Cardiac diagnostic work-up of ischaemic stroke

An Artificial Intelligence-Driven Approach for Automatic Evaluation of Right-to-Left Shunt Grades in Saline-Contrasted Transthoracic Echocardiography

BACKGROUND

Intracardiac or pulmonary right-to-left shunt (RLS) is a common cardiac anomaly associated with an increased risk of neurological disorders, specifically cryptogenic stroke. Saline-contrasted transthoracic echocardiography (scTTE) is often used for RLS diagnosis. However, the identification of saline microbubbles in the left heart can be challenging for novice residents, potentially leading to a delay in diagnosis and treatment. In this study, we proposed an artificial intelligence (AI)-based algorithm designed to automatically detect microbubbles in scTTE images and evaluate right-to-left shunt grades. This tool aims to support residency training and decrease the workload of cardiologists.

METHODS

A dataset of 23,665 scTTE images obtained from 174 individuals was included in this study. This dataset was partitioned into a training set (n = 20,475) and an internal validation set (n = 3,190) on a patient-level basis. An additional cohort of 33 patients diagnosed with cryptogenic ischemic stroke was enrolled as an external validation set. The proposed algorithm for right-to-left shunt degree classification employed the EfficientNet-b4 model, and the model's performance was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity, and compared to the performance of residents.

RESULTS

Our AI model demonstrated robust performance with an accuracy of 0.926, sensitivity of 0.827, and specificity of 0.951 on the internal testing dataset. In the external validation set, our AI model exhibited diagnostic accuracy, sensitivity, and specificity of 0.864, 0.818, and 0.909, respectively. In comparison, residents achieved values of 0.727, 0.636, and 0.818, respectively.

CONCLUSION

Our AI model provides a swift, precise, and easily deployable methodology for grading the degree of right-to-left shunt in scTTE, carrying substantial implications for routine clinical practice. Residents can benefit from our artificial intelligence-based algorithm, enhancing both the accuracy and efficiency of RLS diagnosis.

Ischemic Stroke and Reduced Left Ventricular Ejection Fraction: A Multidisciplinary Approach to Optimize Brain and Cardiac Health

Reduced left ventricular ejection fraction ≤40%, a known risk factor for adverse cardiac outcomes and recurrent acute ischemic stroke, may be detected during an acute ischemic stroke hospitalization. A multidisciplinary care paradigm informed by neurology and cardiology expertise may facilitate the timely implementation of an array of proven heart failure-specific therapies and procedures in a nuanced manner to optimize brain and cardiac health.

Retinal arterial occlusion and patent foramen ovale: A case study-based review

PURPOSE

To identify all reported cases of retinal artery occlusion (RAO) associated with patent foramen ovale (PFO) in the literature and present a similar case of CRAO from our clinic.

METHODS

PubMed database was searched for studies reporting RAO in individuals with PFO. Relevant data were tabulated and reviewed. We estimated each case's Risk of Paradoxical Embolism (RoPE) score.

RESULTS

23 cases of CRAO (n=10; including ours), BRAO (n=10), and CILRAO (n=3) were reviewed. Most cases were under 50 years of age (78.3%). The reported predisposing factors were: hypertension (26.1%), migraine (17.3%), smoking (13.0%), recent immobilization (13.0%), strenuous exertion (8.7%), pregnancy (8.7%), and diabetes (4.3%). A high RoPE score (≥7; suggestive of paradoxical embolism via PFO) was estimated for 71.4% of patients. In most cases, the neurological and cardiovascular examinations, laboratory studies, and imaging were unremarkable, except for the PFO±atrial septal aneurysm (present in 21.7%). In only 28.6% of cases, transthoracic echocardiography (TTE) (± saline contrast) could visualize the PFO; transesophageal echocardiography (TEE) was necessary to detect the PFO in 71.4%. Approximately one-half of the patients underwent percutaneous closure of the PFO; no complications or subsequent acute ischemic events ensued. The visual prognosis was poorer for CRAO than for BRAO or CILRAO.

CONCLUSION

Timely diagnosis, acute management, and ensuring urgent initiation of stroke workup in cases with RAO or transient monocular vision loss are crucial. Clues to a possible paradoxical embolism as the cause include the absence of known cardiovascular risk factors, young age, migraine, recent immobility, vigorous exercise, and pregnancy.

Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk

Transient ischemic attack (TIA) is a warning sign for an impending stroke, with a 10-20% chance of a stroke occurring within 90 days of the initial event. Current clinical practice for cardiac workup in TIA includes cardiac enzymes, with 12-lead electrocardiogram, transthoracic echocardiography, and 24-hour Holter monitoring. However, the diagnostic yield of these investigations is variable, and there is a need for better diagnostic approaches to increase the detection of cardiac abnormalities in a cost-effective way. This review article examines the latest research on emerging diagnostic tools and strategies and discusses the potential benefits and challenges of using these advanced diagnostic approaches in clinical practice. Novel biomarkers, imaging techniques, and prolonged rhythm monitoring devices have shown great promise in enhancing the diagnostic yield of cardiac workup in TIA patients. Echocardiography, Transcranial Doppler ultrasound, cardiac MRI, and cardiac CT are among the promising diagnostic tools being studied. We conclude the article with a suggested diagnostic algorithm for cardiac workup in TIA. Further research is necessary to enhance their usefulness and to outline future directions for research and clinical practice in this field.

Embolic Stroke Associated With a Pulmonary Arteriovenous Fistula: An Unignorable Rare Causes of Stroke

INTRODUCTION

Here, we described a patient with ischemic stroke due to embolism, through an isolated pulmonary arteriovenous fistula (PAVF). Our case could be a paradigm of embolic stroke of undetermined source (ESUS) with an uncommon cause, providing an etiologic investigation process in addition to diagnostic pitfalls and pearls, eventually raising neurologists' ability to treat ESUS.

CASE REPORT

A 37-year-old right-handed woman presented to our emergency department with sudden onset left upper limb and lower limb weakness. She denied a past medical history of hypertension, diabetes, heart diseases, and other cerebrovascular disease risk factors, and she is without a family history of stroke, previous trauma, toxic exposure, or drug use. On admission, her physical and neurological examinations were negative, except for left-sided hemiparesis. Her routine evaluations, serum autoantibody testing, and digital subtraction angiography were negative. Subsequent diffusion-weighted brain magnetic resonance imaging demonstrated acute infarction in the right frontoparietal lobe. To find the etiology of this case, more detailed examinations were performed. Finally, she was diagnosed with ESUS, which was caused by the PAVF.

CONCLUSIONS

This case raises the awareness of a potential important emboligenic mechanism, the existence of an isolated PAVF as a right-to-left shunt in patients with a stroke of unknown origin should not be overlooked, even if a PAVF is not suggested by the initial physical findings or chest x-ray.

Left atrial appendage strain predicts subclinical atrial fibrillation in embolic strokes of undetermined source

Aims

Left atrial (LA) strain is promising in prediction of clinical atrial fibrillation (AF) in stroke patients. However, prediction of subclinical AF is critical in patients with embolic strokes of undetermined source (ESUS). The aim of this prospective study was to investigate novel LA and left atrial appendage (LAA) strain markers in prediction of subclinical AF in ESUS patients.

Methods and results

A total of 185 patients with ESUS, mean age 68 ± 13years, 33% female, without diagnosed AF, were included. LAA and LA function by conventional echocardiographic parameters and reservoir strain (Sr), conduit strain (Scd), contraction strain (Sct), and mechanical dispersion (MD) of Sr were assessed with transoesophageal and transthoracic echocardiography. Subclinical AF was detected by insertable cardiac monitors during follow-up. LAA strain was impaired in 60 (32%) patients with subclinical AF compared to those with sinus rhythm: LAA-Sr, 19.2 ± 4.5% vs. 25.6 ± 6.5% (P < 0.001); LAA-Scd, -11.0 ± 3.1% vs. -14.4 ± 4.5% (P < 0.001); and LAA-Sct, -7.9 ± 4.0% vs. -11.2 ± 4% (P < 0.001), respectively, while LAA-MD was increased, 34 ± 24 ms vs. 26 ± 20 ms (P = 0.02). However, there was no significant difference in phasic LA strain or LA-MD. By ROC analyses, LAA-Sr was highly significant in prediction of subclinical AF and showed the best AUC of 0.80 (95% CI 0.73-0.87) with a sensitivity of 80% and a specificity of 73% (P < 0.001). LAA-Sr and LAA-MD were both independent and incremental markers of subclinical AF in ESUS patients.

