 1.12, P = 0.038), and a higher prevalence of LAAT (63.6% vs. 13.1%, P < 0.001). After having adjusted the logistic model, only contrast retention, LAA cauliflower morphology and left ventricular ejection fraction (LVEF) were independently associated with LAAT. Patients with LAA contrast retention have a higher risk of left atrial appendage thrombosis. Contrast retention may be a cardiac factor strongly associated with cardiogenic stroke.
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Affiliation(s)
- Xu Lu
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing, 100853, China.,Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.,Outpatient Department, The 44th Sanatorium of Retired Cadres in Haidian District, No. 19 Dahuisi Road, Beijing, 100081, China
| | - Tao Chen
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ge Liu
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yutao Guo
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xiangmin Shi
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yundai Chen
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yang Li
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Jun Guo
- Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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13
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Tsai CT, Liao JN, Chen SJ, Jiang YR, Chen TJ, Chao TF. Non-vitamin K antagonist oral anticoagulants versus warfarin in AF patients ≥ 85 years. Eur J Clin Invest 2021; 51:e13488. [PMID: 33420738 DOI: 10.1111/eci.13488] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) prevalence and its risk of stroke rise with ageing. We aimed to investigate the outcomes of NOAC and warfarin in AF patients aged ≥ 85 years. METHODS This is a retrospective study using Taiwan National Health Insurance Research Database. A total of 15,361 patients aged ≥ 85 years with AF on oral anticoagulants were identified. The end points included ischaemic stroke, intracranial haemorrhage (ICH), major bleeding, all-cause mortality and composite adverse events (ICH or major bleeding or all-cause mortality). Clinical outcomes were compared between each NOAC and warfarin after propensity matching. RESULTS Before propensity matching, patients taking warfarin were older, more female with more comorbidities than NOACs users. After propensity matching, baseline characteristics did not differ significantly between matched subjects receiving warfarin and each NOAC. Compared to warfarin, dabigatran was associated with a lower risk of ICH (hazard ratio [HR] 0.496), mortality (HR 0.558) and adverse events (HR 0.628), while rivaroxaban was associated with a lower risk of ischaemic stroke (HR 0.781), ICH (HR 0.453), mortality (HR 0.558) and adverse events (HR 0.636). Apixaban was associated with a lower risk of mortality (HR 0.488) and adverse events (HR 0.557) compared to warfarin. (all P < .05). CONCLUSION For the efficacy, NOACs were associated with a comparable or lower risk of ischaemic stroke compared to warfarin. For adverse events, NOACs were associated with a lower risk of all-cause mortality and composite adverse events. In the elderly AF population, NOACs could be a more favourable choice for stroke prevention.
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Affiliation(s)
- Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Su-Jung Chen
- Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Ru Jiang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
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14
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Matano F, Tamaki T, Yamazaki M, Enomono H, Mizunari T, Tateyama K, Murai Y, Tanikawa R, Morita A. Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages. J Clin Neurosci 2021; 89:206-210. [PMID: 34119268 DOI: 10.1016/j.jocn.2021.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND IMPORTANCE In cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages. CLINICAL PRESENTATION A 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital. CONCLUSION Open surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.
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Affiliation(s)
- Fumihiro Matano
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan.
| | - Tomonori Tamaki
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan
| | - Michio Yamazaki
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroyuki Enomono
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan
| | - Takayuki Mizunari
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Kojiro Tateyama
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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15
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Cong L, Ma W. Early neurological deterioration in cardiogenic cerebral embolism due to nonvalvular atrial fibrillation: Predisposing factors and clinical implications. Brain Behav 2021; 11:e01985. [PMID: 33277821 PMCID: PMC7882173 DOI: 10.1002/brb3.1985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The aim of the study was to investigate factors which may predispose patients to early neurological deterioration (END) and explore peripheral biomarkers for the prediction of END in cardiogenic cerebral embolism (CCE) patients. METHODS Patients diagnosed with CCE within 24 hr of onset between January 2017 and January 2019 were included in this study. END was defined as an increase of ≥2 on the National Institutes of Health Stroke Scale (NIHSS) or the emergence of new neurological symptoms within 3 days of admission. Binary logistic regression was used to investigate the factors associated with END. Receiver operating characteristic (ROC) curves were then generated to determine the predictive value of the potential biomarkers and the optimal cutoff values. RESULTS Of the 129 (male, 55.81%; mean age 71.85 ± 11.99 years) CCE patients, 55 patients with END were identified. Hemorrhage transformation (HT), coronary heart disease (CHD), diastolic blood pressure, cystatin C levels, NIHSS score, and platelet-to-lymphocyte ratio (PLR) at admission were independently associated with END. A peripheral cystatin C level ≥ 1.41 mg/L and a PLR ≥ 132.97 were predictive factors for END in CCE patients. The lymphocyte-to-monocyte ratio (LMR) was negatively independently associated with HT, and LMR < 2.31 may predict the occurrence of HT in patients with CCE. CONCLUSIONS Of the potential predisposing factors considered, increased cystatin C and PLR were associated with END within 3 days of CCE, and a decreased LMR may have predictive value for HT in CCE patients.
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Affiliation(s)
- Lin Cong
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weining Ma
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
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16
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Pagola J, Pagola C, Juega J, González-Alujas T, Alvarez-Sabin J, Molina CA. The Role of Echocardiography Screening at the Stroke Unit. Front Neurol 2020; 11:1003. [PMID: 33013663 PMCID: PMC7516041 DOI: 10.3389/fneur.2020.01003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/30/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jorge Pagola
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Carlos Pagola
- Cardiology Department, Ciudad de Jaén University Hospital, Jaén, Spain
| | - Jesús Juega
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Teresa González-Alujas
- Echocardiography Lab Cardiology Department, Vall D'Hebrón Hospital, CIBER-CV, Barcelona, Spain
| | - José Alvarez-Sabin
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Neurology Department, Vall D'Hebron Hospital, Vall D'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma Barcelona, Barcelona, Spain
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17
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Xia F, Yu X, Li Y, Chen Y, Zhang W, You C, Hu X. Geographic Variations of Stroke Incidence in Chinese Communities: An 18-Year Prospective Cohort Study from 1997 to 2015. J Stroke 2020; 22:345-356. [PMID: 33053950 PMCID: PMC7568967 DOI: 10.5853/jos.2020.02383] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/24/2020] [Indexed: 02/05/2023] Open
Abstract
Background and Purpose As a leading cause of disability and death in China, stroke as well as its epidemiologic features have gained increasing attention. Prior studies, however, have overgeneralized the north-to-south gradient in China. Whether the differences exist across urban and rural areas remains unexplored. This study therefore aims to investigate the north-to-south gradient in stroke incidence across urban and rural China.
