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Gong C, Liu C, Wang Y, Chen L, Yuan J, Zhang J, Xiaoming L, Chen Y, Huang L, Xu T, Chen Y. Effect of statin treatment on clinical outcomes in cardioembolic stroke with endovascular thrombectomy. J Neurointerv Surg 2024; 16:947-954. [PMID: 37586821 DOI: 10.1136/jnis-2023-020619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND While statins have been widely used in patients with large-artery atherosclerotic stroke, their effectiveness in patients with cardioembolic large vessel occlusion (CE-LVO) undergoing endovascular treatment (EVT) remains unclear. This study aimed to evaluate whether combining statin therapy with EVT could improve clinical outcomes in patients with acute ischemic stroke caused by CE-LVO in the anterior circulation. METHODS We performed a retrospective screening on patients with CE-LVO in the anterior circulation who underwent EVT in 27 hospitals across China between 2018 and 2021. The primary outcome measure was functional independence, defined as a 90-day modified Rankin Scale (mRS) score of 0 to 2. Safety outcomes included 90-day mortality and symptomatic intracranial hemorrhage (sICH). RESULTS A total of 510 patients with CE-LVO in the anterior circulation undergoing EVT were included in this study. Of these, 404 (79.2%) patients received statin treatment (statin group), while 106 (20.8%) did not (non-statin group). Statin treatment was significantly associated with improved functional independence (adjusted OR (aOR) 2.072, 95% CI 1.197 to 3.586, P=0.009). Moreover, statin use was associated with a lower rate of 90-day mortality (aOR 0.343, 95% CI 0.197 to 0.596, P<0.001) and a lower rate of sICH (aOR 0.153, 95% CI 0.072 to 0.325, P<0.001). CONCLUSION Statin treatment was associated with improved clinical outcomes and reduced risks of mortality and sICH in patients with CE-LVO in the anterior circulation undergoing EVT.
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Affiliation(s)
- Chen Gong
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chang Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - You Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liyuan Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinxian Yuan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Xiaoming
- Department of Intensive Care Unit, Chongqing University Cancer Hospital, Chongqing, China
| | - Yanru Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liping Huang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Xu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Clark A, Ferkh A, Vandenberg J, Elhindi J, Thomas L. Altered left atrial metrics in patients with cryptogenic stroke: A systematic review and meta-analysis. Eur J Clin Invest 2024; 54:e14175. [PMID: 38308431 DOI: 10.1111/eci.14175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/14/2024] [Accepted: 01/22/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND There is no defined cause for cryptogenic stroke/embolic stroke of undetermined source (CS-ESUS). As atrial fibrillation (AF) develops in a significant proportion of these patients, it has been suggested that left atrial (LA) myopathy may predispose to CS-ESUS. We investigated alterations in echocardiographic measures of LA size and function in patients with CS-ESUS. METHODS A systematic literature review and meta-analysis was performed. PubMed, EMBASE, Cochrane Library, Web of Science and SCOPUS were searched for articles published between 1 January 1990 and 10 February 2023. All observational studies of adult CS-ESUS patients with LA volume or function measurements performed by transthoracic echocardiogram were included. Individual random effects meta-analyses were performed on LA measurements in the CS-ESUS patients using subgroup analysis of comparator groups. RESULTS We included 29 articles with 3927 CS-ESUS patients. Analysis of weighted mean differences showed CS-ESUS patients had altered LA structure and function parameters, with a larger maximum indexed LA volume, reduced LA emptying fraction and/or LA reservoir strain, compared to healthy controls and noncardioembolic stroke patients. Conversely, CS-ESUS patients had a smaller left atrium with better function, compared to cardioembolic stroke patients and CS-ESUS patients who subsequently developed atrial fibrillation. CONCLUSIONS LA volume and function are altered in CS-ESUS patients compared to healthy controls and other stroke aetiologies. An underlying atrial myopathy in a subset of CS-ESUS patients may be involved in both thrombogenesis and dysrhythmia (specifically AF). While LA functional assessment is not currently recommended following stroke, it may offer an opportunity for recurrent stroke risk stratification.
