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Perry JJ, Alsadoon A, Nemnom MJ, Sivilotti MLA, Émond M, Stiell IG, Stotts G, Lee JS, Worster A, Morris J, Cheung KW, Jin AY, Sahlas DJ, Murray HE, Mackey A, Verreault S, Camden MC, Yip S, Teal P, Gladstone DJ, Boulos MI, Chagnon N, Shouldice E, Atzema C, Slaoui T, Teitelbaum J, Giannakakis SM, Thiruganasambandamoorthy V, Dowlatshahi D, Wells GA, Sharma M. A Multicentre Prospective Cohort Study to Identify High-Risk Transient Ischemic Attack/Minor Stroke Patients Benefiting from Echocardiography. Can J Cardiol 2024:S0828-282X(24)00946-2. [PMID: 39277075 DOI: 10.1016/j.cjca.2024.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND We aimed to derive a clinical decision rule to identify transient ischemic attack (TIA)/minor stroke patients most likely to benefit from echocardiography. METHODS This multicentre prospective cohort study enrolled adults diagnosed with TIA/minor stroke in the emergency department who underwent a echocardiogram within 90 days, from 13 Canadian academic emergency departments from October 2006 to May 2017. Our outcome was clinically significant echocardiogram findings. RESULTS In 7,149 eligible patients, a clinically significant finding was found in 556 (7.8%). There were a further 2,421 (33.9%) with a potentially significant finding. History of heart failure (adjusted odds ratio [OR] 3.9) or coronary artery disease (OR 2.7) were the factors most strongly associated with clinically significant echocardiogram findings, while young age, male sex, valvular heart disease and infarct (any age) on neuroimaging were modestly associated (OR between 1.3 and 1.9). The model combining these predictors into a score (range 0 to 15), had a C-statistic of 0.67 (95%CI 0.65-0.70). A cut point of 6 points or more classified 6.6% of cases as high likelihood, defined as >15% for clinically significant echocardiogram findings. CONCLUSION Echocardiography is a very useful test in the investigations of TIA/minor stroke patients. We identified high risk clinical features, combined to create a clinical decision rule, to identify which TIA/minor stroke patients are likely to have clinically significant echocardiogram findings requiring an immediate change in management. These patients should have echocardiography prioritized while others may continue to have echocardiography conducted in a less urgent fashion.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Abdulaziz Alsadoon
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Founder SmartMed, SmartLab and Jiwar Freestanding ER, Saudi Arabia
| | | | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Marcel Émond
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacques S Lee
- Schwartz\\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Ka Wai Cheung
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Albert Y Jin
- Division of Neurology, Queen's University, Kingston, Ontario, Canada
| | - Demetrios J Sahlas
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Heather E Murray
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ariane Mackey
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Neurology, Laval University, Quebec City, Quebec, Canada
| | - Steve Verreault
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Neurology, Laval University, Quebec City, Quebec, Canada
| | - Marie-Christine Camden
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada; Division of Neurology, Laval University, Quebec City, Quebec, Canada
| | - Samuel Yip
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philip Teal
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - David J Gladstone
- Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Mark I Boulos
- Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Nicolas Chagnon
- Department of Emergency Medicine, Montfort Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Elizabeth Shouldice
- Queensway Carleton Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Clare Atzema
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tarik Slaoui
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Jeanne Teitelbaum
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Sophia-Maria Giannakakis
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George A Wells
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mukul Sharma
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Ontario, Canada
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Al-Sabbagh MQ, Thirunavukkarasu S, Eswaradass P. Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk. Cardiol Rev 2023:00045415-990000000-00155. [PMID: 37750739 DOI: 10.1097/crd.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
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.
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Affiliation(s)
- Mohammed Q Al-Sabbagh
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| | | | - Prasanna Eswaradass
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
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Shah S, Malik P, Patel U, Wang Y, Gronseth GS. 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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Affiliation(s)
- Shamik Shah
- Department of Neurology, Stormont Vail Health, Topeka, KS 66604, USA
| | - Preeti Malik
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (P.M.); (U.P.)
| | - Urvish Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (P.M.); (U.P.)
| | - Yunxia Wang
- Department of Neurology, The University of Kansas Health System, Kansas City, KS 66160, USA; (Y.W.); (G.S.G.)
| | - Gary S. Gronseth
- Department of Neurology, The University of Kansas Health System, Kansas City, KS 66160, USA; (Y.W.); (G.S.G.)
