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Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [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: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
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2
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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3
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Onatsu J, Vanninen R, JÄkÄlÄ P, Mustonen P, Pulkki K, Korhonen M, Hedman M, HÖglund K, Blennow K, Zetterberg H, Herukka SK, Taina M. Tau, S100B and NSE as Blood Biomarkers in Acute Cerebrovascular Events. In Vivo 2021; 34:2577-2586. [PMID: 32871787 DOI: 10.21873/invivo.12075] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM We aimed to analyze the diagnostic value of total tau (T-tau), S-100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE) as blood-based biomarkers in acute ischemic stroke (AIS) or transient ischemic attack (TIA), and their correlation with symptom severity, infarct size, etiology and outcome. PATIENTS AND METHODS A total of 102 patients with stroke and 35 with TIA were analyzed. Subacute (63.8±50.1 h) plasma T-tau was measured with the single-molecule array (Simoa) method and NSE and S100B were evaluated for comparison. We evaluated biomarkers associations with: (i) diagnosis of AIS or TIA, (ii) cerebral infarction volume in the brain computed tomography, (iii) stroke etiology, (iv) clinical stroke severity and (iv) functional outcome after three months. RESULTS T-tau was higher in patients with stroke [1.0 pg/ml (IQR=0.3-2.2)] than with TIA [0.5 pg/ml (IQR=0.2-1.0), p=0.02]. The levels of S100B were also increased in stroke [0.082 μg/l (IQR=0.049-0.157)] patients compared to TIA patients [0.045 μg/l (IQR=0.03-0.073), p<0.001]. However, when the results were adjusted for confounders, significance was lost. Serum levels of NSE among patients with AIS [11.85 μg/l (IQR=9.30-16.14)] compared to those with TIA [10.96 μg/l (IQR=7.98-15.33), p=0.30] were equal. T-tau and S100B concentrations significantly correlated with cerebral infarction volume (r=0.412, p<0.001) and (r=0.597, p<0.001), also after corrections (p<0.001). mRS scores at three-month follow-up correlated with T-tau (r=0.248, p=0.016) and S100B concentrations (r=0.205, p=0.045). CONCLUSION For the diagnosis of TIA vs. AIS, blood T-tau and S100B concentrations discriminated only modestly. Additionally, groups were not separable after measuring of T-tau and S100B levels in the blood. T-tau and S100B concentrations correlated with the infarct size, but were not alone predictive for functional outcome at 3 months.
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Affiliation(s)
- Juha Onatsu
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland .,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Department of Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Pekka JÄkÄlÄ
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland.,Eastern Finland Laboratory Centre, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Kina HÖglund
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, U.K.,UK Dementia Research Institute, London, U.K
| | - Sanna-Kaisa Herukka
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Department of Clinical Radiology, University of Eastern Finland, Kuopio, Finland
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4
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany.,Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.,Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany.,University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany. .,Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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5
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Guglielmi V, Rinkel LA, Groeneveld NS, Lobé NH, Boekholdt SM, Bouma BJ, Beenen LF, Marquering HA, Majoie CB, Roos YB, van Randen A, Planken RN, Coutinho JM. Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design. Eur Stroke J 2021; 5:441-448. [PMID: 33598563 PMCID: PMC7856589 DOI: 10.1177/2396987320962911] [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: 06/30/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick Hj Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo Fm Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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6
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Abstract
PURPOSE OF REVIEW Cardiac imaging after ischemic stroke or transient ischemic attack (TIA) is used to identify potential sources of cardioembolism, to classify stroke etiology leading to changes in secondary stroke prevention, and to detect frequent comorbidities. This article summarizes the latest research on this topic and provides an approach to clinical practice to use cardiac imaging after stroke. RECENT FINDINGS Echocardiography remains the primary imaging method for cardiac work-up after stroke. Recent echocardiography studies further demonstrated promising results regarding the prediction of non-permanent atrial fibrillation after ischemic stroke. Cardiac magnetic resonance imaging and computed tomography have been tested for their diagnostic value, in particular in patients with cryptogenic stroke, and can be considered as second line methods, providing complementary information in selected stroke patients. Cardiac imaging after ischemic stroke or TIA reveals a potential causal condition in a subset of patients. Whether systematic application of cardiac imaging improves outcome after stroke remains to be established.
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Affiliation(s)
- S Camen
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany.
- University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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7
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Groeneveld NS, Guglielmi V, Leeflang MMG, Matthijs Boekholdt S, Nils Planken R, Roos YBWEM, Majoie CBLM, Coutinho JM. CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis. J Neurol 2020; 267:1793-1801. [PMID: 32140869 PMCID: PMC7293690 DOI: 10.1007/s00415-020-09766-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac thrombi are an important cause of embolic stroke. We studied the diagnostic yield and diagnostic accuracy of cardiac CT angiography (CTA) compared to echocardiography for detection of cardiac thrombi in ischemic stroke patients. METHODS We performed a systematic review and meta-analysis of the literature on cardiac CTA versus echocardiography for detection of cardiac thrombi in ischemic stroke patients. We included studies (N ≥ 20) in which both cardiac CTA (index test) and echocardiography (reference test) were performed and data on cardiac thrombi were reported. Results were stratified for type of echocardiography: transesophageal (TEE) vs transthoracic (TTE). RESULTS Out of 1530 studies, 14 were included (all single center cohort studies), with data on 1568 patients. Mean age varied between 52 and 69 years per study and 66% were men. Reported time intervals ranged from 0 to 21 days between stroke and first test, and from 0 to 199 days between tests. In ten studies that compared CTA to TEE, CTA detected cardiac thrombi in 87/1385 (6.3%) patients versus 68/1385 (4.9%) on TEE (p < 0.001). In four studies comparing CTA to TTE, CTA detected thrombi in 23/183 (12.5%) patients versus 12/183 (6.6%) on TTE (p = 0.010). Pooled sensitivity and specificity of CTA versus TEE were 86.0% (95% CI 65.6-95.2) and 97.4% (95% CI 95.0-98.7), respectively. CONCLUSIONS CTA may be a promising alternative to echocardiography for detection of cardiac thrombi in patients with ischemic stroke, especially now that CTA is standard care for patient selection for endovascular treatment. However, studies were too heterogeneous and of insufficient methodological quality to draw firm conclusions. Large, prospective studies on this topic are warranted.