Conclusion

LAA function by strain and mechanical dispersion predicted subclinical AF in ESUS patients. These novel echocardiographic markers may improve risk stratification in ESUS patients.

Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study - the importance of comprehensive clinical evaluation

BACKGROUND

Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.

METHODS

Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.

RESULTS

After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA₂DS₂-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091).

CONCLUSION

Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management

Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.

Multi-territory stroke preceded by pulmonary embolism with asymptomatic coronavirus disease 2019: a case report

Background

Non-bacterial thrombotic endocarditis is characterized by the presence of sterile vegetations on a cardiac valve. We present a case of multi-territory stroke caused by embolism of a non-bacterial thrombotic aortic valve endocarditis, leading to the diagnosis of a prostate adenocarcinoma with bone metastases.

Case summary

A 66-year-old patient was diagnosed with pulmonary embolism, first attributed to an asymptomatic coronavirus disease 2019 infection. Edoxaban was started, which was discontinued by the patient. Four weeks later, he presented with subacute vertigo and balance disorders. Magnetic resonance imaging showed a multi-territory stroke. A transoesophageal echocardiogram demonstrated a small vegetation on the aortic valve with moderate aortic insufficiency. Blood cultures remained negative. Malignancy screening showed a markedly elevated prostate-specific antigen. Prostate adenocarcinoma was confirmed on biopsy. A positron emission tomography revealed metastatic disease. A diagnosis of non-bacterial thrombotic endocarditis and paraneoplastic pulmonary embolism secondary to prostate cancer was made. Edoxaban was restarted and the patient was referred for treatment of the prostate adenocarcinoma. Follow-up after 5 months showed no evidence of aortic valve vegetations.

Discussion

Coronavirus disease 2019 in ambulatory patients may be insufficient as a predisposing factor for venous thrombo-embolism and these patients, especially the elderly, should undergo a screening for malignancy. Non-bacterial thrombotic endocarditis is a rare cause of multi-territory stroke. When related to cancer, the prostate can be the primary tumour.

Monocyte-to-Lymphocyte Ratio in Clot Analysis as a Marker of Cardioembolic Stroke Etiology

The aim of the study was to find markers of high-risk cardioembolic etiology (HRCE) in patients with cryptogenic strokes (CS) through the analysis of intracranial clot by flow cytometry (FC). A prospective single-center study was designed including patients with large vessel occlusion strokes. The percentage of granulocytes, monocytes, lymphocytes, and monocyte-to-lymphocyte ratio (MLr) were analyzed in clots extracted after endovascular treatment (EVT) and in peripheral blood. Large arterial atherosclerosis (LAA) strokes and high-risk cardioembolic (HRCE) strokes were matched by demographics and acute reperfusion treatment data to obtain FC predictors for HRCE. Multilevel decision tree with boosting random forest classifiers was performed with each feature importance for HRCE diagnosis among CS. We tested the validity of the best FC predictor in a cohort of CS that underwent extensive diagnostic workup. Among 211 patients, 178 cases underwent per-protocol workup. The percentage of monocytes (OR 1.06, 95% CI 1.01-1.11) and MLr (OR 1.83, 95% CI 1.12-2.98) independently predicted HRCE diagnosis when LAA clots (n = 28) were matched with HRCE clots (n = 28). Among CS (n = 82), MLr was the feature with the highest weighted importance in the multilevel decision tree as a predictor for HRCE. MLr cutoff point of 1.59 yield sensitivity of 91.23%, specificity of 44%, positive predictive value of 78.79%, and negative predictive value of 68.75 for HRCE diagnosis among CS. MLr ≥ 1.6 in clot analysis predicted HRCE diagnosis (OR, 6.63, 95% CI 1.85-23.71) in a multivariate model adjusted for age. Clot analysis by FC revealed high levels of monocyte-to-lymphocyte ratio as an independent marker of cardioembolic etiology in cryptogenic strokes.

Cardiac imaging in ischemic stroke or transient ischemic attack of undetermined cause: Systematic review & meta-analysis

BACKGROUND

Patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with "cryptogenic stroke or TIA" the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT).

METHODS AND RESULTS

We performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3-71.2 years, 49.2-59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies.

CONCLUSIONS

TTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.

Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design

Rationale

About one-third of ischaemic strokes are caused by cardioembolism, and a substantial proportion of cryptogenic strokes likely also originate from the heart or aortic arch. Early determination of aetiology is important to optimise management. Computed Tomography-angiography of the heart is emerging as an alternative to echocardiography to detect cardio-aortic sources of embolism in stroke patients, but its diagnostic yield in acute ischaemic stroke has not been thoroughly assessed.Hypothesis: We hypothesise that electrocardiography-gated computed tomography-angiography of the heart and aortic arch, acquired in the acute phase in patients with ischaemic stroke, has a higher diagnostic yield than transthoracic echocardiography as a first-line screening method for detection of cardio-aortic sources of embolism.

Methods and design

Mind the Heart is a single-centre prospective observational cohort study. We will include consecutive adult patients with acute ischaemic stroke who are potentially eligible for reperfusion therapy. Patients undergo non-electrocardiography-gated computed tomography-angiography of the aortic arch, cervical and intracranial arteries, directly followed by prospective sequential electrocardiography-gated cardiac computed tomography-angiography. Routine work-up for cardioembolism including 12-leads electrocardiography, Holter electrocardiography and transthoracic echocardiography is performed as soon as possible. The primary endpoint is the proportion of patients with a predefined high-risk cardio-aortic source of embolism on computed tomography-angiography versus transthoracic echocardiography in patients who underwent both investigations. Based on an expected 5% additional yield of computed tomography-angiography, a sample size of 450 patients is required.

Conclusions

The Mind the Heart study will generate a reliable estimate of the diagnostic yield of echocardiography-gated cardio-aortic computed tomography-angiography performed in the acute phase of ischaemic stroke.

Deep learning reconstruction versus iterative reconstruction for cardiac CT angiography in a stroke imaging protocol: reduced radiation dose and improved image quality

Background

To assess the radiation dose and image quality of cardiac computed tomography angiography (CCTA) in an acute stroke imaging protocol using a deep learning reconstruction (DLR) method compared to a hybrid iterative reconstruction algorithm.

Methods

Retrospective analysis of 296 consecutive patients admitted to the emergency department for stroke suspicion. All patients underwent a stroke CT imaging protocol including a non-enhanced brain CT, a brain perfusion CT imaging if necessary, a CT angiography (CTA) of the supra-aortic vessels, a CCTA and a post-contrast brain CT. The CCTA was performed with a prospectively ECG-gated volume acquisition. Among all CT scans performed, 143 were reconstructed with an iterative reconstruction algorithm (AIDR 3D, adaptive iterative dose reduction three dimensional) and 146 with a DLR algorithm (AiCE, advanced intelligent clear-IQ engine). Image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality (IQ) scored from 1 to 4 were assessed. Dose-length product (DLP), volume CT dose index (CTDIvol) and effective dose (ED) were obtained.

Results

The radiation dose was significantly lower with AiCE than with AIDR 3D (DLP =106.4±50.0 vs. 176.1±37.1 mGy·cm, CTDIvol =6.9±3.2 vs. 11.5±2.2 mGy, and ED =1.5±0.7 vs. 2.5±0.5 mSv) (P<0.001). The median SNR and CNR were higher [9.9 (IQR, 8.1-12.3); and 12.6 (IQR, 10.5-15.5), respectively], with AiCE than with AIDR 3D [6.5 (IQR, 5.2-8.5); and 8.4 (IQR, 6.7-11.0), respectively] (P<0.001). SNR and CNR were increased by 51% and 49%, respectively, with AiCE compared to AIDR 3D. The image quality was significantly better with AiCE (mean IQ score =3.4±0.7) than with AIDR 3D (mean IQ score =3±0.9) (P<0.001).

Conclusions

The use of a DLR algorithm for cardiac CTA in an acute stroke imaging protocol reduced the radiation dose by about 40% and improved the image quality by about 50% compared to an iterative reconstruction algorithm.

CT Angiography of the Heart and Aorta in TIA and Ischaemic Stroke: Cardioembolic Risk Sources and Clinical Implications

BACKGROUND

Cardiac emboli are important causes of (recurrent) ischaemic stroke. Aorta atherosclerosis might also be associated with an increased risk of stroke recurrence. This study aimed to evaluate the yield and clinical implications of CT-angiography (CTA) of the heart and aorta in the diagnostic workup of transient ischaemic attack (TIA) or ischaemic stroke.