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Kuriki A, Ueno Y, Kamiya Y, Shimizu T, Doijiri R, Tateishi Y, Kikuno M, Shimada Y, Takekawa H, Yamaguchi E, Koga M, Ihara M, Ono K, Tsujino A, Hirata K, Toyoda K, Hasegawa Y, Hattori N, Urabe T. Atrial Septal Aneurysm may Cause In-Hospital Recurrence of Cryptogenic Stroke. J Atheroscler Thromb 2021; 28:514-523. [PMID: 32684557 PMCID: PMC8193779 DOI: 10.5551/jat.56440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/28/2020] [Indexed: 01/01/2023] Open
Abstract
AIMS Awareness of potentially embologenic diseases is critical to determining the prognosis of cryptogenic stroke. The clinical significance of atrial septal aneurysm (ASA) in cryptogenic stroke has not been fully studied. Therefore, we explored clinical characteristics and in-hospital recurrence in patients with ASA in cryptogenic stroke. METHODS A multicenter observational registry of cryptogenic stroke patients was conducted. We obtained baseline characteristics, radiological and laboratory findings, and echocardiographic findings, especially of embolic sources on transesophageal echocardiography. The CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for embolic stroke of undetermined source/cryptogenic stroke) registry was recorded at http://www.umin.ac.jp/ctr/ (UMIN000032957). Patients' clinical characteristics were compared according to the presence of ASA, and factors associated with in-hospital stroke recurrence were assessed. RESULTS The study included 671 patients (age, 68.7±12.7 years; 450 males; median National Institutes of Health Stroke Scale score, 2). ASA was detected in 92 patients (14%), displaying higher age (72.4±11.0 vs. 68.1 ±12.9 years, p=0.004), reduced frequency of diabetes mellitus (16% vs. 27%, p=0.030), higher frequency of right-to-left shunt (66% vs. 45%, p<0.001), and in-hospital stroke recurrence (8% vs. 3%, p=0.034). ASA was relatively associated with in-hospital recurrence (odds ratio 2.497, 95% confidence interval 0.959-6.500, p= 0.061). CONCLUSIONS The CHALLENGE ESUS/CS registry indicated that ASA was not rare in cryptogenic stroke, and ASA's clinical characteristics included higher age, reduced frequency of diabetes mellitus, and increased frequency of concomitant right-to-left shunt. ASA may be related to in-hospital stroke recurrence in cryptogenic stroke.
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Affiliation(s)
- Ayako Kuriki
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takahiro Shimizu
- Department of Neurology, St.Marianna University School of Medicine, Kanagawa, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Muneaki Kikuno
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiaki Shimada
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | | | - Eriko Yamaguchi
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenjiro Ono
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St.Marianna University School of Medicine, Kanagawa, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
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5
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Rodriguez-Granillo GA, Cirio JJ, Ciardi C, Caballero ML, Diluca P, Castrillon R, Ceron M, Scrivano E, Lylyk P. Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19. Minerva Cardiol Angiol 2021; 69:606-618. [PMID: 33703860 DOI: 10.23736/s2724-5683.21.05547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina - .,National Council of Scientific and Technical Investigations - Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina -
| | - Juan J Cirio
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Celina Ciardi
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Maria L Caballero
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pablo Diluca
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Ricardo Castrillon
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Marcos Ceron
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Esteban Scrivano
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
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Powers WJ. Clinical utility of echocardiography in secondary ischemic stroke prevention. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:359-375. [PMID: 33632453 DOI: 10.1016/b978-0-12-819814-8.00022-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Echocardiography employs ultrasound to evaluate cardiac function, structure and pathology. The clinical value in secondary ischemic stroke prevention depends on identification of associated conditions for which a change in treatment from antiplatelet agents and risk factor intervention leads to improved outcomes. Such therapeutically relevant findings include primarily intracardiac thrombus, valvular heart disease and, in highly selected patients, patent foramen ovale (PFO). Echocardiography in unselected patients with ischemic stroke has a very low yield of therapeutically relevant findings and is not cost-effective. With the exception of PFO, findings on echocardiography that are therapeutically relevant for secondary stroke prevention are almost always associated with history, signs or symptoms of cardiac or systemic disease. Choice of specific echocardiographic modalities should be based on the specific pathology or pathologies that are under consideration for the individual clinical situation. Transthoracic echocardiography (TTE) with agitated saline has comparable accuracy to transesophageal echocardiography (TEE) for PFO detection. For other therapeutically relevant pathologies, with the possible exception of left ventricular thrombus (LVT), TEE is more sensitive than TTE. Professional societies recommend TTE as the initial test but these recommendations do not take cost into account. In contrast, cost-effectiveness studies have determined that the most sensitive echocardiographic modality should be selected as the initial and only test.