Methods The present prospective cohort study analyzed data from the China Health and Nutrition Survey 1997 to 2015. By including 16,917 individuals from diverse social contexts, we calculated the age-standardized incidence of stroke across regions and the age-adjusted risk ratio (aRR). Cox proportional hazards models with time-varying covariates were employed to analyze variations in incident stroke.
Results During the follow-up, age-standardized incidence of stroke ranged from 4.17 per 1,000 person-years (95% confidence interval [CI], 3.38 to 4.96) in the north region to 1.95 (95% CI, 1.60 to 2.30) in the south region (aRR, 2.04; 95% CI, 1.58 to 2.64; P<0.001). The north-to-south gradient of stroke incidence was observed only in rural areas, but not in urban areas. Hierarchical modelling analyses further indicated that the regional differences could be mostly explained by the disparities in the prevalence of hypertension.
Conclusions The present study extends the current evidence on the north-to-south gradient by demonstrating that the difference varied across urban and rural China. Our findings highlight the importance of hypertension management as the measure for alleviating regional differences in stroke incidence.
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Affiliation(s)
- Fan Xia
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xuexin Yu
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yunke Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Zhang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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18
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Differentiation of left atrial appendage thrombus from circulatory stasis using cardiac CT radiomics in patients with valvular heart disease. Eur Radiol 2020; 31:1130-1139. [PMID: 32812175 DOI: 10.1007/s00330-020-07173-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/19/2020] [Accepted: 08/10/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To determine whether quantitative radiomic features from cardiac CT could differentiate the left atrial appendage (LAA) thrombus from circulatory stasis in patients with valvular heart disease. METHODS Ninety-five consecutive patients with valvular heart disease and filling defects in LAA on two-phase cardiac CT from March 2016 to August 2018 were retrospectively enrolled and classified as having thrombus or stasis by transesophageal echocardiography or cardiac surgery. The ratio of Hounsfield units in the filling defects to those in the ascending aorta (AA) was calculated on early- and late-phase CT (LAA/AAE and LAA/AAL, respectively). Radiomic features were extracted from semi-automated three-dimensional segmentation of the filling defect on early-phase CT. The diagnostic ability of radiomic features for differentiating thrombus from stasis was assessed and compared to LAA/AAE and LAA/AAL by comparing the AUC of ROC curves. Diagnostic performances of CT attenuation ratios and radiomic features were validated with an independent validation set. RESULTS Thrombus was diagnosed in 25 cases and stasis in 70. Sixty-eight radiomic features were extracted. Values of 8 wavelet-transformed features were lower in thrombus than in stasis (p < 0.001). The AUC value of a radiomic feature, wavelet_LHL, for diagnosing thrombus was 0.78, which was higher than that of LAA/AAE (AUC = 0.54, p = 0.025) and similar to that of LAA/AAL (AUC = 0.76, p = 0.773). In the validation set, the AUC of wavelet_LHL was 0.71, which was higher than that of LAA/AAE (AUC = 0.57, p = 0.391) and similar to that of LAA/AAL (AUC = 0.75, p = 0.707). CONCLUSIONS Quantitative radiomic features from the early phase of cardiac CT may help diagnose LAA thrombus in patients with valvular heart disease. KEY POINTS • Wavelet-transformed grey-level non-uniformity values from radiomic analysis are significantly lower for LAA thrombus than for circulatory stasis. • Radiomic features may have an additional value for differentiating LAA thrombus from circulatory stasis when interpreting single-phase cardiac CT. • Radiomic features extracted from single-phase images may show similar diagnostic ability as conventional quantitative analysis from two-phase images.
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19
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Lionnet A, Cueff C, de Gaalon S, Manigold T, Sévin M, Testard N, Guillon B. Cause cardiache di embolia cerebrale. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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20
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Hernández García E, Díaz Gómez L, Borrego García E. Ischemic ictus by calcium embolus in a patient in hemodialysis with secondary hyperparathyroidism. Med Clin (Barc) 2020; 156:257. [PMID: 32115201 DOI: 10.1016/j.medcli.2019.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 11/28/2019] [Accepted: 12/05/2019] [Indexed: 10/24/2022]
Affiliation(s)
| | - Lidia Díaz Gómez
- Servicio de Nefrología, Hospital Universitario San Cecilio, Granada, España
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21
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Mohamed WS, Abd ElGawad EA, ElMotayam ASE, Fathy SE. Cardio embolic stroke and blood biomarkers: diagnosis and predictors of short-term outcome. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0102-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The brain is a productive source of a variety of enzymes and any brain injury like a stroke to brain tissue could similarly result in an increase in these enzymes in cerebrospinal fluid and serum. Evaluation of these enzymes represents a simple method for the ischemic stroke subtype diagnosis and prognosis. Objective: This study aimed to determine the role of brain natriuretic peptide (BNP), d-dimer, creatine–kinase-MB (CK-MB), C-reactive protein (CRP) serum levels, and globulin/albumin ratio in the diagnosis of CES stroke and its ability to predict short-term outcome.
Methods
This study was conducted on 96 patients with acute ischemic stroke, subdivided into two groups: group Ι was 48 patients with cardio-embolic stroke and group ΙΙ was 48 patients with non-cardio-embolic. All patients were subjected to the assessment of serum BNP, d-dimer and CK-MB, and CRP and globulin/albumin ratio within the first 24 h of stroke. In the third week, they were assessed by mRS.
Results
The mean levels of BNP, d-dimer level, and CK-MB were significantly higher in patients with cardio-embolic stroke than in patients with non-cardio-embolic stroke (P < 0.001) and also were associated with poor short-term outcome.