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Affiliation(s)
| | - Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariska M G Leeflang
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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8
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Abstract
About 20–25% of all ischemic strokes are of cardioembolic etiology, with atrial fibrillation and heart failure as the most common underlying pathologies. Diagnostic work-up by noninvasive cardiac imaging is essential since it may lead to changes in therapy, e.g., in—but not exclusively—secondary stroke prevention. Echocardiography remains the cornerstone of cardiac imaging after ischemic stroke, with the combination of transthoracic and transesophageal echocardiography as gold standard thanks to their high sensitivity for many common pathologies. Transesophageal echocardiography should be considered as the initial diagnostic tool when a cardioembolic source of stroke is suspected. However, to date, there is no proven benefit of transesophageal echocardiography-related therapy changes on the main outcomes after ischemic stroke. Based on the currently available data, cardiac computed tomography and magnetic resonance imaging should be regarded as complementary methods to echocardiography, providing additional information in specific situations; however, they cannot be recommended as first-line modalities.
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Affiliation(s)
- S Camen
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany. .,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany.
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9
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Onatsu J, Vanninen R, Jäkälä P, Mustonen P, Pulkki K, Korhonen M, Hedman M, Zetterberg H, Blennow K, Höglund K, Herukka SK, Taina M. Serum Neurofilament Light Chain Concentration Correlates with Infarct Volume but Not Prognosis in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:2242-2249. [PMID: 31151840 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/22/2019] [Accepted: 05/06/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND PURPOSE We studied serum neurofilaments diagnostic value in patients with acute ischemic stroke (AIS) or TIA and evaluated any correlation with symptom severity, cerebral infarction volume, aetiology, and clinical outcome. METHODS One hundred and thirty-six patients (101 with AIS, and 35 with TIA) were included. Acute-phase serum neurofilament light chain (sNfL) was analyzed with a novel ultrasensitive single molecule array (Simoa). Cerebral infarction volume was measured from brain computed tomography in the subacute phase (>2 days). Stroke aetiology was defined by trial of ORG 10172 in acute stroke treatment classification, severity by National Institute of Health stroke scale (NIHSS) and the degree of disability by the Modified Rankin Scale (mRS) after 90 days. RESULTS sNfL was markedly higher in patients with AIS (89.5 pg/mL [IQR: 44.7-195.3]) than with TIA (25.2 pg/mL [IQR: 14.6-48.0]), P= <.001), also after adjusting for age, NIHSS, and stroke volume (P= .003). In receiver operating characteristic analysis, sNfL concentration greater than or equal to 49 pg/mL proved to be the best cut-off value to differentiate between patients with stroke and those with TIA (sensitivity of 73% and specificity of 80%). sNfL concentration significantly correlated with cerebral infarction volume (r = .413, P= <.001), this association remained significant after adjusting for established predictors (P= .019). Patients with AIS due to cardioembolism or large artery atherosclerosis had the highest sNfL concentrations. NIHSS on admission (r = .343, P = <.001) and mRS scores after 3 months (r = .306, P = .004) correlated with sNfL concentration, however functional outcome 3 months after stroke was not associated with sNfL after adjusting for potential confounders. CONCLUSIONS Cases with stroke were distinguishable from those with TIA following the determination of sNfL in the blood samples. The presence and amount of axonal damage estimated by sNfL correlated with the final cerebral infarction volume but was not predictive of degree of disability.
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Affiliation(s)
- Juha Onatsu
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Radiology, University of Eastern Finland, Kuopio Finland
| | - Pekka Jäkälä
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland; Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Kari Pulkki
- Department of Clinical Radiology and Clinical Chemistry, Kuopio, Finland; Eastern Finland Laboratory Center and Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom; UK Dementia Research Institute, London, United Kingdom
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kina Höglund
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Sanna-Kaisa Herukka
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland; Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
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10
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Onatsu J, Taina M, Mustonen P, Hedman M, Muuronen A, Arponen O, Korhonen M, Jäkälä P, Vanninen R, Pulkki K. Soluble Urokinase-type Plasminogen Activator Receptor Predicts All-cause 5-Year Mortality in Ischemic Stroke and TIA. ACTA ACUST UNITED AC 2018; 31:381-386. [PMID: 28438866 DOI: 10.21873/invivo.11070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 02/26/2017] [Accepted: 03/01/2017] [Indexed: 12/26/2022]
Abstract
AIM We evaluated soluble urokinase-type plasminogen activator receptor (suPAR) levels in different stroke subtypes and assessed their prognostic value regarding 5-year outcomes. MATERIALS AND METHODS The study included 117 stroke patients (81 males; mean=age 61±11 years) with suspected cardioembolic stroke whose plasma suPAR concentration was assessed. Altogether, 20 (17.1%) patients suffered from stroke as a result of cardioembolism, 12 (10.3%) from large-artery atherosclerosis, 9 (7.7%) from small-vessel disease, 11 (9.4%) from both large-artery and cardioembolic etiology, and 65 (55.6%) had cryptogenic stroke. The mean follow-up period was 5 years. RESULTS suPAR concentration was higher in patients who suffered from stroke/transient ischemic attack due to large-artery atherosclerosis (3.2±0.9 ng/ml) compared to small-vessel disease (2.0±0.5 ng/ml, p<0.001). An elevated plasma suPAR concentration was associated with all-cause mortality during the follow-up period (p=0.003). CONCLUSION Elevated plasma suPAR concentrations predicted all-cause mortality during the 5-year follow-up after ischemic stroke. suPAR was not able to differentiate patients with cardioembolic stroke from those with other stroke types.