METHODS

CTA of the heart and aortic arch was performed in TIA/ischaemic stroke patients, in addition to routine diagnostic workup. Occurrence of cardioembolic (CE) risk sources and complex aortic plaques were assessed. Implications of cardiac CTA for therapeutic management were evaluated RESULTS: Sixty-seven patients were included (TIA n = 33, ischaemic stroke n = 34) with a mean age of 68 years (range 51-89) and median NIHSS of 0 (interquartile range 0-2). CE risk sources were detected in 29 (43%) patients. An intracardiac thrombus was present in 2 patients (3%; TIA 0%; ischaemic stroke 6%). Medium/low-risk CE sources included mitral annular calcification (9%), aortic valve calcification (18%) and patent foramen ovale (18%). Complex aortic plaque was identified in 16 patients (24%). In two patients with an intracardiac thrombus, therapeutic management changed from antiplatelet to oral anticoagulation.

CONCLUSIONS

CTA of the heart and aorta has a high yield for detection of embolic risk sources in TIA/ischaemic stroke, with clinical consequences for 6% of ischaemic stroke patients. Implementation of CTA of the heart and aorta in the acute stroke setting seems valuable, but cost-effectiveness of this approach remains to be determined.

Screening of Embolic Sources by Point-of-Care Ultrasound in the Acute Phase of Ischemic Stroke

Our objective was to evaluate hand-held echocardiography as point of care ultrasound scanning (POCUS) to detect sources of embolism in the acute phase of stroke. Prospective, unicentric observational cohort study of non-lacunar ischemic stroke patients evaluated by V Scan device. The main sources of embolism (MSEs) were classified into embolic valvulopathies and severe ventricular dysfunction. We looked for atrial fibrillation (AF) predictors in strokes of undetermined etiology. MSEs were detected in 19.23% (25/130). Large vessel occlusion (LVO) (odds ratio [OR]: 4.24, 95% confidence interval [CI]: 1.01-17.85) and chronic heart failure (OR: 13.25, 95% CI: 3.54-49.50) were independent predictors of MSEs. LVO (OR: 6.54, 95% CI: 1.62-26.27) and left atrial area >20 cm² (OR: 7.01, 95% CI: 1.75-28.09) independently predicted AF. Patients with LVO and chronic heart disease may benefit from hand-held echocardiography as part of POCUS in the acute phase of ischemic stroke. Left atrial area measured was an independent predictor of AF in strokes of undetermined etiology.

Long-term (>10-year) clinical follow-up after young embolic stroke/TIA of undetermined source

Background

To date, the pathophysiology of first-ever and recurrent stroke/TIA still remains unclear in young patients with embolic stroke/TIA of undetermined source (ESUS). Clinical studies with long-term follow-up in young ESUS patients are necessary to investigate the underlying pathophysiology of first-ever and recurrent stroke/TIA in this patient population, in particular the role of new-onset atrial fibrillation.

Aims

Our aim was to study the long-term (>10-year) clinical outcome of young patients (<50 years) with ESUS.

Methods

This cohort study included all patients aged ≤ 50 years who underwent transoesophageal echocardiography for diagnostic work-up of ESUS during 1996–2008 from one tertiary center. All patients were contacted by telephone between September–November 2018 to update clinical information from medical records. The clinical outcomes of this study were incidence rates of all-cause and cardiovascular mortality, recurrent stroke/TIA, new-onset clinical AF, and ischemic vascular events.

Results

In total, 108 patients (57% female, mean age 40 ± 7.2 years [range 19–50 years], n = 72 stroke) were included. Across clinical follow-up (median 13[IQR 10–16] years), 24 patients died (n = 14 cardiovascular). The 15-year incidence rate of recurrent stroke/TIA was 15% (incidence rate = 1.09[95%CI 0.54–1.65]/100 patient-years) and a 5.5% incidence of new-onset clinical AF (incidence rate = 0.44[95%CI 0.09–0.79]/100 patient-years) following ESUS.

Conclusions

The incidence of recurrent stroke/TIA is relatively high during long-term clinical follow-up of young patients with ESUS. In contrast, new-onset clinical AF is relatively low and therefore may not play an important part in the pathophysiology of first-ever and recurrent stroke/TIA of these patients.