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Affiliation(s)
- William J Powers
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
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Specktor P, Yalonetsky S, Agmon Y, Sprecher E, Ali FH, Telman G. The effect of TEE on treatment change in patients with acute ischemic stroke. PLoS One 2020; 15:e0243142. [PMID: 33270736 PMCID: PMC7714247 DOI: 10.1371/journal.pone.0243142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Ischemic stroke is a widespread disease carrying high morbidity and mortality. Transesophageal echocardiography (TEE) is considered an important tool in the work-up of patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients; its utility is limited by a semi-invasive nature. The purpose of this study was to evaluate the probability of treatment change due to TEE findings (yield) in the work-up of AIS and TIA patients. Methods Retrospective data on patients with AIS or TIA who underwent TEE examination between 2000–2013 were collected from the institutional registry. Results The average age of 1284 patients who were included in the study was 57±10.4, 66% of patients were male. The most frequent TEE findings included aortic plaques in 54% and patent foramen ovale (PFO) in 15%. TEE findings led to treatment change in 135 (10.5%) patients; anticoagulant treatment was initiated in 110 of them (81%). Most common etiology for switch to anticoagulation was aortic plaques (71 patients); PFO was second most common reason (26 patients). Significant TEE findings (thrombus, endocarditis, tumor) were found in 1.9% of patients, they were more common in young patients (<55; 56% of the patients). Conclusions The beginning of anticoagulation treatment in patients with thick and complicated plaques was found frequently in our study. Significant TEE findings, were infrequent, constituted an absolute indication for treatment change and were more common in younger patients.
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Affiliation(s)
- Polina Specktor
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Department of Neurology, Carmel Hospital, Haifa, Israel
| | | | - Yoram Agmon
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Elliot Sprecher
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Faten Haj Ali
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Gregory Telman
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Technion, Israel Institute of Technology, Haifa, Israel
- * E-mail:
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Consoli A, Coskun O, Perier M, Di Maria F, Gratieux J, Dean P, Pizzuto S, Badat N, Condette-Auliac S, Boulin A, Rodesch G. [Therapeutic and endovascular management of cerebral mycotic aneurysms]. Ann Cardiol Angeiol (Paris) 2020; 69:411-414. [PMID: 33131724 DOI: 10.1016/j.ancard.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/04/2020] [Indexed: 11/15/2022]
Abstract
Infective endocardites are associated with both ischemic and hemorrhagic neurological complications and also with cerebral abscesses and the development of "mycotic" aneurysms, which are detected in about 5 % of patients in the acute and sub-acute phase of the infection. Data about their natural history and their hemorrhagic risk are scarce and fragmented. The therapeutic management is represented by the medical treatment of the infection with interventional abstention, the surgical treatment and the endovascular approach by selective embolization of the aneurysm. No evidence is provided concerning the superiority of a specific approach. Mycotic aneurysms remain a diagnostic and therapeutic challenge and their management is necessarily based on a multidiscplinary approach.
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Affiliation(s)
- A Consoli
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France.
| | - O Coskun
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - M Perier
- Service de cardiologie, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - F Di Maria
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - J Gratieux
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - P Dean
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - S Pizzuto
- Unité de neuroradiologie, ospedale Civile S.Agostino-Estense, CHU Modène, université de Modène et Reggio Emilia, Via Pietro Giardini 1355, Modène, Baggiovara, 41126, Italie
| | - N Badat
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - S Condette-Auliac
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - A Boulin
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - G Rodesch
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
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9
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Sgreccia A, Carità G, Coskun O, Maria FD, Benamer H, Tisserand M, Scemama A, Rodesch G, Lapergue B, Consoli A. Acute ischemic stroke treated with mechanical thrombectomy and fungal endocarditis: A case report and systematic review of the literature. J Neuroradiol 2020; 47:386-392. [DOI: 10.1016/j.neurad.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/27/2018] [Accepted: 03/15/2019] [Indexed: 11/27/2022]
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10
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Mehrotra R, Kumar R, Bhat S, Bansal B, Bhagwati M. Transesophageal echocardiography in patients of acute ischemic stroke. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2019. [DOI: 10.4103/jiae.jiae_46_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Comparison of the Utility of Transesophageal Echocardiography in Patients With Acute Ischemic Stroke and Transient Ischemic Attack Stratified by Age Group (<60, 60 to 80, ≥80 Years). Am J Cardiol 2018; 122:2142-2146. [PMID: 30477726 DOI: 10.1016/j.amjcard.2018.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/30/2018] [Accepted: 09/05/2018] [Indexed: 11/22/2022]
Abstract
The objective was to study the utility of transesophageal echocardiography (TEE) in affecting acute ischemic stroke treatment of older adults (age ≥80 years). Patients hospitalized in January 2010 and February 2015 were included who had TEE ordered as part of their diagnostic workup at a tertiary medical center. We studied 515 hospitalized patients with acute stroke or transient ischemic attack who underwent TEE. The proportion of patients with important TEE findings was 35%. However, TEE changed management in only 2.5% of cases. When anticoagulation for proximal mobile aorta atheroma was excluded, no change in management resulted from TEE for patients older than 80 years. In conclusion, TEE has a low likelihood of a pathologic finding that resulted in a change in treatment strategy, especially in patients ≥80 years of age.