Conclusion
Elevated plasma levels of BNP, d-dimer levels, and CK-MB can be used as surrogate biomarkers for the diagnosis of cardio-embolic stroke and prediction of poor short-term outcomes.
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22
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Yang H, Nassif M, Khairy P, de Groot JR, Roos YBWEM, de Winter RJ, Mulder BJM, Bouma BJ. Cardiac diagnostic work-up of ischaemic stroke. Eur Heart J 2019; 39:1851-1860. [PMID: 29788298 DOI: 10.1093/eurheartj/ehy043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/17/2016] [Indexed: 12/20/2022] Open
Abstract
Cardioembolic sources account for 20-30% of ischaemic strokes and are important to identify considering their prognostic and therapeutic implications. During the past years, new developments have been made in the cardiac diagnostic evaluation and management of patients with ischaemic stroke, especially regarding strokes of unknown aetiology. These recent advances have had a major impact on our understanding of embolic strokes, their diagnostic work-up, and clinical management. Herein, we propose a cardiac diagnostic work-up scheme for patients with ischaemic stroke from definite cardioembolic sources and embolic strokes of undetermined source.
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Affiliation(s)
- Hayang Yang
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Martina Nassif
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Paul Khairy
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, 5000 Rue Bélanger, QC H1T 1C8, Montreal, Canada
| | - Joris R de Groot
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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23
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Abstract
How to cite this article: Chugh C. Acute Ischemic Stroke: Management Approach. Indian J Crit Care Med 2019;23(Suppl 2):S140–S146.
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Affiliation(s)
- Chandril Chugh
- Department of Interventional Neurology, MAX Saket Hospital, New Delhi, India
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24
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Kang EYC, Lin YH, Wang NK, Yeung L, Luo C, Wu WC, Sun CC, Kang JH, Hung MJ, Chen TH. Aspirin use in central retinal arterial occlusion to prevent ischaemic stroke: a retrospective cohort study in Taiwan. BMJ Open 2019; 9:e025455. [PMID: 30819710 PMCID: PMC6398622 DOI: 10.1136/bmjopen-2018-025455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To understand the efficacy of aspirin use for preventing ischaemic stroke after central retinal artery occlusion (CRAO). DESIGN The retrospective cohort study was conducted using the National Health Insurance Research Database from 1998 to 2013. SETTING A population-based study. PARTICIPANTS A total of 9437 participants with newly diagnosed CRAO were identified. Participants who had a previous stroke and/or retinal vascular occlusion, were aged <20 years and used aspirin 3 months before the event were excluded. There were 3778 eligible participants matched by propensity score, and they were divided into aspirin (n=434) and aspirin-naive (n=1736) groups after the matching. METHODS Cox proportional hazard models and cumulative survival curves were used to assess ischaemic stroke in the study groups, along with log-rank tests to compare group differences. MAIN OUTCOME MEASURES Incidence of ischaemic stroke in the aspirin and aspirin-naive groups 1 year after CRAO. RESULTS Of the 3778 patients with newly diagnosed CRAO, 151 (4%) had a subsequent ischaemic stroke within 1 year. The risk was especially high during the first week of the CRAO. No difference between the aspirin and aspirin-naive groups was found in risk of ischaemic stroke, haemorrhagic stroke, gastrointestinal bleeding, major bleeding, acute coronary syndrome, retinal vein occlusion, new-onset glaucoma, undergoing panretinal photocoagulation or all-cause mortality. Risk factors for ischaemic stroke within 1 year of CRAO included male gender (p=0.031; HR=1.46) and age (p=0.032; HR=1.14). CONCLUSIONS Aspirin use after a CRAO showed no benefit on attenuating the risk of ischaemic stroke. The risk of ischaemic stroke was increased after CRAO especially during the first week. Male gender and age were risk factors for ischaemic stroke after CRAO.
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Affiliation(s)
- Eugene Yu-Chuan Kang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Yun-Hsuan Lin
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Nan-Kai Wang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Edward S. Harkness Eye Institute, Department of Ophthalmology, Columbia University, New York, NY, USA
| | - Ling Yeung
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Caesar Luo
- Bay Area Retina Associates, Oakland, CA, USA
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chi-Chin Sun
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Je-Ho Kang
- Department of Internal Medicine, Yang Ming Hospital, Taoyuan, Taiwan
| | - Ming-Jui Hung
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Tien-Hsing Chen
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan
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25
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Luciani M, Del Monte F. The more we learn, the less we know: A novel cardiac mechanism of brain damage. J Mol Cell Cardiol 2019; 128:158-159. [PMID: 30703354 DOI: 10.1016/j.yjmcc.2019.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/28/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Marco Luciani
- Herzzentrum, University Hospital of Zürich, Zürich, Switzerland
| | - Federica Del Monte
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States.
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Miles JA, Garber L, Ghosh S, Spevack DM. Association of Transthoracic Echocardiography Findings and Long-Term Outcomes in Patients Undergoing Workup of Stroke. J Stroke Cerebrovasc Dis 2018; 27:2943-2950. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/31/2018] [Accepted: 06/17/2018] [Indexed: 11/15/2022] Open
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27
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Quantitative Analysis of a Whole Cardiac Mass Using Dual-Energy Computed Tomography: Comparison with Conventional Computed Tomography and Magnetic Resonance Imaging. Sci Rep 2018; 8:15334. [PMID: 30337716 PMCID: PMC6194136 DOI: 10.1038/s41598-018-33635-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/03/2018] [Indexed: 12/13/2022] Open
Abstract
It is critical to distinguish between cardiac tumors and thrombi because they require different treatment strategies. Although accurate differentiation of these cardiac masses can be challenging, computed tomography (CT) and magnetic resonance imaging (MRI) are promising tools to improve their diagnosis. This study aimed to assess the diagnostic value of a volume-based quantification strategy using dual-energy CT to differentiate between cardiac tumors and thrombi. We prospectively enrolled 41 patients who had a cardiac mass. All patients underwent electrocardiography gated dual-energy CT. Among them, 28 patients underwent late gadolinium enhancement cardiac MRI. For quantitative analysis, the following parameters of the entire cardiac masses were measured: CT attenuation values in Hounsfield units (HU), iodine concentration (mg/ml), and signal intensity (SI) ratio. A mixed effects model was used to evaluate the significance of differences in mean CT attenuation, mean iodine concentration, and SI ratios between the cardiac tumor and thrombus groups. Diagnostic performance of each parameter was evaluated by constructing a receiver operating characteristics curve. A total of 24 cardiac tumors and 19 cardiac thrombi were analyzed. The mean iodine concentration was significantly higher in tumors than in thrombi (tumors: 2.98 ± 0.23; thrombi: 1.79 ± 0.26, p = 0.002). The diagnostic performance of iodine concentration was better than that of post-contrast HU (area under the curve [AUC]: 0.77 vs. 0.51; p < 0.001), and worse than that of SI ratio (AUC: 0.89; p = 0.04) for differentiation of cardiac tumors and thrombi. Dual-energy CT using volume-based iodine measurements can differentiate between cardiac tumors and thrombi.