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Affiliation(s)
- Juha Onatsu
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Antti Muuronen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Otso Arponen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- Department of Neurology, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland.,Department of Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland.,Eastern Finland Laboratory Centre, Kuopio, Finland
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11
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Muuronen AT, Taina M, Onatsu J, Korhonen M, Pulkki K, Jäkälä P, Vanninen R, Mustonen P. vWF correlates with visceral and pericardial adipose tissue in patients with a recent stroke of suspected cardiogenic etiology. PLoS One 2017; 12:e0178508. [PMID: 28570705 PMCID: PMC5453529 DOI: 10.1371/journal.pone.0178508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 05/15/2017] [Indexed: 01/31/2023] Open
Abstract
Aims A chronically elevated level of von Willebrand factor (vWF) is a common finding in patients with cardiovascular diseases. Obesity is a well-recognized risk factor for thrombotic cardiovascular complications including ischemic stroke, and it has been linked with increased plasma vWF. We evaluated whether elevated plasma levels of vWF associate with areas of visceral (VAT), pericardial (PAT), and subcutaneous adipose tissue (SAT) compartments in patients with acute/subacute stroke. Methods and results A total of 69 patients with stroke of suspected cardiogenic etiology were examined. The plasma level of vWF antigen (vWF-ag) was measured both in the acute phase and in the chronic phase three months after stroke. The areas of VAT and/or PAT were assessed with computed tomography. As expected, in stroke patients, the levels of plasma vWF-ag were significantly higher than in the national reference population both in the acute and in the chronic phase. The level of vWF-ag in the chronic phase correlated with the amounts of VAT and PAT, but not with subcutaneous adipose tissue. Conclusions These results agree with previous observations of the chronic inflammation/prothrombotic tendency in patients with cerebrovascular disease. Future studies should seek to clarify the role of visceral type adipose tissue in the pathophysiology of ischemic stroke.
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Affiliation(s)
- Antti Tapani Muuronen
- Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, Unit of Radiology, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Keski-Suomi Central Hospital, Jyväskylä, Finland
- * E-mail:
| | - Mikko Taina
- Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, Unit of Radiology, University of Eastern Finland, Kuopio, Finland
| | - Juha Onatsu
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | - Miika Korhonen
- Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, Unit of Radiology, University of Eastern Finland, Kuopio, Finland
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland
- Eastern Finland Laboratory Centre, Kuopio, Finland
| | - Pekka Jäkälä
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, Unit of Neurology, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, Unit of Radiology, University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital, Jyväskylä, Finland
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12
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Yaghi S, Bernstein RA, Passman R, Okin PM, Furie KL. Cryptogenic Stroke: Research and Practice. Circ Res 2017; 120:527-540. [PMID: 28154102 DOI: 10.1161/circresaha.116.308447] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/23/2016] [Accepted: 10/04/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cryptogenic stroke accounts for 30% to 40% of ischemic stroke. It is essential to determine the possible culprit because this will improve secondary stroke prevention strategies. METHODS We performed a narrative nonsystematic review of the literature that included randomized trials, exploratory comparative studies, and case series on cryptogenic stroke. RESULTS There are several possible mechanisms implicated in cryptogenic stroke, including occult paroxysmal atrial fibrillation, patent foramen ovale, aortic arch atherosclerosis, atrial cardiopathy, and substenotic atherosclerosis. The heterogeneity of these mechanisms leads to differences in stroke prevention strategies among cryptogenic stroke patients. CONCLUSIONS A thorough diagnostic evaluation is essential to determine the pathogenesis in cryptogenic stroke. This approach, in addition to risk factor management and lifestyle modifications, will lead to improved stroke prevention strategies in patients with cryptogenic stroke. This will allow for targeted clinical trials to improve stroke prevention strategies in this patient population.
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Affiliation(s)
- Shadi Yaghi
- From the Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.); Department of Neurology (R.A.B.) and Department of Internal Medicine, Division of Cardiovascular Medicine (R.P.), The Feinberg School of Medicine, Northwestern University, Chicago, IL; and Department of Internal Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY (P.M.O.)
| | - Richard A Bernstein
- From the Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.); Department of Neurology (R.A.B.) and Department of Internal Medicine, Division of Cardiovascular Medicine (R.P.), The Feinberg School of Medicine, Northwestern University, Chicago, IL; and Department of Internal Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY (P.M.O.)
| | - Rod Passman
- From the Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.); Department of Neurology (R.A.B.) and Department of Internal Medicine, Division of Cardiovascular Medicine (R.P.), The Feinberg School of Medicine, Northwestern University, Chicago, IL; and Department of Internal Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY (P.M.O.)
| | - Peter M Okin
- From the Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.); Department of Neurology (R.A.B.) and Department of Internal Medicine, Division of Cardiovascular Medicine (R.P.), The Feinberg School of Medicine, Northwestern University, Chicago, IL; and Department of Internal Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY (P.M.O.)
| | - Karen L Furie
- From the Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.); Department of Neurology (R.A.B.) and Department of Internal Medicine, Division of Cardiovascular Medicine (R.P.), The Feinberg School of Medicine, Northwestern University, Chicago, IL; and Department of Internal Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY (P.M.O.).
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13
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Haeusler KG, Wollboldt C, Bentheim LZ, Herm J, Jäger S, Kunze C, Eberle HC, Deluigi CC, Bruder O, Malsch C, Heuschmann PU, Endres M, Audebert HJ, Morguet AJ, Jensen C, Fiebach JB. Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin. Stroke 2017; 48:1241-1247. [DOI: 10.1161/strokeaha.116.016227] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 02/03/2017] [Accepted: 02/27/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Etiology of acute ischemic stroke remains undetermined (cryptogenic) in about 25% of patients after state-of-the-art diagnostic work-up.