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Al-Khaled M, Scheef B, Brüning T. Is transesophageal echocardiography needed for evaluating tissue-based transient ischemic attack? Neural Regen Res 2018; 13:1212-1215. [PMID: 30028329 PMCID: PMC6065226 DOI: 10.4103/1673-5374.235058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Transient ischemic attack (TIA) is a warning signal for stroke. A comprehensive evaluation of TIA may reduce the risk for subsequent stroke. Data on the findings of cardiac evaluation with transesophageal echocardiography (TEE) in patients with TIA are sparse. Our aims were to determine the frequency of TEE performance and to investigate the findings of TEE in patients with TIA based on the new definition of TIA (i.e., transient neurological symptoms without evidence of infarction). During a 4-year period (2011-2014), 1071 patients (mean age, 70 ± 13 years; female, 49.7%) with TIA were included in a prospective study and evaluated. Of 1071 consecutive patients suffering from TIA, 288 patients (27%) underwent TEE. The median time between admission and TEE was 6 days. Patients with TIA who were evaluated by TEE were younger (67 vs. 71 years, P < 0.001) than those who were not evaluated by TEE. They had a higher rate of sensibility disturbance as a TIA symptom (39% vs. 31%, P = 0.012) but a lower rate of previous stroke (15% vs. 25%, P = 0.001) and atrial fibrillation (2% vs. 21%, P < 0.001) than those who did not. Foramen ovale was detected in 71 patients (25.7%), atrial septal aneurysm in 13 patients (4.6%), and severe atherosclerotic plaques (grade 4 and 5) in the aortic arch in 25 patients (8.7%). One patient (0.3%) had a fibroma detected by TEE. In 17 of the 288 patients (6%) who underwent TEE, the indication for anticoagulation therapy was based on the TEE results, and 1 patient with fibroma underwent heart surgery. During hospitalization, 7 patients experienced a subsequent stroke, and 27 patients had a recurrent TIA. At 3 months following discharge, the rates of readmission, stroke, recurrent TIA, and death were 19%, 2.7%, 4.2%, and 1.6%, respectively. The rates of mortality (0.9% vs. 1.8%, P = 0.7), stroke risk (1.9% vs. 3.0%, P = 0.8), and recurrent TIA (5.0% vs. 3.9%, P = 0.8) were similar in patients who underwent TEE and in those who did not. Performing TEE in patients with tissue-based TIA is helpful in detecting cardiac sources for embolism and may indicate for anticoagulation.