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Song I, Kang JH, Kim MY, Hwang HK, Kim HY, Ko SM. Diagnostic Accuracy of Electrocardiogram-Gated Thoracic Computed Tomography Angiography without Heart Rate Control for Detection of Significant Coronary Artery Stenosis in Patients with Acute Ischemic Stroke: A Comparative Study. Korean J Radiol 2018; 19:905-915. [PMID: 30174480 PMCID: PMC6082753 DOI: 10.3348/kjr.2018.19.5.905] [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: 08/26/2017] [Accepted: 03/03/2018] [Indexed: 11/16/2022] Open
Abstract
Objective To compare the diagnostic performance of electrocardiogram (ECG)-gated thoracic computed tomography angiography (TCTA) without heart rate (HR) control in ischemic stroke patients with coronary CTA (CCTA) in non-stroke patients for detection of significant coronary artery stenosis. Materials and Methods From September 2009 through August 2014, we retrospectively enrolled 138 consecutive patients diagnosed with acute ischemic stroke who had undergone ECG-gated TCTA and conventional coronary angiography (CCA). Over the same period, we selected 167 non-stroke patients with suspected or known coronary artery disease who had undergone CCTA and CCA. With CCA as the reference standard, the diagnostic performance of TCTA and CCTA for identification of significant coronary stenosis (diameter reduction ≥ 50%) was calculated. Results There was no significant difference in baseline characteristics between TCTA (n = 132) and CCTA (n = 164), except for the higher prevalence of atrial fibrillation in the stroke group. There was significant difference (p < 0.001) between TCTA and CCTA in average HR (68 ± 12 vs. 61 ± 10 beats per minute) and image quality score (1.3 ± 0.6 vs. 1.2 ± 0.6). Significant coronary stenosis was identified in 101 (77%) patients, 179 (45%) vessels, and 293 (15%) segments of stroke patients, and in 136 (83%) patients, 259 (53%) vessels, and 404 (16%) segments of non-stroke patients. Diagnostic performance on a per-vessel and per-patient basis was similar in both TCTA and CCTA groups. There was only significant difference in area under receiver-operating characteristic curve between TCTA and CCTA groups (0.79 vs. 0.87, p < 0.001) on per-segment basis. Conclusion Electrocardiogram-gated TCTA without HR control facilitates the identification of significant coronary stenosis in patients with ischemic stroke.
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Affiliation(s)
- Inyoung Song
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Ji Hun Kang
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Mi Young Kim
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Hweung Kon Hwang
- Department of Cardiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Han Young Kim
- Department of Neurology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
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Gao H, Sun X, Li W, Gao Q, Zhang J, Zhang Y, Ma Y, Yang X, Kang X, Jiang W. Development and validation of a risk score to predict 30-day mortality in patients with atrial fibrillation-related stroke: GPS-GF score. Neurol Res 2018; 40:532-540. [PMID: 29544401 DOI: 10.1080/01616412.2018.1451431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Hua Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaolong Sun
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jing Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yi Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yue Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiai Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaogang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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Liu C, Shi F, Chen Z, Yan S, Ding X, Lou M. Severe Blood-Brain Barrier Disruption in Cardioembolic Stroke. Front Neurol 2018; 9:55. [PMID: 29472890 PMCID: PMC5809413 DOI: 10.3389/fneur.2018.00055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/22/2018] [Indexed: 12/24/2022] Open
Abstract
Background Previous studies demonstrated that cardioembolism (CE) was prone to develop hemorrhagic transformation (HT), whereas hyper-permeability of blood–brain barrier (BBB) might be one reason for the development of HT. We, thus, aimed to investigate whether the BBB permeability (BBBP) was higher in CE stroke than other stroke subtypes in acute ischemic stroke (AIS) patients. Methods This study was a retrospective review of prospectively collected clinical and imaging database of AIS patients who underwent CT perfusion. Hypoperfusion was defined as Tmax >6 s. The average relative permeability-surface area product (rPS), reflecting the BBBP, was calculated within the hypoperfusion region (rPShypo). CE was diagnosed according to the international Trial of Org 10172 in Acute Stroke Treatment criteria. Receiver operating characteristics (ROC) curve analysis was used to determine predictive value of rPShypo for CE. Logistic regression was used to identify independent predictors for CE. Results A total of 187 patients were included in the final analysis [median age, 73 (61–80) years; 75 (40.1%) females; median baseline National Institutes of Health Stroke Scale score, 12 (7–16)]. Median rPShypo was 65.5 (35.8–110.1)%. Ninety-seven (51.9%) patients were diagnosed as CE. ROC analysis revealed that the optimal rPShypo threshold for CE was 86.71%. The value of rPShypo and the rate of rPShypo>86.71% were significantly higher in patients with CE than other stroke subtypes (p < 0.05), after adjusting for the potential confounds. Conclusion The extent of BBB disruption is more severe in CE stroke than other stroke subtypes during the hyperacute stage.
