2
|
Xiao J, Poblete RA, Lerner A, Nguyen PL, Song JW, Sanossian N, Wilcox AG, Song SS, Lyden PD, Saver JL, Wasserman BA, Fan Z. MRI in the Evaluation of Cryptogenic Stroke and Embolic Stroke of Undetermined Source. Radiology 2024; 311:e231934. [PMID: 38652031 PMCID: PMC11070612 DOI: 10.1148/radiol.231934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 04/25/2024]
Abstract
Cryptogenic stroke refers to a stroke of undetermined etiology. It accounts for approximately one-fifth of ischemic strokes and has a higher prevalence in younger patients. Embolic stroke of undetermined source (ESUS) refers to a subgroup of patients with nonlacunar cryptogenic strokes in whom embolism is the suspected stroke mechanism. Under the classifications of cryptogenic stroke or ESUS, there is wide heterogeneity in possible stroke mechanisms. In the absence of a confirmed stroke etiology, there is no established treatment for secondary prevention of stroke in patients experiencing cryptogenic stroke or ESUS, despite several clinical trials, leaving physicians with a clinical dilemma. Both conventional and advanced MRI techniques are available in clinical practice to identify differentiating features and stroke patterns and to determine or infer the underlying etiologic cause, such as atherosclerotic plaques and cardiogenic or paradoxical embolism due to occult pelvic venous thrombi. The aim of this review is to highlight the diagnostic utility of various MRI techniques in patients with cryptogenic stroke or ESUS. Future trends in technological advancement for promoting the adoption of MRI in such a special clinical application are also discussed.
Collapse
Affiliation(s)
- Jiayu Xiao
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Roy A. Poblete
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Alexander Lerner
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Peggy L. Nguyen
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Jae W. Song
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Nerses Sanossian
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Alison G. Wilcox
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Shlee S. Song
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Patrick D. Lyden
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Jeffrey L. Saver
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Bruce A. Wasserman
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| | - Zhaoyang Fan
- From the Departments of Radiology (J.X., A.L., A.G.W., Z.F.),
Neurology (R.A.P., P.L.N., N.S., P.D.L.), Physiology and Neuroscience (P.D.L.),
Biomedical Engineering (Z.F.), and Radiation Oncology (Z.F.), University of
Southern California, 2250 Alcazar St, CSC Room 104, Los Angeles, CA 90033;
Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, Pa (J.W.S.); Department of Neurology, Cedars-Sinai Medical Center,
Los Angeles, Calif (S.S.S.); Comprehensive Stroke Center and Department of
Neurology, David Geffen School of Medicine, University of California–Los
Angeles, Los Angeles, Calif (J.L.S.); Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland–Baltimore, Baltimore, Md
(B.A.W.); and Department of Radiology and Radiological Sciences, Johns Hopkins
University, Baltimore, Md (B.A.W.)
| |
Collapse
|
4
|
van der Maten G, Meijs MFL, Timmer JR, Brouwers PJAM, von Birgelen C, Coutinho JM, Bouma BJ, Kerkhoff H, Helming AM, van Tuijl JH, van der Meer NA, Saxena R, Ebink C, van der Palen J, den Hertog HM. Routine transthoracic echocardiography in ischaemic stroke or transient ischaemic attack of undetermined cause: a prospective multicentre study. Neth Heart J 2024; 32:91-98. [PMID: 37870709 PMCID: PMC10834921 DOI: 10.1007/s12471-023-01819-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Guidelines recommend routine transthoracic echocardiography (TTE) after ischaemic stroke or transient ischaemic attack of undetermined cause; yet, only limited scientific evidence exists. Therefore, we aimed to determine in these patients the prevalence of TTE-detected major cardiac sources of embolism (CSE), which are abnormalities leading to therapeutic changes. METHODS Six Dutch hospitals conducted a prospective observational study that enrolled patients with ischaemic stroke or transient ischaemic attack of undetermined cause. Patients underwent TTE after comprehensive diagnostic evaluation on stroke units, including blood chemistry, 12-lead electrocardiogram (ECG), ≥ 24 h continuous ECG monitoring, brain imaging and cervical artery imaging. Primary outcome measure was the proportion of patients with TTE-detected major CSE. RESULTS From March 2018 to October 2020, 1084 patients, aged 66.6 ± 12.5 years, were enrolled; 456 (42.1%) patients were female and 869 (80.2%) had ischaemic stroke. TTE detected major CSE in only 11 (1.0%) patients. Ten (90.9%) of these patients also had major ECG abnormalities (previous infarction, major repolarisation abnormalities, or previously unknown left bundle branch block) that would have warranted TTE assessment regardless of stroke evaluation. Such ECG abnormalities were present in 11.1% of the total study population. A single patient (0.1%) showed a major CSE despite having no ECG abnormality. CONCLUSIONS This multicentre cross-sectional study in patients who-after workup on contemporary stroke units-were diagnosed with ischaemic stroke or transient ischaemic attack of undetermined cause found TTE-detected major CSE in only 1% of all patients. Most of these patients also had major ECG abnormalities. These findings question the value of routine TTE assessment in this clinical setting.
Collapse
Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Jorik R Timmer
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Anne Mijn Helming
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Ritu Saxena
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Corné Ebink
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Job van der Palen
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | | |
Collapse
|