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Affiliation(s)
| | - Björn Scheef
- Department of Neurology, University of Lübeck, Lübeck; Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Toralf Brüning
- Department of Neurology, University of Lübeck, Lübeck, Germany
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Katsanos AH, Bhole R, Frogoudaki A, Giannopoulos S, Goyal N, Vrettou AR, Ikonomidis I, Paraskevaidis I, Pappas K, Parissis J, Kyritsis AP, Alexandrov AW, Triantafyllou N, Malkoff MD, Voumvourakis K, Alexandrov AV, Tsivgoulis G. The value of transesophageal echocardiography for embolic strokes of undetermined source. Neurology 2016; 87:988-95. [PMID: 27488602 DOI: 10.1212/wnl.0000000000003063] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/18/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Our aim was to evaluate the diagnostic yield of transesophageal echocardiography (TEE) in consecutive patients with ischemic stroke (IS) fulfilling the diagnostic criteria of embolic strokes of undetermined source (ESUS). METHODS We prospectively evaluated consecutive patients with acute IS satisfying ESUS criteria who underwent in-hospital TEE examination in 3 tertiary care stroke centers during a 12-month period. We also performed a systematic review and meta-analysis estimating the cumulative effect of TEE findings on therapeutic management for secondary stroke prevention among different IS subgroups. RESULTS We identified 61 patients with ESUS who underwent investigation with TEE (mean age 44 ± 12 years, 49% men, median NIH Stroke Scale score = 5 points [interquartile range: 3-8]). TEE revealed additional findings in 52% (95% confidence interval [CI]: 40%-65%) of the study population. TEE findings changed management (initiation of anticoagulation therapy, administration of IV antibiotic therapy, and patent foramen ovale closure) in 10 (16% [95% CI: 9%-28%]) patients. The pooled rate of reported anticoagulation therapy attributed to abnormal TEE findings among 3,562 acute IS patients included in the meta-analysis (12 studies) was 8.7% (95% CI: 7.3%-10.4%). In subgroup analysis, the rates of initiation of anticoagulation therapy on the basis of TEE investigation did not differ (p = 0.315) among patients with cryptogenic stroke (6.9% [95% CI: 4.9%-9.6%]), ESUS (8.1% [95% CI: 3.4%-18.1%]), and IS (9.4% [95% CI: 7.5%-11.8%]). CONCLUSIONS Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.
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Affiliation(s)
- Aristeidis H Katsanos
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Rohini Bhole
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Alexandra Frogoudaki
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Sotirios Giannopoulos
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Nitin Goyal
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Agathi-Rosa Vrettou
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Ignatios Ikonomidis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Ioannis Paraskevaidis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Konstantinos Pappas
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - John Parissis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Athanassios P Kyritsis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Anne W Alexandrov
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Nikos Triantafyllou
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Marc D Malkoff
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Konstantinos Voumvourakis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Andrei V Alexandrov
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Georgios Tsivgoulis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic.
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14
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Wilson CA, Tai W, Desai JA, Mulvihill I, Olivot JM, Murphy S, Coutts SB, Albers GW, Kelly P, Cucchiara BL. Diagnostic Yield of Echocardiography in Transient Ischemic Attack. J Stroke Cerebrovasc Dis 2016; 25:1135-1140. [PMID: 26915604 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 01/02/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Echocardiography is often performed to identify a cardiac source of embolism (CSE) causing transient ischemic attack (TIA). However, the diagnostic yield of echocardiography in TIA remains uncertain, and its role in routine evaluation of TIA is controversial. METHODS Patients with acute TIA were prospectively enrolled at 4 stroke centers. A CSE was defined using the Causative Classification of Stroke system; patent foramen ovale was considered a relevant CSE only if the patient underwent closure or was placed on anticoagulation. Patients with a known CSE at time of admission were excluded from analysis of the yield of echocardiography. RESULTS A total of 869 patients were enrolled at stroke centers, and 129 had a known CSE at presentation. Of the 740 remaining patients, 603 (81%) underwent echocardiography. A potential CSE was identified in 60 (10%) of these patients. The most common CSEs noted on echocardiography were complex aortic arch atherosclerosis and patent foramen ovale. History of coronary artery disease (P < .001), lack of prior stroke or TIA (P = .007), and presence of acute infarction on magnetic resonance imaging (MRI) (P < .001) were predictors of CSE on echocardiography. The yield of echocardiography was 29% in patients with both history of coronary artery disease and acute infarction on MRI, 14% with one of these features, and 5% with neither of these features (P < .0001). A CSE identified by echocardiography prompted initiation of anticoagulation in 15 of the 603 (2.5%) subjects. CONCLUSIONS Echocardiography demonstrates a relevant CSE in a significant portion of patients with TIA. However, changes in antithrombotic therapy resulting from echocardiography are infrequent.