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Affiliation(s)
- Chang Liu
- Department of Neurology, School of Medicine, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Feina Shi
- Department of Neurology, School of Medicine, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Zhicai Chen
- Department of Neurology, School of Medicine, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, School of Medicine, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Xinfa Ding
- Department of Radiology, School of Medicine, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Min Lou
- Department of Neurology, School of Medicine, The 2nd Affiliated Hospital of Zhejiang University, Hangzhou, China
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Liu C, Yan S, Zhang R, Chen Z, Shi F, Zhou Y, Zhang M, Lou M. Increased blood-brain barrier permeability in contralateral hemisphere predicts worse outcome in acute ischemic stroke after reperfusion therapy. J Neurointerv Surg 2018; 10:937-941. [PMID: 29352054 DOI: 10.1136/neurintsurg-2017-013663] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 01/20/2023]
Abstract
AIMS We sought to investigate the risk factors of blood-brain barrier (BBB) disruption, and its potential impact on 90-day clinical outcome in acute ischemic stroke (AIS) patients after reperfusion therapy. METHODS Consecutive acute anterior circulation AIS patients imaged with computed tomographic perfusion (CTP) before reperfusion therapy were included. Tmax >6 s was used for the volumetric measurement of the hypoperfusion area. BBB permeability (BBBP) was calculated as the average relative permeability-surface area product (rPS) within the hypoperfusion region (rPShypo-i) and its contralateral mirror region (rPShypo-c) on CTP-derived PS color maps. Modified Rankin Scale (mRS) score was obtained at 90-day post-stroke. RESULTS A total of 187 patients were included, among whom the median age was 73 (61-80) years and 76 (40.6%) were women. Median baseline NIHSS score was 12 (7- 16). Ninety-eight (52.4%) patients had mRS score >2. Increased rPShypo-i and rPShypo-c were both independently associated with males and large infarct volume. The increased rPShypo-i was also independently associated with a history of atrial fibrillation and high NIHSS score. Multivariable analysis showed higher rPShypo-c was independently associated with higher mRS (OR: 1.064, 95% CI 1.011 to 1.121; P=0.018). CONCLUSION BBBP in both the hypoperfusion region and its contralateral mirror region are associated with stroke severity, but only increased BBBP in the contralateral mirror hypoperfusion region relates to worse outcome after reperfusion therapy.
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Affiliation(s)
- Chang Liu
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Shenqiang Yan
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Ruiting Zhang
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Zhicai Chen
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Feina Shi
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Ying Zhou
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Meixia Zhang
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
| | - Min Lou
- The Second Affiliated Hospital of Zhejiang University, School of Medicine, Neurology, Hangzhou, Zhejiang, China
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Araszkiewicz A, Sławek S, Trojnarska O, Lesiak M, Grygier M. Interventional closure of patent foramen ovale with Nit-occlud® device in prevention of recurrent neurologic events-Long-term results. Catheter Cardiovasc Interv 2017; 92:159-164. [DOI: 10.1002/ccd.27386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 12/29/2022]
Affiliation(s)
| | - Sylwia Sławek
- Department of Cardiology; Poznan University of Medical Sciences; Poland
| | - Olga Trojnarska
- Department of Cardiology; Poznan University of Medical Sciences; Poland
| | - Maciej Lesiak
- Department of Cardiology; Poznan University of Medical Sciences; Poland
| | - Marek Grygier
- Department of Cardiology; Poznan University of Medical Sciences; Poland
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Hur J, Choi BW. Cardiac CT Imaging for Ischemic Stroke: Current and Evolving Clinical Applications. Radiology 2017; 283:14-28. [DOI: 10.1148/radiol.2016152043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jin Hur
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, 120-752, Seoul, Republic of Korea
| | - Byoung Wook Choi
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, 120-752, Seoul, Republic of Korea
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Inertial particle dynamics in large artery flows – Implications for modeling arterial embolisms. J Biomech 2017; 52:155-164. [DOI: 10.1016/j.jbiomech.2016.12.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/07/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
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Incidental Thrombus in Transit Causing Embolic Stroke. Case Rep Med 2017; 2017:3161972. [PMID: 28713430 PMCID: PMC5496107 DOI: 10.1155/2017/3161972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/04/2017] [Indexed: 11/18/2022] Open
Abstract
Thrombus in transit leading to paradoxical systemic arterial embolism is a rare echocardiographic finding in patients presenting with embolic stroke. We present a case of a patient who had an atrial thrombus in transit discovered incidentally and later suffered a fatal stroke. Etiologies of cardioembolic stroke and the use of echocardiography in diagnosis and management are briefly discussed.
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Geraghty O, Korompoki E, Filippidis FT, Rudd A, Veltkamp R. Cardiac diagnostic work-up for atrial fibrillation after transient ischaemic attacks in England and Wales: results from a cross-sectional survey. BMJ Open 2016; 6:e012714. [PMID: 28186939 PMCID: PMC5129110 DOI: 10.1136/bmjopen-2016-012714] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Transient ischaemic attacks (TIAs) are an important precursor of stroke. Atrial fibrillation (AF) is among the most dangerous aetiologies shared between TIAs and strokes. Detection of AF after TIAs is essential for the initiation of oral anticoagulants. We aimed to identify variations in the use of cardiac investigations used to detect AF and cardiac pathology in patients with TIA in the UK. SETTING All TIA clinical leads in England and Wales received an invitation by email to participate in an online survey in February 2015. The questionnaire consisted of 36 multiple choice questions covering the domains: (1) general information about stroke units, (2) ECG diagnostics and cardiologic work-up and (3) management of AF. RESULTS 146 survey invitations were sent. The response rate was 40% (n=59). Diagnosis of AF largely depends on medical history and 12-channel ECG which is performed in the vast majority of patients with TIA (>75%) in 94.1% of the TIA services. Many patients with TIA either do not receive 24-hour Holter recording (requested regularly in 42% of the services) or only after considerable delay (>2 weeks). Prolonged event recording is only rarely performed (16%). Only about half of patients with TIA undergo echocardiography. Cranial imaging in patients with TIA is mainly performed as CT (62%). The majority of TIA clinics rapidly initiate anticoagulation in TIA patients with AF (81.6%) preferably using new oral anticoagulants (75.5%). CONCLUSIONS Significant variation in the cardiac diagnostic work-up following TIA exists regarding the use of particular detection techniques and the duration of cardiac ECG monitoring. Only limited resources are allocated to cardiac evaluation. In addition to research establishing the optimal ECG technique for patients with TIA, healthcare delivery programmes are needed to ensure proper management to prevent strokes.