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Affiliation(s)
- Amy Clark
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Aaisha Ferkh
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Jamie Vandenberg
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, UNSW Sydney, Darlinghurst, New South Wales, Australia
| | - James Elhindi
- WSLHD Research and Education Network, Westmead Hospital, Westmead, New South Wales, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Camperdown, Sydney, New South Wales, Australia
- South West Clinical School, University of New South Wales, Kensington, New South Wales, Australia
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Kotadia ID, O'Dowling R, Aboagye A, Crawley RJ, Bodagh N, Gharaviri A, O'Hare D, Solis‐Lemus JA, Roney CH, Sim I, Ramsey D, Newby D, Chiribiri A, Plein S, Sztriha L, Scott P, Masci P, Harrison J, Williams MC, Birns J, Somerville P, Bhalla A, Niederer S, O'Neill M, Williams SE. High Prevalence of New Clinically Significant Findings in Patients With Embolic Stroke of Unknown Source Evaluated by Cardiac Magnetic Resonance Imaging. J Am Heart Assoc 2024; 13:e031489. [PMID: 38240222 PMCID: PMC11056130 DOI: 10.1161/jaha.123.031489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Embolic stroke of unknown source (ESUS) accounts for 1 in 6 ischemic strokes. Current guidelines do not recommend routine cardiac magnetic resonance (CMR) imaging in ESUS, and beyond the identification of cardioembolic sources, there are no data assessing new clinical findings from CMR in ESUS. This study aimed to assess the prevalence of new cardiac and noncardiac findings and to determine their impact on clinical care in patients with ESUS. METHODS AND RESULTS In this prospective, multicenter, observational study, CMR imaging was performed within 3 months of ESUS. All scans were reported according to standard clinical practice. A new clinical finding was defined as one not previously identified through prior clinical evaluation. A clinically significant finding was defined as one resulting in further investigation, follow-up, or treatment. A change in patient care was defined as initiation of medical, interventional, surgical, or palliative care. From 102 patients recruited, 96 underwent CMR imaging. One or more new clinical findings were observed in 59 patients (61%). New findings were clinically significant in 48 (81%) of these patients. Of 40 patients with a new clinically significant cardiac finding, 21 (53%) experienced a change in care (medical therapy, n=15; interventional/surgical procedure, n=6). In 12 patients with a new clinically significant extracardiac finding, 6 (50%) experienced a change in care (medical therapy, n=4; palliative care, n=2). CONCLUSIONS CMR imaging identifies new clinically significant cardiac and noncardiac findings in half of patients with recent ESUS. Advanced cardiovascular screening should be considered in patients with ESUS. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04555538.
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Affiliation(s)
- Irum D. Kotadia
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Robert O'Dowling
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Akosua Aboagye
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Richard J. Crawley
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Neil Bodagh
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Ali Gharaviri
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Daniel O'Hare
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Jose Alonso Solis‐Lemus
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Caroline H. Roney
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - David Newby
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Sven Plein
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - Paul Scott
- King’s College HospitalLondonUnited Kingdom
| | - Pier‐Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - Michelle C. Williams
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Jonathan Birns
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Peter Somerville
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
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Berdalin AB, Namestnikova DD, Cherkashova EA, Golovin DA, Gubskiy IL, Lelyuk VG. Arterial Hypertension and Its Consequences Are the Main Predictors of Embolic Stroke of Undetermined Source. DISEASE MARKERS 2023; 2023:3469755. [PMID: 38025665 PMCID: PMC10667056 DOI: 10.1155/2023/3469755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/09/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023]
Abstract
Methods We performed a hospital-based prospective cohort study with 1,317 enrolled participants. We compared patients and healthy volunteers according to the main demographic, anthropometric parameters, stroke risk factors, comorbidities, and data of clinical and instrumental examination. In order to balance the study and the control groups for age and sex, the propensity score matching was performed. In order to generate the overall predictive model, a multivariate analysis was performed using the binary logistic regression method. Results The following predictors of ESUS were identified in current study: arterial hypertension (AH); increased heart rate and pulmonary arterial systolic pressure (PASP); the presence of conduction disturbance; the enlargement of left, right atrium, and left ventricle end-systolic length; increased intima-media thickness (IMT) in right and left common carotid artery (CCA); lowered Montreal Cognitive Assessment (MoСA) cognitive scale score; the presence of subcortical microbleeds; central brain atrophy; the larger size of third ventricle; and the higher medial temporal lobe atrophy (MTA) score. The following risk factors were included in the final predictive model: the presence of AH (p < 0.0005; OR = 12.98 (95% CI: 4.53-37.21)) and PASP (p=0.018; OR = 1.13 (95% CI: 1.02-1.25)) and male sex (p=0.046; OR = 2.771 (95% CI: 1.017-7.555)). The Nagelkerke's pseudo-R-squared value was 0.404 and the significance of the Hosmer-Lemeshow test was 0.733, which indicate the goodness of the final logistic regression model. Conclusions We propose that AH and its consequences are the main predictors of ESUS. The results of this study emphasize the importance of AH control for primary and secondary prevention of ESUS.