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Affiliation(s)
| | - Waimei Tai
- Department of Neurology, Stanford University, Stanford, California
| | - Jamsheed A Desai
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Jean-Marc Olivot
- Department of Neurology, Stanford University, Stanford, California
| | - Sean Murphy
- Mater Misericordiae Hospital, Dublin, Ireland
| | - Shelagh B Coutts
- Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gregory W Albers
- Department of Neurology, Stanford University, Stanford, California
| | - Peter Kelly
- Mater Misericordiae Hospital, Dublin, Ireland
| | - Brett L Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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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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16
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Khariton Y, House JA, Comer L, Coggins TR, Magalski A, Skolnick DG, Good TH, Main ML. Impact of transesophageal echocardiography on management in patients with suspected cardioembolic stroke. Am J Cardiol 2014; 114:1912-6. [PMID: 25438921 DOI: 10.1016/j.amjcard.2014.09.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 09/14/2014] [Accepted: 09/14/2014] [Indexed: 10/24/2022]
Abstract
Transesophageal echocardiography (TEE) is frequently performed in patients with acute ischemic cerebrovascular events to exclude a cardioembolic source. We aimed to determine the clinical impact of TEE on management. This is a retrospective single-center study of 1,458 consecutive patients hospitalized with acute ischemic stroke or transient ischemic attack who underwent TEE for evaluation of a suspected cardioembolic cause. Significant TEE findings were determined for each patient as recorded on the TEE report. The medical record was reviewed for baseline, clinical, and demographic variables and to determine whether significant management changes occurred as a result of the TEE findings. Potential significant changes in management included initiation of anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of antibiotic therapy for endocarditis, surgical PFO closure, other cardiac surgery, and coil embolization of a pulmonary arteriovenous malformation. A significant change in management occurred in 243 patients (16.7%); 173 (71%) underwent treatment for PFO with a percutaneous PFO closure device (n = 100), initiation of chronic systemic anticoagulation (n = 68), or surgical PFO closure (n = 5). Additional findings leading to a change in management included endocarditis (n = 20), aortic arch atheroma (n = 14), intracardiac thrombus (n = 13), pulmonary arteriovenous malformation (n = 2), aortic valve fibroelastoma (n = 2), other valve masses (n = 4), and miscellaneous causes (n = 15). In conclusion, in patients with suspected cardioembolic stroke, TEE findings led to a change in management in 16.7% of patients. Of these, most (71%) were directed at prevention of subsequent paradoxical emboli in patients with PFO.
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17
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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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Fleury O, Sibon I. Accidente ischemico cerebrale e retinico transitorio. Neurologia 2014. [DOI: 10.1016/s1634-7072(14)67977-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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19
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Bhatia N, Abushora MY, Donneyong MM, Stoddard MF. Determination of the optimum number of cardiac cycles to differentiate intra-pulmonary shunt and patent foramen ovale by saline contrast two- and three-dimensional echocardiography. Echocardiography 2013; 31:293-301. [PMID: 24028319 DOI: 10.1111/echo.12360] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) and intra-pulmonary shunt (IPS) are potential causes of stroke. The most optimum cardiac cycle cutoff for bubbles to appear in the left heart on saline contrast transthoracic echocardiography (TTE) as criteria to differentiate the 2 entities is unknown. METHODS Ninety-five adult patients had saline contrast transesophageal echocardiography (TEE), two-dimensional (2D) and 3DTTE. Sensitivity and specificity of each cardiac cycle as cutoff to differentiate a PFO and IPS were obtained. RESULTS Transesophageal echocardiography showed IPS in 28 and PFO in 15 patients. If bubbles appeared in the left heart within the first 4 cardiac cycles (the 4th cardiac cycle rule) as compared to alternate cutoffs, a PFO was most accurately diagnosed by both 2D and 3DTTE. Bubbles appearing at or after the 5th cardiac cycle most accurately determined an IPS. 3D versus 2DTTE had a trend for a higher sensitivity (61% vs. 36%, P = 0.06), but similar specificity (94% vs. 91%) for IPS. Accuracy of 3DTTE was 84% and 2DTTE was 75% (P = 0.08) for IPS. For PFO, 2DTTE sensitivity (87%) and specificity (98%) did not differ (P = NS) from that of 3DTTE sensitivity (73%) and specificity (100%). CONCLUSIONS This study demonstrates for the first time that the 4th cardiac cycle rule differentiates PFO and IPS most optimally by 2D and 3DTTE. 3DTTE appears to have higher sensitivity for diagnosing IPS. These data suggest that 3DTTE is preferable when IPS is to be diagnosed. Both methods are similar for diagnosing PFO.