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Affiliation(s)
- Olivia Geraghty
- Department of Stroke Medicine, Imperial College London, London, UK
| | - Eleni Korompoki
- Department of Stroke Medicine, Imperial College London, London, UK
| | | | - Anthony Rudd
- Department of Stroke Medicine, Guy's and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
- National Clinical Director of Stroke, NHS England
- London Stroke Clinical Director, London, UK
| | - Roland Veltkamp
- Department of Stroke Medicine, Imperial College London, London, UK
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Fu M, He W, Dai W, Ye Y, Ruan Z, Wang S, Xie H. Efficacy of Solitaire Stent Arterial Embolectomy in Treating Acute Cardiogenic Cerebral Embolism in 17 Patients. Med Sci Monit 2016; 22:1302-8. [PMID: 27090916 PMCID: PMC4839270 DOI: 10.12659/msm.895908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Thrombolysis with rtPA is the only accepted drug therapy for acute ischemic stroke. Since acute cerebral stroke is so pervasive, newly developed recanalization methods have the potential for wide-ranging impacts on patient health and safety. We explored the efficacy and safety of Solitaire stent arterial embolectomy in the treatment of acute cardiogenic cerebral embolism. Material/Methods Between October 2012 and June 2015, 17 patients underwent Solitaire stent arterial embolectomy, either alone or in combination with rtPA intravenous thrombolysis, to treat acute cardiogenic cerebral embolism. Sheath placement time, vascular recanalization time, number of embolectomy attempts, and IV rtPA dose and time were recorded. Success and safety of the recanalization procedure, as well as clinical outcomes, were assessed. These results were compared to 16 control patients who were treated using only rtPA IV thrombolysis. Results Full recanalization of the occluded arteries was achieved in 15 (88.2%) of the Solitaire stent patients. NIH Stroke Scale scores of embolectomy patients improved by an average of 12.59±8.24 points between admission and discharge, compared to 5.56±5.96 in the control group (P<0.05). Glasgow Coma Score improvement between admission and discharge was also significantly higher in the embolectomy group (P<0.05). There was no significant difference in symptomatic intracerebral hemorrhage, high perfusion encephalopathy, incidence of hernia, or mortality between the 2 groups (P>0.05). Conclusions Solitaire stent embolectomy is a safe and effective alternative to simple venous thrombolytic therapy, and it can significantly improve short-term neurological function and long-term prognosis in acute cardiogenic cerebral embolism.
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Affiliation(s)
- Maolin Fu
- Department of Neurology, The 180th Hospital of PLA, Quanzhou, Fujian, China (mainland)
| | - Wenqin He
- Department of Neurology, The 180th Hospital of PLA, Quanzhou, Fujian, China (mainland)
| | - Weizheng Dai
- Department of Neurology, The 180th Hospital of PLA, Quanzhou, Fujian, China (mainland)
| | - Yingan Ye
- Department of Neurology, The 180th Hospital of PLA, Quanzhou, Fujian, China (mainland)
| | - Zhifang Ruan
- Department of Neurology, The 180th Hospital of PLA, Quanzhou, Fujian, China (mainland)
| | - Shuanghu Wang
- Department of Neurology, The 180th Hospital of PLA, Quanzhou, Fujian, China (mainland)
| | - Huifang Xie
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (mainland)
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The role of echocardiography in patients after ischemic stroke. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Katsanos AH, Giannopoulos S, Frogoudaki A, Vrettou A, Ikonomidis I, Paraskevaidis I, Zompola C, Vadikolias K, Boviatsis E, Parissis J, Voumvourakis K, Kyritsis AP, Tsivgoulis G. The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta‐analysis. Eur J Neurol 2015; 23:569-79. [DOI: 10.1111/ene.12897] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/01/2015] [Indexed: 01/11/2023]
Affiliation(s)
- A. H. Katsanos
- Department of Neurology School of Medicine University of Ioannina IoanninaGreece
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - S. Giannopoulos
- Department of Neurology School of Medicine University of Ioannina IoanninaGreece
| | - A. Frogoudaki
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - A.‐R. Vrettou
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - I. Ikonomidis
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - I. Paraskevaidis
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - C. Zompola
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - K. Vadikolias
- Department of Neurology Democritus University of Thrace AlexandroupolisGreece
| | - E. Boviatsis
- Second Department of Neurosurgery ‘Attikon University Hospital’ School of Medicine University of Athens Athens Greece
| | - J. Parissis
- Second Department of Cardiology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - K. Voumvourakis
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
| | - A. P. Kyritsis
- Department of Neurology School of Medicine University of Ioannina IoanninaGreece
| | - G. Tsivgoulis
- Second Department of Neurology ‘Attikon University Hospital’ School of Medicine University of Athens AthensGreece
- Department of Neurology Democritus University of Thrace AlexandroupolisGreece
- International Clinical Research Center Department of Neurology St Anne's University Hospital Brno Czech Republic
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Sullivan R, Duncan K, Dailey T, Kaneko Y, Tajiri N, Borlongan CV. A possible new focus for stroke treatment - migrating stem cells. Expert Opin Biol Ther 2015; 15:949-58. [PMID: 25943632 DOI: 10.1517/14712598.2015.1043264] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Stroke is a leading cause of mortality in the US. More so, its infliction often leaves patients with lasting morbidity and deficits. Ischemic stroke comprises nearly 90% of incidents and the majority of medical treatment aims at reestablishing perfusion and preventing recurrence. AREAS COVERED Long-term options for neurorestoration are limited by the infancy of their innovative approach. Accumulating evidence suggests the therapeutic potential of stem cells in neurorestoration, however, proper stem cell migration remains a challenge in translating stem cell therapy from the laboratory to the clinic. In this paper, we propose the role that exogenous stem cell transplantation may serve in facilitating the migration of endogenous stem cells to the site of injury, an idea termed 'biobridge'. EXPERT OPINION Recent research in the field of traumatic brain injury has provided a foundational understanding that, through the use of exogenous stem cells, native tissue architecture may be manipulated by proteinases to allow better communication between the endogenous sites of neural stem cells and the regions of injury. There is still much to be learned about these mechanisms, though it is the devastating nature of stroke that necessitates continued research into the prospective therapeutic potential of this novel approach.