Methods—
One-hundred and three patients with magnetic resonance imaging (MRI)–proven acute ischemic stroke of undetermined origin were prospectively enrolled and underwent 3-T cardiac MRI and magnetic resonance angiography of the aortic arch in addition to state-of-the-art diagnostic work-up, including transesophageal echocardiography (TEE). We analyzed the feasibility, diagnostic accuracy, and added value of cardiovascular MRI (cvMRI) compared with TEE for detecting sources of stroke.
Results—
Overall, 102 (99.0%) ischemic stroke patients (median 63 years [interquartile range, 53–72], 24% female, median NIHSS (National Institutes of Health Stroke Scale) score on admission 2 [interquartile range, 1–4]) underwent cvMRI and TEE in hospital; 89 (86.4%) patients completed the cvMRI examination. In 93 cryptogenic stroke patients, a high-risk embolic source was found in 9 (8.7%) patients by cvMRI and in 11 (11.8%) patients by echocardiography, respectively. cvMRI and echocardiography findings were consistent in 80 (86.0%) patients, resulting in a degree of agreement of κ=0.24. In 82 patients with cryptogenic stroke according to routine work-up, including TEE, cvMRI identified stroke etiology in additional 5 (6.1%) patients. Late gadolinium enhancement consistent with previous myocardial infarction was found in 13 (14.6%) out of 89 stroke patients completing cvMRI. Only 2 of these 13 patients had known coronary artery disease.
Conclusions—
Our study demonstrated that cvMRI was feasible in the vast majority of included patients with acute ischemic stroke. The diagnostic information of cvMRI seems to be complementary to TEE but is not replacing echocardiography after acute ischemic stroke.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01917955.
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Affiliation(s)
- Karl Georg Haeusler
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Christian Wollboldt
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Laura zu Bentheim
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Juliane Herm
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Sebastian Jäger
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Claudia Kunze
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Holger-Carsten Eberle
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Claudia Christina Deluigi
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Oliver Bruder
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Carolin Malsch
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Peter U. Heuschmann
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Matthias Endres
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Heinrich J. Audebert
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Andreas J. Morguet
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Christoph Jensen
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
| | - Jochen B. Fiebach
- From the Department of Neurology (K.G.H., C.W., L.z.B., J.H., M.E., H.J.A.) and Center for Stroke Research Berlin (K.G.H., C.K., M.E., H.J.A., J.B.F.), Charité - Universitätsmedizin Berlin, Germany; Contilia Heart and Vascular Center, Department of Cardiology and Angiology, Elisabeth-Krankenhaus, Essen, Germany (H.-C.E., C.C.D., O.B., C.J.); Department of Cardiology, Alexianer Berlin Krankenhaus Hedwigshöhe, Germany (S.J.); Institute of Clinical Epidemiology and Biometry, University Würzburg and
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Impact of Implementing Cardiac CT in Evaluating Patients Suspected of Cardioembolic Stroke. J Comput Assist Tomogr 2017; 40:380-6. [PMID: 26854417 DOI: 10.1097/rct.0000000000000369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES In practice, clinical and logistic hurdles may hamper performing transesophageal echocardiography in stroke patients. Cardiac computed tomography (CT) is a recently introduced noninvasive modality able to detect various embolic causes. Thus, we retrospectively assessed possible added values of applying cardiac CT in the real-world work-up of suspected cardioembolic stroke cases. METHODS Forty-seven patients were neurology service referrals for suspected cardioembolic stroke. The CT images and clinical reports of our cardiac CT radiologists were retrospectively evaluated. Cardiac CT was assessed in terms of detecting major embolic potential findings, potentially significant stroke-unrelated findings, and coronary arterial disease (CAD). Computed tomography results were correlated with echocardiographic reports. RESULTS Cardiac CT showed findings of major embolic potential in 10 patients (21%, 5 thrombi cases, 2 vasculitis cases, 1 case of metastasis invading the left superior pulmonary artery, 1 myocardial infarction case, and 1 pulmonary arteriovenous malformations case), none of which were documented in echocardiography reports. Two cases (4%) with findings of major embolic potential where identified on echocardiography but not on CT (1 left atrial appendage thrombus and 1 mitral valve vegetation). Computed tomography of 13 patients (28%) showed 16 potentially significant stroke-unrelated findings. Twenty-one patients (47%) had unexpected CAD on CT, 11 (52%) of which were obstructive. CONCLUSIONS Implementing cardiac CT in assessing patients suspected of cardioembolic stroke added value to echocardiographic evaluation, by detecting major embolic potential findings. In addition, cardiac CT revealed additional potentially significant stroke-unrelated findings and CAD.