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Affiliation(s)
- Nirmanmoh Bhatia
- Department of Medicine, Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky
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Abushora MY, Bhatia N, Alnabki Z, Shenoy M, Alshaher M, Stoddard MF. Intrapulmonary shunt is a potentially unrecognized cause of ischemic stroke and transient ischemic attack. J Am Soc Echocardiogr 2013; 26:683-90. [PMID: 23669596 DOI: 10.1016/j.echo.2013.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ischemic stroke is a major cause of mortality and disability. Transient ischemic attack (TIA) is a harbinger of stroke. The etiology of stroke in as many as 40% of patients remains undetermined after extensive evaluation. It was hypothesized that intrapulmonary shunt is a potential facilitator of cerebrovascular accident (CVA) or TIA. METHODS Patients undergoing clinically indicated transesophageal echocardiography were prospectively enrolled. Comprehensive multiplane transesophageal echocardiographic imaging was performed and saline contrast done to assess for intrapulmonary shunt and patent foramen ovale. RESULTS Three hundred twenty-one patients with either nonhemorrhagic CVA (n = 262) or TIA (n = 59) made up the stroke group. Three hundred twenty-one age-matched and gender-matched patients made up the control group. Intrapulmonary shunt occurred more frequently in the stroke group (72 of 321) compared with the control group (32 of 321) (22% vs 10%, P < .0001). Intrapulmonary shunt was an independent predictor of CVA and/or TIA (odds ratio, 2.6; P < .0001). In subjects with cryptogenic CVA or TIA (n = 71), intrapulmonary shunt occurred more frequently (25 of 71) than in the control group (5 of 71) (35% vs 7%, P < .0001). Intrapulmonary shunt was an independent multivariate predictor of CVA or TIA in patients with cryptogenic CVA or TIA (odds ratio, 6.3; P < .005). CONCLUSIONS These results suggest that intrapulmonary shunt is a potentially unrecognized facilitator of CVA and TIA, especially in patients with cryptogenic CVA and TIA. Future studies assessing the prognostic significance of intrapulmonary shunt on cerebral vascular event recurrence rates in patients after initial CVA or TIA would be of great interest.
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Affiliation(s)
- Mohannad Y Abushora
- Department of Medicine, Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
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Ogbara J, Logani S, Ky B, Chirinos JA, Silvestry FE, Eberman K, Moss JD, Ferrari VA, Keane MG, John Sutton MS, Wiegers SE, Kirkpatrick JN. The Utility of Prescreening Transesophageal Echocardiograms: A Prospective Study. Echocardiography 2011; 28:767-73. [DOI: 10.1111/j.1540-8175.2011.01421.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Galougahi KK, Stewart T, Choong CYP, Storey CE, Yates M, Tofler GH. The utility of transoesophageal echocardiography to determine management in suspected embolic stroke. Intern Med J 2010; 40:813-8. [DOI: 10.1111/j.1445-5994.2009.02103.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Young KC, Benesch CG. Transesophageal echocardiography screening in subjects with a first cerebrovascular ischemic event. J Stroke Cerebrovasc Dis 2010; 20:503-9. [PMID: 20813548 DOI: 10.1016/j.jstrokecerebrovasdis.2010.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 03/02/2010] [Accepted: 03/09/2010] [Indexed: 11/25/2022] Open
Abstract
Our goal was to develop decision guides to predict the presence of a high-risk source of embolus and to predict a change in management following transesophageal echocardiography (TEE) in subjects who present with a first cerebral ischemic event. We conducted a retrospective review of subjects age ≥18 years who underwent TEE after a first ischemic event and were admitted to our stroke service between 2004 and 2007 (n = 287). A high-risk source of embolus and a change in clinical management (including medication changes or subsequent testing) were analyzed as separate endpoints, using multivariate techniques and receiver operating characteristic curves. We found that 14.3% of the subjects had a high-risk source, and an additional 61.3% had a potential (or low-risk) source of embolus. Increasing age and no history of diabetes mellitus were independently associated with a high-risk source of embolus. TEE would be recommended for nondiabetic individuals age ≥66 years (sensitivity, 68%; specificity, 76%). The area under the curve (AUC) for detecting a high-risk source was 0.773. TEE results changed medications or clinical management in 30.3% of the subjects. Current smokers were less likely to undergo a change in management. The AUC was uninformative (0.56) for predicting changes in management. Subjects presenting with a first ischemic event age ≥66 years may benefit from TEE. Although changes in management occurred in at least 30% of our cohort, no factors that predicted a change in management better than chance alone could be identified.
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Affiliation(s)
- Kate C Young
- Department of Neurology, University of Rochester Medical Center, 575 Elmwood Ave., Rochester, NY 14620, USA.