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Affiliation(s)
- Robert Sullivan
- University of South Florida College of Medicine, Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair , 12901 Bruce B. Downs Blvd, Tampa, FL , USA +1 813 974 3154 ; +1 813 974 3078 ;
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Abstract
The clinical significance of persistent patent foramen ovale (PFO) is not well defined. Empirically, PFO has been associated with many clinical conditions. In cryptogenic stroke, migraine, and orthodeoxia/platypnea, a plausible biologic mechanism exists to support PFO closure as a possible treatment. Although transcatheter closure of PFO has been available for over 2 decades, it has remained controversial due to a paucity of evidence to guide patient and device selection. Contemporary studies investigating PFO closure as treatment for patients with these conditions have been published recently and longitudinal data regarding the safety and efficacy of the devices is now available. In this review, we aim to describe the potential clinical significance of a patent foramen in the adult, appraise the newest additions to the body of evidence, and discuss the safety, benefit, patient selection, and future of transcatheter treatment of PFO.
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Affiliation(s)
- N Rohrhoff
- Duke University Medical Center, 3331 DUMC, Durham, NC, 27710, USA
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McGrath ER, Paikin JS, Motlagh B, Salehian O, Kapral MK, O'Donnell MJ. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review. Am Heart J 2014; 168:706-12. [PMID: 25440799 DOI: 10.1016/j.ahj.2014.07.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 07/18/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND The clinical utility of routine transesophageal echocardiography (TEE) for patients with unexplained ischemic stroke is controversial. We performed a systematic review to determine the frequency of detection of new cardiac findings in patients with cryptogenic ischemic stroke (IS) undergoing transesophageal echocardiography (TEE). METHODS Systematic review and meta-analysis of cohort studies of consecutive patients with "cryptogenic" IS undergoing TEE after routine etiologic workup. Patients were categorized into 2 groups: A (< 55 years) and B (≥ 55 years). Outcomes included proportion of patients with new TEE-detected cardiac findings and proportion of patients commenced on oral anticoagulation after TEE. RESULTS Twenty-seven studies were included (n = 5,653). We identified significant heterogeneity among studies and report a range of prevalence rates and I2 statistic as our primary analysis. Prevalence of individual cardiac findings on TEE varied significantly among studies; patent foramen ovale (A: 12.0%-57.8%, I2 = 89.9%; B: 3.9%-43.5%, I2 = 86.7%), atrial septal aneurysm (A: 0-48.9%, I2 = 91.9%; B: 3.5%-25.0%, I2 = 84.5%), left atrial thrombus (A: 0-10.9%, I2 = 61.1%; B: 0-21.2%, I2 = 91.7%), spontaneous echo contrast (A: 0-11.9%, I2 = 57.2%; B: 0-21.3%, I2 = 89.8%), and aortic atheroma (A: 0-9.6%, I2 = 53.8%; B: 2.8%-44.4%, I2 = 89.7%). Definitions of common findings were not provided for many studies. Five studies (n = 591) reported on the proportion of patients who were commenced on anticoagulant therapy after TEE (range 0-30.7%). CONCLUSIONS Routine TEE in patients with cryptogenic IS identifies cardiac findings in a large proportion. However, there is marked interstudy variation in the definition and prevalence of common findings. Transesophageal echocardiography-detected findings prompted the introduction of anticoagulant therapy in up to one-third of patients. However, these were mostly not for established guideline-based indications based on randomized controlled trial evidence. It is unclear if routine use of TEE in patients with cryptogenic IS is indicated.
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Affiliation(s)
- Emer R McGrath
- HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Department of Neurology, Massachusetts General Hospital, Boston MA.
| | - Jeremy S Paikin
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Bahareh Motlagh
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Omid Salehian
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Moira K Kapral
- Department of Internal Medicine and Clinical Epidemiology, University of Toronto, Ontario, Canada
| | - Martin J O'Donnell
- HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
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Wei CY, Chung TC, Chen CH, Lin CC, Sung FC, Chung WT, Kung WM, Hsu CY, Yeh YH. Gallstone disease and the risk of stroke: a nationwide population-based study. J Stroke Cerebrovasc Dis 2014; 23:1813-20. [PMID: 24957305 DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/14/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Gallstone disease (GD) and stroke share a number of risk factors including diabetes and hyperlipidemia. This nationwide population-based study was designed to estimate the risk of stroke after a diagnosis of GD. METHODS Data were obtained from the Taiwan National Health Insurance Research Database. A total of 135,512 patients with a diagnosis of GD and 271,024 age- and gender-matched non-GD control patients were included to assess the risk of stroke using Cox proportional hazard regression. RESULTS During the study period (2000-2003), 12,234 (153.67/10,000 person-years) strokes occurred among the GD patients, and 20,680 (114.83/10,000 person-years) among the controls. The diagnosis of GD carried a higher risk of developing ischemic and hemorrhagic stroke, with a hazard ratio (HR) of 1.28 and 1.33 (95% confidence interval [CI], 1.25-1.31 and 1.25-1.41, both P < .0001), respectively. Stroke risk was increased in both genders but at a higher rate in younger age. The GD group had significantly higher prevalence rate of comorbidities that are known stroke risk factors, including hypertension, diabetes, and coronary artery disease. Stroke risk was higher in the GD group with or without any of these comorbidities. CONCLUSIONS In this population-based longitudinal follow-up study, GD carried a significantly higher stroke risk, particularly for younger age with or without stroke risk factors. Stroke preventive measures maybe needed for patients with GD, especially those of younger age and with stroke risk factor(s).