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Wehrum T, Guenther F, Vach W, Gladstone BP, Wendel S, Fuchs A, Wu K, Maurer CJ, Harloff A. Aortic Atherosclerosis Determines Increased Retrograde Blood Flow as a Potential Mechanism of Retrograde Embolic Stroke. Cerebrovasc Dis 2017; 43:132-138. [PMID: 28049202 DOI: 10.1159/000455053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrograde brain embolization from complex plaques of the proximal descending aorta (DAo) has been identified as a new potential mechanism of stroke. Our purpose was to identify predictors of increased retrograde aortic blood flow indicating an elevated risk of brain embolization from the DAo. METHODS A total of 485 patients with acute ischemic stroke were prospectively included and underwent transesophageal echocardiography. Blood flow velocities in the proximal DAo were studied using 2D pulse-wave Doppler ultrasound. Velocity-time integrals (VTI) were calculated for antegrade and retrograde velocity directions. The ratio (VTIretrograde/VTIantegrade) was used to estimate retrograde flow extent. Associations between patient demographics, cardiovascular risk factors, echocardiographic parameters, and VTIratio were analyzed using multivariate linear regression. RESULTS Retrograde blood flow in the DAo occurred in all patients. Velocity profiles in the proximal DAo were as follows (mean ± SD): VTIantegrade = 21.1 ± 6.5, VTIretrograde = 11.0 ± 3.6, and VTIratio = 0.54 ± 0.16. Diameter (r = 0.25, p < 0.001), presence of complex plaques (r = 0.12, p = 0.007), and reduced strain of the DAo (r = -0.23, p < 0.001) had significant partial effects in a predictor model based on predefined variables, which predicted 26% (adjusted R2 = 0.26) of the variance in VTIratio. A unit increase in the DAo diameter was associated with a 2% increase in VTIratio (95% CI 1-2.8%, p < 0.001). Presence of complex plaques increased VTIratio by 7% (95% CI 2-13%, p = 0.007) and an increase in strain by 0.1 indicated a decrease in VTIratio by about 11% (95% CI 6.2-15.5%, p < 0.001). Complex atheroma was found in the proximal DAo of 79 subjects, of which 40 (50.6%) had a VTIratio above average (VTIratio ≥0.54) compared to 87 of 261 (33.3%) patients without any complex plaques (p < 0.001). Twenty-five of 79 (31.7%) patients with complex DAo plaques had a VTIratio ≥0.60, which indicates a high likelihood of retrograde pathline length of ≥3 cm and thus increased risk of retrograde cerebral embolization. Stroke etiology of those 25 patients was determined in 13 and cryptogenic in 12 cases. CONCLUSIONS Retrograde blood flow in the DAo was found in all stroke patients. However, it increased further in patients with concomitant complex plaques, low strain, and/or large aortic diameter, that is, in those with atherosclerosis of the DAo. Accordingly, such patients may be predisposed to retrograde embolization in case of occurrence of a complex plaque in proximity to a brain-supplying artery.
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Affiliation(s)
- Thomas Wehrum
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
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16
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Yaghi S, Liberman AL, Atalay M, Song C, Furie KL, Kamel H, Bernstein RA. Cardiac magnetic resonance imaging: a new tool to identify cardioaortic sources in ischaemic stroke. J Neurol Neurosurg Psychiatry 2017; 88:31-37. [PMID: 27659922 DOI: 10.1136/jnnp-2016-314023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/19/2016] [Accepted: 09/06/2016] [Indexed: 12/27/2022]
Abstract
Stroke of undetermined aetiology or 'cryptogenic' stroke accounts for 30-40% of ischaemic strokes despite extensive diagnostic evaluation. The role and yield of cardiac imaging is controversial. Cardiac MRI (CMR) has been used for cardiac disorders, but its use in cryptogenic stroke is not well established. We reviewed the literature (randomised trials, exploratory comparative studies and case series) on the use of CMR in the diagnostic evaluation of patients with ischaemic stroke. The literature on the use of CMR in the diagnostic evaluation of ischaemic stroke is sparse. However, studies have demonstrated a potential role for CMR in the diagnostic evaluation of patients with cryptogenic stroke to identify potential aetiologies such as cardiac thrombi, cardiac tumours, aortic arch disease and other rare cardiac anomalies. CMR can also provide data on certain functional and structural parameters of the left atrium and the left atrial appendage which have been shown to be associated with ischaemic stroke risk. CMR is a non-invasive modality that can help identify potential mechanisms in cryptogenic stroke and patients who may be targeted for enrolment into clinical trials comparing anticoagulation to antiplatelet therapy in secondary stroke prevention. Prospective studies are needed to compare the value of CMR as compared to transthoracic and transesophageal echocardiography in the diagnostic evaluation of cryptogenic stroke.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ava L Liberman
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Atalay
- Department of Radiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher Song
- Division of Cardiology, Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hooman Kamel
- Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York, USA
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
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Arponen O, Muuronen A, Taina M, Sipola P, Hedman M, Jäkälä P, Vanninen R, Pulkki K, Mustonen P. Acute phase IL-10 plasma concentration associates with the high risk sources of cardiogenic stroke. PLoS One 2015; 10:e0120910. [PMID: 25923658 PMCID: PMC4414573 DOI: 10.1371/journal.pone.0120910] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/27/2015] [Indexed: 11/18/2022] Open
Abstract
Background Etiological assessment of stroke is essential for accurate treatment decisions and for secondary prevention of recurrence. There is evidence that interleukin-10 (IL-10) associates with ischemic stroke. The aim of this prospective study was to assess the levels of IL-10 in ischemic stroke with unknown or suspected cardiogenic etiology, and evaluate the correlation between IL-10 plasma concentration and the number of diagnosed high risk sources for cardioembolism. Methods A total of 141 patients (97 males; mean age 61±11 years) with acute ischemic stroke with unknown etiology or suspected cardiogenic etiology other than known atrial fibrillation (AF) underwent imaging investigations to assess high risk sources for cardioembolic stroke established by the European Association of Echocardiography (EAE). IL-10 was measured on admission to the hospital and on a three month follow-up visit. Results Acute phase IL-10 concentration was higher in patients with EAE high risk sources, and correlated with their number (p<0.01). In patients with no risk sources (n = 104), the mean IL-10 concentration was 2.7±3.1 ng/L (range 0.3–16.3 ng/L), with one risk source (n = 26) 3.7±5.5 ng/L (0.3–23.6 ng/L), with two risk sources (n = 10) 7.0±10.0 ng/L (1.29–34.8 ng/L) and with three risk sources (n = 1) 37.2 ng/L. IL-10 level was not significantly associated with cerebral infarct volume, presence of previous or recent myocardial infarction, carotid/vertebral artery atherosclerosis, paroxysmal AF registered on 24-hour ECG Holter monitoring or given intravenous thrombolytic treatment. Conclusion IL-10 plasma concentration correlates independently with the number of EAE cardioembolic risk sources in patients with acute stroke. IL-10 may have potential to improve differential diagnostics of stroke with unknown etiology.