Exploring the experiences of individuals with an insertable cardiac monitor: Making the decision for device insertion

BACKGROUND

Little is known about the decision-making process for insertable cardiac monitors (ICM) in those with suspected arrhythmias.

OBJECTIVE

The purpose of this qualitative study was to describe how individuals make a decision to insert an ICM.

METHODS

A qualitative descriptive design was used. Data were analyzed using content analysis and constant comparison. NVivo 10 was used for data grouping and patterns.

RESULTS

Participants (N = 12) ranged in age from 41to 95. Most (n = 7) had the device inserted because of syncope or atrial fibrillation (AF), and others (n = 5) for cryptogenic stroke. Three categories emerged: pre-decision, definitive decision, and deliberated decision. Event symptoms, including physical, cognitive and emotional, and trust emerged as factors in decision-making.

CONCLUSIONS

Those who perceived their experience as life-threatening, trusted the healthcare provider and assented to the ICM insertion. Conversely, those who perceived symptoms as episodic, used other strategies to resolve symptoms prior to making the decision for insertion.

Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective

BACKGROUND

There is no universally accepted age cut-off for defining young strokes.

AIMS

We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes.

METHODS

A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria.

RESULTS

We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke.

CONCLUSIONS

The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

The Relationship between Diffusion-Weighted Magnetic Resonance Imaging Lesions and 24-Hour Rhythm Holter Findings in Patients with Cryptogenic Stroke

BACKGROUND AND OBJECTIVES

Cranial magnetic resonance imaging findings of patients considered to be cryptogenic stroke may be useful in determining the clinical and prognostic significance of arrhythmias, such as atrial premature beats and atrial run attacks, that are frequently encountered in rhythm Holter analysis. This study was conducted to investigate the relationship between short atrial runs and frequent premature atrial contractions detected in Holter monitors and infarct distributions in cranial magnetic resonance imaging of patients diagnosed with cryptogenic stroke.

MATERIALS AND METHODS

We enrolled the patients with acute ischemic stroke whose etiology were undetermined. We divided the patients in two groups according to diffusion-weighted magnetic resonance imaging as single or multiple vascular territory acute infarcts. The demographic, clinical, laboratory, echocardiographic, and rhythm Holter analyses were compared.

RESULTS

The study investigated 106 patients diagnosed with cryptogenic stroke. Acute cerebral infarctions were detected in 31% of the investigated patients in multiple territories and in 69% in a single territory. In multivariate logistic regression analysis, the total premature atrial contraction count (OR = 1.002, 95% CI: 1.001⁻1.004, p = 0.001) and short atrial run count (OR = 1.086, 95% CI: 1.021⁻1.155, p = 0.008) were found as independent variables that could distinguish between infarctions in a single or in multiple vascular territories.

CONCLUSIONS

Rhythm Holter monitoring of patients with infarcts detected in multiple vascular territories showed significantly higher premature atrial contractions and short atrial run attacks. More effort should be devoted to the identification of cardioembolic etiology in cryptogenic stroke patients with concurrent acute infarcts in the multiple vascular territories of the brain.

Management of Acute Retinal Ischemia: Follow the Guidelines!

Acute retinal arterial ischemia, including vascular transient monocular vision loss (TMVL) and branch (BRAO) and central retinal arterial occlusions (CRAO), are ocular and systemic emergencies requiring immediate diagnosis and treatment. Guidelines recommend the combination of urgent brain magnetic resonance imaging with diffusion-weighted imaging, vascular imaging, and clinical assessment to identify TMVL, BRAO, and CRAO patients at highest risk for recurrent stroke, facilitating early preventive treatments to reduce the risk of subsequent stroke and cardiovascular events. Because the risk of stroke is maximum within the first few days after the onset of visual loss, prompt diagnosis and triage are mandatory. Eye care professionals must make a rapid and accurate diagnosis and recognize the need for timely expert intervention by immediately referring patients with acute retinal arterial ischemia to specialized stroke centers without attempting to perform any further testing themselves. The development of local networks prompting collaboration among optometrists, ophthalmologists, and stroke neurologists should facilitate such evaluations, whether in a rapid-access transient ischemic attack clinic, in an emergency department-observation unit, or with hospitalization, depending on local resources.