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Affiliation(s)
- Alexander B. Berdalin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Daria D. Namestnikova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Elvira A. Cherkashova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Denis A. Golovin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Ilya L. Gubskiy
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Vladimir G. Lelyuk
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
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Lim ICZY, Teo YH, Fang JT, Teo YN, Ho JSY, Lee YQ, Chen X, Ong KHX, Leow AST, Ho AFW, Lim Y, Low TT, Kuntjoro I, Yeo LLL, Sia CH, Sharma VK, Tan BYQ. Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management. J Clin Med 2023; 12:jcm12030941. [PMID: 36769589 PMCID: PMC9917737 DOI: 10.3390/jcm12030941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke. METHODS Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF. RESULTS The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043]. CONCLUSIONS In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.
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Affiliation(s)
- Isis Claire Z. Y. Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Jamie S. Y. Ho
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Yong Qin Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Xintong Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Kathleen Hui-Xin Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Aloysius S. T. Leow
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
- Pre-Hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
- Centre for Population Health Research and Implementation, Singhealth Regional Health System, Singapore 168753, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Ting Ting Low
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Leonard L. L. Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Vijay K. Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
- Correspondence: ; Tel.: +65-9138-9555; Fax: +65-6908-2222
| | - Benjamin Y. Q. Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
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Platelet-Neutrophil Association in NETs-Rich Areas in the Retrieved AIS Patient Thrombi. Int J Mol Sci 2022; 23:ijms232214477. [PMID: 36430952 PMCID: PMC9694992 DOI: 10.3390/ijms232214477] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Histological structure of thrombi is a strong determinant of the outcome of vascular recanalization therapy, the only treatment option for acute ischemic stroke (AIS) patients. A total of 21 AIS patients from this study after undergoing non-enhanced CT scan and multimodal MRI were treated with mechanical stent-based and manual aspiration thrombectomy, and thromboembolic retrieved from a cerebral artery. Complementary histopathological and imaging analyses were performed to understand their composition with a specific focus on fibrin, von Willebrand factor, and neutrophil extracellular traps (NETs). Though distinct RBC-rich and platelet-rich areas were found, AIS patient thrombi were overwhelmingly platelet-rich, with 90% of thrombi containing <40% total RBC-rich contents (1.5 to 37%). Structurally, RBC-rich areas were simple, consisting of tightly packed RBCs in thin fibrin meshwork with sparsely populated nucleated cells and lacked any substantial von Willebrand factor (VWF). Platelet-rich areas were structurally more complex with thick fibrin meshwork associated with VWF. Plenty of leukocytes populated the platelet-rich areas, particularly in the periphery and border areas between platelet-rich and RBC-rich areas. Platelet-rich areas showed abundant activated neutrophils (myeloperoxidase+ and neutrophil-elastase+) containing citrullinated histone-decorated DNA. Citrullinated histone-decorated DNA also accumulated extracellularly, pointing to NETosis by the activated neutrophils. Notably, NETs-containing areas showed strong reactivity to VWF, platelets, and high-mobility group box 1 (HMGB1), signifying a close interplay between these components.