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Affiliation(s)
- Otso Arponen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
- * E-mail:
| | - Antti Muuronen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Mikko Taina
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
| | - Petri Sipola
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Marja Hedman
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland, and Unit of Neurology, University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland
| | - Ritva Vanninen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland
- Eastern Finland Laboratory Centre, Kuopio, Finland
| | - Pirjo Mustonen
- Keski-Suomi Central Hospital, Department of Cardiology, Jyväskylä, Finland
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Wehrum T, Kams M, Günther F, Beryl P, Vach W, Dragonu I, Harloff A. Quantification of Retrograde Blood Flow in the Descending Aorta Using Transesophageal Echocardiography in Comparison to 4D Flow MRI. Cerebrovasc Dis 2015; 39:287-92. [PMID: 25896851 DOI: 10.1159/000381682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrograde diastolic blood flow in the proximal descending aorta (DAo), which connects plaques ≥4 mm thickness with brain-supplying arteries, has previously been identified as a possible source of brain embolism. Currently, only 4D flow MRI is able to visualize and quantify potential retrograde embolization pathways in the DAo in-vivo. Hence, it was our aim to test if the extent of retrograde flow could be estimated by routine 2D transesophageal echocardiography (TEE). METHODS Forty-eight acute stroke patients were prospectively included and they underwent Doppler examinations of the transition zone between the aortic arch and the DAo using a 20 mm 2D sample volume in longitudinal section at 90-140° Doppler angle during routine TEE. Velocity-time-integrals (VTI) were studied for antegrade and retrograde velocities and the ratio (VTIratio) was calculated and correlated with the length of retrograde pathlines at that site, which were visualized using 4D flow MRI at 3-Tesla. A receiver operating characteristic (ROC) curve was used to evaluate a threshold value of VTIratio in differentiating large (≥3 cm) from small (<3 cm) retrograde flow extent. RESULTS At the TEE measurement site, the mean VTIratio was 0.53 ± 0.16 and the mean length of retrograde pathlines reaching back into the aortic arch was 3.1 ± 1.4 cm. VTIratio was an independent predictor of retrograde pathline length (r = 0.44; p = 0.002). ROC analysis identified a VTIratio threshold value of 0.6012 with a sensitivity of 0.5, a specificity of 0.92, and positive and negative predictive values of 0.84 and 0.68, respectively. Accordingly, 11 (22.91%) patients had a VTIratio cutoff value ≥0.6012 and corresponding retrograde pathline length ≥3 cm in 4D flow MRI. CONCLUSIONS TEE allows predicting the length of retrograde pathlines. Hence, it may offer a cost-effective way to investigate independent predictors of DAo flow reversal in large-scale studies. However, TEE is only of limited value as a screening tool for high retrograde flow in a clinical setting, as only ∼23% of patients can be spared 4D flow MRI, which remains indispensable for the exact assessment of individual embolization pathways from plaques of the DAo in-vivo.
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Affiliation(s)
- Thomas Wehrum
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
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Muuronen AT, Taina M, Hedman M, Marttila J, Kuusisto J, Onatsu J, Vanninen R, Jäkälä P, Sipola P, Mustonen P. Increased visceral adipose tissue as a potential risk factor in patients with embolic stroke of undetermined source (ESUS). PLoS One 2015; 10:e0120598. [PMID: 25756793 PMCID: PMC4354901 DOI: 10.1371/journal.pone.0120598] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/24/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The etiology of an ischemic stroke remains undetermined in 20-35% of cases and many patients do not have any of the conventional risk factors. Increased visceral adipose tissue (VAT) is a suggested new risk factor for both carotid artery atherosclerosis (CAA) and atrial fibrillation (AF), but its role in the remaining stroke population is unknown. We assessed the amount of VAT in patients with embolic stroke of undetermined source (ESUS) after excluding major-risk cardioembolic sources, occlusive atherosclerosis, and lacunar stroke. METHODS Altogether 58 patients (mean age 57.7 ± 10.2 years, 44 men) with ischemic stroke of unknown etiology but without CAA, known AF or small vessel disease underwent computed tomography angiography and assessment of VAT. For comparison VAT values from three different reference populations were used. Conventional risk factors (smoking, hypertension, diabetes, increased total and LDL-cholesterol, decreased HDL-cholesterol) were also registered. RESULTS Mean VAT area was significantly higher in stroke patients (205 ± 103 cm2 for men and 168 ± 99 cm2 for women) compared to all reference populations (P < 0.01). 50% of male and 57% of female patients had an increased VAT area. In male patients, VAT was significantly higher despite similar body mass index (BMI). Increased VAT was more common than any of the conventional risk factors. CONCLUSION Increased VAT was found in over half of our patients with ESUS suggesting it may have a role in the pathogenesis of thromboembolism in this selected group of patients.