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Affiliation(s)
- Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan, Republic of China; Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan, Republic of China
| | - Tieh-Chi Chung
- Graduate Institute of Health Care, Meiho University, Pingtung County, Taiwan, Republic of China
| | - Chien-Hua Chen
- Digestive Disease Center, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan, Republic of China
| | - Che-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Fung-Chang Sung
- Department of Public Health, China Medical University, Taichung, Taiwan, Republic of China
| | - Wen Ting Chung
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Woon-Man Kung
- Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan, Republic of China; Department of Neurosurgery, Lo-Hsu Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan, Republic of China
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan, Republic of China
| | - Yung-Hsiang Yeh
- Digestive Disease Center, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan, Republic of China.
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Dual-energy cardiac computed tomography for differentiating cardiac myxoma from thrombus. Int J Cardiovasc Imaging 2014; 30 Suppl 2:121-8. [PMID: 25011535 DOI: 10.1007/s10554-014-0490-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 07/03/2014] [Indexed: 11/27/2022]
Abstract
Although intra-cardiac masses are rare, diagnosis and refined characterization of these masses are important because of the different therapeutic strategies used to treat these lesions. The purpose of this study was to evaluate the diagnostic value of dual-energy cardiac computed tomography (CCT) for differentiating cardiac myxomas from thrombi. Our institutional review board approved this study, and patients provided informed consent. We prospectively enrolled 37 patients who had an intra-cardiac mass on echocardiography or computed tomography (CT). All patients underwent dual-energy CCT. For quantitative analysis, the CT attenuation density and iodine concentration of the intra-cardiac mass were measured on CT images. The Mann-Whitney test was used to evaluate differences in the mean CT attenuation density and the mean iodine concentrations between the cardiac myxoma and thrombus groups. Pathological results or follow-up with echocardiography was used to make the final diagnosis. There were a total of 17 cardiac myxomas and 20 thrombi. On CT, the mean CT numbers were not significantly different between cardiac myxomas and cardiac thrombi (91.7 ± 11.6 HU vs. 85.2 ± 10.9 HU, respectively, P = 0.241), whereas, the mean iodine concentration (mg/ml) was significantly different between cardiac myxomas and cardiac thrombi (3.53 ± 0.72 vs. 1.37 ± 0.31, respectively, P < 0.001). Dual-energy CCT using a quantitative analytic methodology can be used to differentiate between cardiac myxomas and thrombi.
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Langdon W, Donahue MJ, van der Kolk AG, Rane S, Strother MK. Correlating hemodynamic magnetic resonance imaging with high-field intracranial vessel wall imaging in stroke. J Radiol Case Rep 2014; 8:1-10. [PMID: 25426229 DOI: 10.3941/jrcr.v8i6.1795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vessel wall magnetic resonance imaging at ultra-high field (7 Tesla) can be used to visualize vascular lesions noninvasively and holds potential for improving stroke-risk assessment in patients with ischemic cerebrovascular disease. We present the first multi-modal comparison of such high-field vessel wall imaging with more conventional (i) 3 Tesla hemodynamic magnetic resonance imaging and (ii) digital subtraction angiography in a 69-year-old male with a left temporal ischemic infarct.
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Affiliation(s)
- Weston Langdon
- Vanderbilt University School of Medicine, Nashville, USA
| | - Manus J Donahue
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, USA
| | - Anja G van der Kolk
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Swati Rane
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, USA
| | - Megan K Strother
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, USA
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Baher A, Mowla A, Kodali S, Polsani VR, Nabi F, Nagueh SF, Volpi JJ, Shah DJ. Cardiac MRI Improves Identification of Etiology of Acute Ischemic Stroke. Cerebrovasc Dis 2014; 37:277-84. [DOI: 10.1159/000360073] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 01/27/2014] [Indexed: 11/19/2022] Open
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The PFO Gets Blamed Again…Perhaps This Time it Is Real. JACC Cardiovasc Interv 2014; 7:409-10. [DOI: 10.1016/j.jcin.2014.01.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 01/12/2014] [Accepted: 01/16/2014] [Indexed: 11/19/2022]
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A comparison of clinical characteristics and long-term prognosis in asymptomatic and symptomatic patients with first-diagnosed atrial fibrillation: the Belgrade Atrial Fibrillation Study. Int J Cardiol 2013; 168:4744-9. [PMID: 23958417 DOI: 10.1016/j.ijcard.2013.07.234] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/11/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND To investigate baseline characteristics and long-term prognosis of carefully characterized asymptomatic and symptomatic patients with atrial fibrillation (AF) in a 'real-world' cohort of first-diagnosed non-valvular AF over a 10-year follow-up period. METHODS AND RESULTS We conducted an observational, non-interventional, and single-centre registry-based study of consecutive first-diagnosed AF patients. Of 1100 patients (mean age 52.7±12.2 years and mean follow-up 9.9±6.1 years), 146 (13.3%) had asymptomatic AF. Persistent or permanent AF, slower ventricular rate during AF (<100/min), CHA2DS2-VASc score of 0, history of diabetes mellitus and male gender were independent baseline risk factors for asymptomatic AF presentation (all p<0.01) with a good predictive ability of the multivariable model (c-statistic 0.86, p<0.001). Kaplan-Meier 10-year estimates of survival free of progression of AF (log-rank test=33.4, p<0.001) and ischemic stroke (log-rank test=6.2, p=0.013) were significantly worse for patients with asymptomatic AF compared to those with symptomatic arrhythmia. In the multivariable Cox regression analysis, intermittent asymptomatic AF was significantly associated with progression to permanent AF (Hazard Ratio 1.6; 95% CI, 1.1-2.2; p=0.009). CONCLUSIONS In a 'real-world' setting, patients with asymptomatic presentation of their first-diagnosed AF could have different risk profile and long-term outcomes compared to those with symptomatic AF. Whether more intensive monitoring and comprehensive AF management including AF ablation at early stage following the incident episode of AF and increased quality of oral anticoagulation could alter the long-term prognosis of these patients requires further investigation.
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Management of the Stroke Patient with Patent Foramen Ovale: New Insights and Persistent Questions in the Wake of Recent Randomized Trials. Curr Atheroscler Rep 2013; 15:338. [DOI: 10.1007/s11883-013-0338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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