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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Perkins JD, Akhtar N, Singh R, Kamran A, Ilyas S. Partitioning risk factors for embolic stroke of undetermined source using exploratory factor analysis. Int J Stroke 2021; 17:407-414. [PMID: 33787396 PMCID: PMC8969073 DOI: 10.1177/17474930211009847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Embolic stroke of undetermined source (ESUS) accounts for up to 25% of strokes. Understanding risk factors associated with ESUS is important in reducing stroke burden worldwide. However, ESUS patients are younger and present with fewer traditional risk factors. Significant global variation in ESUS populations also exists making the clinical picture of this type of stroke unclear. Methods and results ESUS patients were pair matched for age, sex, and ethnicity with a group of all other strokes (both n = 331). Exploratory factor analysis was applied in both groups to 14 risk and clinical factors to identify latent factors. In ESUS patients, two latent factors emerged consisting primarily of heart-related variables such as left ventricular wall motion abnormalities, reduced ejection fraction, and increased left atrial volume index, as well as aortic arch atherosclerosis. This is in comparison to the all other strokes group, which was dominated by traditional stroke risk factors. Conclusions Our findings support the existence of a unique pattern of risk factors specific to ESUS. We show that LVWMA and corresponding changes in left heart function are a potential source of emboli in these patients. In addition, the clustering of aortic arch atherosclerosis with left heart factors suggests a causal link. Through the application of exploratory factor analysis, this work contributes to a further understanding of stroke mechanisms in ESUS.
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Affiliation(s)
- Jon D Perkins
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,PMARC, University of Edinburgh, Edinburgh, UK
| | - Naveed Akhtar
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
| | - Rajvir Singh
- Heart Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Asad Kamran
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Saadat Ilyas
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
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10
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Guo Y, Zhang J, Lip GYH. Embolic Stroke of Undetermined Source: The Need for an Integrated and Holistic Approach to Care. Thromb Haemost 2020; 121:251-254. [PMID: 33307563 DOI: 10.1055/a-1336-0576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Yutao Guo
- Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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11
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Kamran S, Singh R, Akhtar N, George P, Salam A, Babu B, Own A, Hamid T, Perkins JD. Left Heart Factors in Embolic Stroke of Undetermined Source in a Multiethnic Asian and North African Cohort. J Am Heart Assoc 2020; 9:e016534. [PMID: 32750304 PMCID: PMC7792276 DOI: 10.1161/jaha.120.016534] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Cardiac features diverge in Asians; however, it is not known how these differences relate to embolic stroke of unknown source (ESUS) in Southeast Asian and Eastern Mediterranean regions. Methods and Results A retrospective analysis of prospectively collected acute ischemic stroke data from 2014 to 2018 was performed. Stroke subtypes were noncardioembolic stroke (large‐vessel and small‐vessel disease; n=1348), cardioembolic stroke (n=532), and ESUS (n=656). Subtypes were compared by demographic, clinical, and echocardiographic factors. In multivariate logistic regression, patients with ESUS in comparison with noncardioembolic stroke were twice as likely to have left ventricular diastolic dysfunction (P=0.001), 3 times the odds of global hypokinesia (P=0.001), and >7 times the odds of left ventricular wall motion abnormalities (P=0.001). In the second model comparing ESUS with cardioembolic stroke, patients with ESUS were 3 times more likely to have left ventricular wall motion abnormalities (P=0.001) and 1.5 times more likely to have left ventricular diastolic dysfunction grade I (P=0.009), and 3 times more likely to have left ventricular diastolic dysfunction grades II and III (P=0.009), whereas age (P=0.001) and left atrial volume index (P=0.004) showed an inverse relation with ESUS. ESUS in patients ≥61 years old had higher levels of traditional risk factors such as coronary artery disease, but the coronary artery disease was not significantly different in ESUS age groups (P=0.80) despite higher left ventricular wall motion abnormalities (P=0.001). Conclusions Patients with ESUS and noncardioembolic stroke were younger than patients with cardioembolic stroke. While a third of the patients with ESUS >45 years old had coronary artery disease, it was unrecognized or underreported in the older ESUS age group (≥61 years old). In patients with ESUS from Southeast Asia and Eastern Mediterranean regions, left ventricular wall motion abnormalities and left ventricular diastolic dysfunction were related to ESUS.
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Affiliation(s)
- Saadat Kamran
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medicine Doha Qatar
| | - Rajvir Singh
- Acute Care Surgery Department Hamad General Hospital Doha Qatar
| | - Naveed Akhtar
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medicine Doha Qatar
| | - Pooja George
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Abdul Salam
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Blessy Babu
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Ahmed Own
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Tahir Hamid
- Heart Hospital Hamad Medical Corporation Doha Qatar
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