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Affiliation(s)
- Antti T. Muuronen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- * E-mail:
| | - Mikko Taina
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
| | - Marja Hedman
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- Kuopio University Hospital, Heart Center, Kuopio, Finland
| | - Jarkko Marttila
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
| | - Johanna Kuusisto
- Kuopio University Hospital, Department of Medicine, Kuopio, Finland
| | - Juha Onatsu
- Kuopio University Hospital, Neuro Center, Kuopio, Finland
| | - Ritva Vanninen
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Pekka Jäkälä
- Kuopio University Hospital, Neuro Center, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Neurology, Kuopio, Finland
| | - Petri Sipola
- Kuopio University Hospital, Diagnostic Imaging Centre, Department of Clinical Radiology, Kuopio, Finland
- University of Eastern Finland, Institute of Clinical Medicine, Unit of Radiology, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
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Left atrial appendage morphology in patients with suspected cardiogenic stroke without known atrial fibrillation. PLoS One 2015; 10:e0118822. [PMID: 25751618 PMCID: PMC4353716 DOI: 10.1371/journal.pone.0118822] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/07/2015] [Indexed: 11/19/2022] Open
Abstract
The left atrial appendage (LAA) is the typical origin for intracardiac thrombus formation. Whether LAA morphology is associated with increased stroke/TIA risk is controversial and, if it does, which morphological type most predisposes to thrombus formation. We assessed LAA morphology in stroke patients with cryptogenic or suspected cardiogenic etiology and in age- and gender-matched healthy controls. LAA morphology and volume were analyzed by cardiac computed tomography in 111 patients (74 males; mean age 60 ± 11 years) with acute ischemic stroke of cryptogenic or suspected cardiogenic etiology other than known atrial fibrillation (AF). A subgroup of 40 patients was compared to an age- and gender-matched control group of 40 healthy individuals (21 males in each; mean age 54 ± 9 years). LAA was classified into four morphology types (Cactus, ChickenWing, WindSock, CauliFlower) modified with a quantitative qualifier. The proportions of LAA morphology types in the main stroke group, matched stroke subgroup, and control group were as follows: Cactus (9.0%, 5.0%, 20.0%), ChickenWing (23.4%, 37.5%, 10.0%), WindSock (47.7%, 35.0%, 67.5%), and CauliFlower (19.8%, 22.5%, 2.5%). The distribution of morphology types differed significantly (P<0.001) between the matched stroke subgroup and control group. The proportion of single-lobed LAA was significantly higher (P<0.001) in the matched stroke subgroup (55%) than the control group (6%). LAA volumes were significantly larger (P<0.001) in both stroke study groups compared to controls patients. To conclude, LAA morphology differed significantly between stroke patients and controls, and single-lobed LAAs were overrepresented and LAA volume was larger in patients with acute ischemic stroke of cryptogenic or suspected cardiogenic etiology.
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Wehrum T, Kams M, Strecker C, Dragonu I, Günther F, Geibel A, Drexl J, Hennemuth A, Schumacher M, Jung B, Harloff A. Prevalence of Potential Retrograde Embolization Pathways in the Proximal Descending Aorta in Stroke Patients and Controls. Cerebrovasc Dis 2014; 38:410-7. [DOI: 10.1159/000369001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/13/2014] [Indexed: 11/19/2022] Open
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Yang HL, Lin YP, Long Y, Ma QL, Zhou C. Predicting Cardioembolic Stroke with the B-Type Natriuretic Peptide Test: A Systematic Review and Meta-analysis. J Stroke Cerebrovasc Dis 2014; 23:1882-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.02.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 02/21/2014] [Indexed: 10/25/2022] Open
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23
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Taina M, Korhonen M, Haataja M, Muuronen A, Arponen O, Hedman M, Jäkälä P, Sipola P, Mustonen P, Vanninen R. Morphological and volumetric analysis of left atrial appendage and left atrium: cardiac computed tomography-based reproducibility assessment. PLoS One 2014; 9:e101580. [PMID: 24988467 PMCID: PMC4079282 DOI: 10.1371/journal.pone.0101580] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/07/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Left atrial appendage (LAA) dilatation and morphology may influence an individual's risk for intracardiac thrombi and ischemic stroke. LAA size and morphology can be evaluated using cardiac computed tomography (cCT). The present study evaluated the reproducibility of LAA volume and morphology assessments. METHODS A total of 149 patients (47 females; mean age 60.9±10.6 years) with suspected cardioembolic stroke/transient ischemic attack underwent cCT. Image quality was rated based on four categories. Ten patients were selected from each image quality category (N = 40) for volumetric reproducibility analysis by two individual readers. LAA and left atrium (LA) volume were measured in both two-chamber (2CV) and transversal view (TV) orientation. Intertechnique reproducibility was assessed between 2CV and TV (200 measurement pairs). LAA morphology (A = Cactus, B = ChickenWing, C = WindSock, D = CauliFlower), LAA opening height, number of LAA lobes, trabeculation, and orientation of the LAA tip was analysed in all study subjects by three individual readers (447 interobserver measurement pairs). The reproducibility of volume measurements was assessed by intra-class correlation (ICC) and the reproducibility of LAA morphology assessments by Cohen's kappa. RESULTS The intra-observer and interobserver reproducibility of LAA and LA volume measurements was excellent (ICCs>0.9). The LAA (ICC = 0.954) and LA (ICC = 0.945) volume measurements were comparable between 2CV and TV. Morphological classification (ĸ = 0.24) and assessments of LAA opening height (ĸ = 0.1), number of LAA lobes (ĸ = 0.16), trabeculation (ĸ = 0.15), and orientation of the LAA tip (ĸ = 0.37) was only slightly to fairly reproducible. CONCLUSIONS LA and LAA volume measurements on cCT provide excellent reproducibility, whereas visual assessment of LAA morphological features is challenging and results in unsatisfactory agreement between readers.
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Affiliation(s)
- Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mika Haataja
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Antti Muuronen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Otso Arponen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Petri Sipola
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Ay I, Blasi F, Rietz TA, Rotile NJ, Kura S, Brownell AL, Day H, Oliveira BL, Looby RJ, Caravan P. In vivo molecular imaging of thrombosis and thrombolysis using a fibrin-binding positron emission tomographic probe. Circ Cardiovasc Imaging 2014; 7:697-705. [PMID: 24777937 DOI: 10.1161/circimaging.113.001806] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fibrin is a major component of arterial and venous thrombi and represents an ideal candidate for molecular imaging of thrombosis. Here, we describe imaging properties and target uptake of a new fibrin-specific positron emission tomographic probe for thrombus detection and therapy monitoring in 2 rat thrombosis models. METHODS AND RESULTS The fibrin-binding probe FBP7 was synthesized by conjugation of a known short cyclic peptide to a cross-bridged chelator (CB-TE2A), followed by labeling with copper-64. Adult male Wistar rats (n=26) underwent either carotid crush injury (mural thrombosis model) or embolic stroke (occlusive thrombosis model) followed by recombinant tissue-type plasminogen activator treatment (10 mg/kg, IV). FBP7 detected thrombus location in both animal models with a high positron emission tomographic target-to-background ratio that increased over time (>5-fold at 30-90 minutes, >15-fold at 240-285 minutes). In the carotid crush injury animals, biodistribution analysis confirmed high probe uptake in the thrombotic artery (≈0.5%ID/g; >5-fold greater than blood and other tissues of the head and thorax). Similar results were obtained from ex vivo autoradiography of the ipsilateral versus contralateral carotid arteries. In embolic stroke animals, positron emission tomographic-computed tomographic imaging localized the clot in the internal carotid/middle cerebral artery segment of all rats. Time-dependent reduction of activity at the level of the thrombus was detected in recombinant tissue-type plasminogen activator-treated rats but not in vehicle-injected animals. Brain autoradiography confirmed clot dissolution in recombinant tissue-type plasminogen activator-treated animals, but enduring high thrombus activity in control rats. CONCLUSIONS We demonstrated that FBP7 is suitable for molecular imaging of thrombosis and thrombolysis in vivo and represents a promising candidate for bench-to-bedside translation.