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Importance of Performing Transesophageal Echocardiography in Acute Stroke Patients older than Fifty. Echocardiography 2010; 27:1086-92. [DOI: 10.1111/j.1540-8175.2010.01203.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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25
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Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL. Definition and Evaluation of Transient Ischemic Attack. Stroke 2009; 40:2276-93. [PMID: 19423857 DOI: 10.1161/strokeaha.108.192218] [Citation(s) in RCA: 1188] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Morris JG, Duffis EJ, Fisher M. Cardiac workup of ischemic stroke: can we improve our diagnostic yield? Stroke 2009; 40:2893-8. [PMID: 19478214 DOI: 10.1161/strokeaha.109.551226] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Discovering potential cardiac sources of stroke is an important part of the urgent evaluation of the ischemic stroke patient as it often impacts treatment decisions that are essential for determining secondary stroke prevention strategies, yet the optimal approach to the cardiac workup of an ischemic stroke patient is not known. METHODS A review of the literature concerning the utility of cardiac rhythm monitoring (ECG, telemetry, Holter monitors, and event recorders) and structural imaging (transthoracic and transesophageal echocardiography) was performed. RESULTS Data supporting a definitive, optimal, and cost-effective approach are lacking, though some data suggest that appropriate patient selection can improve the diagnostic and therapeutic yield of rhythm monitoring and echocardiography in the evaluation of stroke etiology. CONCLUSIONS Based on available data, an algorithmic approach for the evaluation of patients with acute ischemic cerebrovascular events that takes into account therapeutic and diagnostic yield as well as cost-efficiency is proposed.
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Affiliation(s)
- Jane G Morris
- Department of Neurology, University of Massachusetts Medical Center, 55 Lake Ave North, Worcester, MA 01655, USA.
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Tateishi Y, Iguchi Y, Kimura K, Kobayashi K, Shibazaki K, Eguchi K. Right-to-left shunts may be not uncommon cause of TIA in Japan. J Neurol Sci 2009; 277:13-6. [DOI: 10.1016/j.jns.2008.09.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 09/20/2008] [Accepted: 09/25/2008] [Indexed: 10/21/2022]
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Thrombus Detection by Echocardiography in Patients with Acute Ischemic Stroke and Chronic or New-Onset Atrial Fibrillation. J Stroke Cerebrovasc Dis 2008; 17:208-11. [DOI: 10.1016/j.jstrokecerebrovasdis.2008.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Revised: 02/15/2008] [Accepted: 02/25/2008] [Indexed: 10/21/2022] Open
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Strandberg M, Marttila RJ, Helenius H, Hartiala J. Transoesophageal echocardiography should be considered in patients with ischaemic stroke or transient ischaemic attack. Clin Physiol Funct Imaging 2008; 28:156-60. [DOI: 10.1111/j.1475-097x.2007.00785.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Leslie-Mazwi TM, Brott TG, Brown RD, Worrall BB, Silliman SL, Case LD, Frankel MR, Rich SS, Meschia JF. Sex differences in stroke evaluations in the Ischemic Stroke Genetics Study. J Stroke Cerebrovasc Dis 2007; 16:187-93. [PMID: 17845914 PMCID: PMC2613848 DOI: 10.1016/j.jstrokecerebrovasdis.2007.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 03/14/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Epidemiologic studies suggest sex differences in evaluation of patients presenting with ischemic stroke. Sex differences in stroke evaluation could lead to sex differences in the validity of diagnosing ischemic stroke subtypes. This study assessed sex differences in the Ischemic Stroke Genetics Study (ISGS). METHODS The ISGS is a prospective case-control genetic association study of patients with first-ever ischemic stroke at 5 US tertiary stroke centers. The diagnostic tests performed as part of medical care were recorded for each enrolled patient. RESULTS A total of 505 patients were enrolled; 45% (229 of 505) were women and 55% (276 of 505) were men. Mean age at time of stroke was greater for women (66.6 v 61.9 years; P = .001). Frequency of brain computed tomography was 92% (254 of 276) for men and 90% (206 of 229) for women (P = .42). Magnetic resonance imaging was completed in 84% (232 of 276) of men and 83% (191 of 229) of women (P = .91). Frequency of electrocardiography was 91% (252 of 276) for men and 90% (206 of 229) for women (P = .60). Echocardiography was done in 74% (203 of 276) of men and 79% (180 of 229) of women (P = .19). Cervical arterial imaging occurred in 91% (208 of 229) of women and 86% (237 of 276) of men (P = .09). Intracranial vascular imaging was performed in 75% (207 of 276) of men and 79% (181 of 229) of women (P = .28). CONCLUSIONS Our findings suggest no significant sex differences in the extent to which major diagnostic tests were performed in patients in ISGS. Dedicated tertiary stroke centers may reduce the sex bias in stroke evaluation that has been identified by previous studies.
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