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Affiliation(s)
- Ilknur Ay
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Francesco Blasi
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Tyson A Rietz
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Nicholas J Rotile
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Sreekanth Kura
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Anna Liisa Brownell
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Helen Day
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Bruno L Oliveira
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Richard J Looby
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Peter Caravan
- From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA.
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Bang OY, Ovbiagele B, Kim JS. Evaluation of Cryptogenic Stroke With Advanced Diagnostic Techniques. Stroke 2014; 45:1186-94. [DOI: 10.1161/strokeaha.113.003720] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Oh Young Bang
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Bruce Ovbiagele
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Jong S. Kim
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
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26
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Taina M, Sipola P, Muuronen A, Hedman M, Mustonen P, Kantanen AM, Jäkälä P, Vanninen R. Determinants of left atrial appendage volume in stroke patients without chronic atrial fibrillation. PLoS One 2014; 9:e90903. [PMID: 24595515 PMCID: PMC3942499 DOI: 10.1371/journal.pone.0090903] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 02/06/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Left atrial appendage (LAA) volume has been shown to be increased in patients with acute cryptogenic stroke. Atrial fibrillation (AF) is a well-recognized risk factor but it is not the only one associated with LAA enlargement. The aim of the study was to clarify the multifactorial etiology of LAA enlargement in cardiogenic stroke/TIA patients without AF. METHODS Altogether 149 patients with suspected cardioembolic stroke/TIA (47 females; mean age 61 years) underwent cardiac CT. Diagnosed AF on admittance was an exclusion criteria but 24-hour Holter ambulatory ECG revealed paroxysmal AF (PAF) in 20 patients. Body surface area adjusted LAA volume was evaluated. Eighteen different variables were registered including general characteristics, definite and potential causal risk factors for ischemic stroke/TIA, clinical echoparameters and CT based cardiac volumetric and adipose tissue measurements. A stepwise linear regression analysis was performed to achieve a model adjusted for the number of predictors of LAA volume increase. RESULTS In linear regression analysis, the best model accounted for 30% of the variability in LAA volume, including PAF (19%) and enlarged left atrial volume (6%), enlarged left ventricle end-systolic diameter (3%) and decreased pericardial adipose tissue (2%). No multi-colinearity between variables was observed. In addition to PAF, no other definitive or potential causal risk factors could account for the LAA volume in these patients. CONCLUSIONS LAA volume increase seems to be poorly associated with currently known stroke/TIA risk factors, except for AF. Targeting more comprehensive ECG monitoring for stroke patients with increased LAA volume should be considered.
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Affiliation(s)
- Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Petri Sipola
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Antti Muuronen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Anne-Mari Kantanen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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27
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Taina M, Vanninen R, Hedman M, Jäkälä P, Kärkkäinen S, Tapiola T, Sipola P. Left atrial appendage volume increased in more than half of patients with cryptogenic stroke. PLoS One 2013; 8:e79519. [PMID: 24223960 PMCID: PMC3817123 DOI: 10.1371/journal.pone.0079519] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 09/26/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ischemic strokes without a well-defined etiology are labeled as cryptogenic, and account for 30-40% of strokes in stroke registries. The left atrial appendage (LAA) is the most typical origin for intracardiac thrombus formation when associated with atrial fibrillation. Here, we examined whether increased LAA volume detected with cardiac computed tomography (cCT) constitutes a risk factor in cryptogenic stroke patients. METHODS This study included 82 stroke/TIA patients (57 males; mean age, 58 years) with a diagnosis of cryptogenic stroke after extensive radiological and cardiological investigations. Cases were classified using the TOAST criteria modified by European Association of Echocardiography recommendations for defining cardiac sources of embolism. Forty age- and gender-matched control subjects without cardiovascular diseases were selected for pair-wise comparisons (21 males; mean age, 54 years). LAA volume adjusted for body surface area was measured three dimensionally by tracing the LAA borders on electrocardiogram-gated CT slices. RESULTS In control subjects, mean LAA volume was 3.4±1.1 mL/m(2). Mean+2SD, which was considered the upper limit for normal LAA volume was 5.6 mL/m(2). In paired Student t-test between the patient group and matched controls, LAA volume was 67% larger in cryptogenic stroke/TIA patients (5.7±2.0 mL/m(2) vs. 3.4±1.1 mL/m(2); P<0.001). Forty-five (55%) patients with cryptogenic stroke/TIA had enlarged LAA. CONCLUSION LAA is significantly enlarged in more than half of patients with cryptogenic stroke/TIA. LAA thrombosis may contribute to the pathogenesis of stroke in patients considered to have cryptogenic stroke after conventional evaluation.
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Affiliation(s)
- Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- * E-mail:
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | | | - Tero Tapiola
- Department of Neurology, North Kymi Hospital, Kouvola, Finland
| | - Petri Sipola
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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