1
|
Apostolos A, Tsiachris D, Drakopoulou M, Trantalis G, Oikonomou G, Ktenopoulos N, Simopoulou C, Katsaros O, Tsalamandris S, Aggeli C, Tsivgoulis G, Tsioufis C, Toutouzas K. Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management. J Am Heart Assoc 2024; 13:e034249. [PMID: 38639354 PMCID: PMC11179870 DOI: 10.1161/jaha.124.034249] [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: 01/01/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.
Collapse
Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Trantalis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Oikonomou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Chrysavgi Simopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Odysseas Katsaros
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Sotirios Tsalamandris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Constantina Aggeli
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Medical SchoolNational and Kapodistrian University of Athens, Attikon University Hospital of AthensAthensGreece
| | - Costas Tsioufis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| |
Collapse
|
2
|
Lee IH, Heo J, Lee H, Jeong J, Kim J, Han M, Yoo J, Kim J, Baik M, Park H, Jung JW, Kim YD, Nam HS. Long-term outcomes of patients with embolic stroke of undetermined source according to subtype. Sci Rep 2024; 14:9295. [PMID: 38653743 DOI: 10.1038/s41598-024-58292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024] Open
Abstract
The prognosis of patients with embolic stroke of undetermined source (ESUS) may vary according to the underlying cause. Therefore, we aimed to divide ESUS into subtypes and assess the long-term outcomes. Consecutive patients with acute ischemic stroke who underwent a comprehensive workup, including transesophageal echocardiography and prolonged electrocardiography monitoring, were enrolled. We classified ESUS into minor cardioembolic (CE) ESUS, arteriogenic ESUS, two or more causes ESUS, and no cause ESUS. Arteriogenic ESUS was sub-classified into complex aortic plaque (CAP) ESUS and non-stenotic (< 50%) relevant artery plaque (NAP) ESUS. A total of 775 patients were enrolled. During 1286 ± 748 days follow-up, 116 major adverse cardiovascular events (MACE) occurred (4.2 events/100 patient-years). Among the ESUS subtypes, CAP ESUS was associated with the highest MACE frequency (9.7/100 patient-years, p = 0.021). Cox regression analyses showed that CAP ESUS was associated with MACE (hazard ratio 2.466, 95% confidence interval 1.305-4.660) and any stroke recurrence (hazard ratio 2.470, 95% confidence interval, 1.108-5.508). The prognosis of ESUS varies according to the subtype, with CAP ESUS having the worst prognosis. Categorizing ESUS into subtypes could improve patient care and refine clinical trials.
Collapse
Affiliation(s)
- Il Hyung Lee
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyungwoo Lee
- Department of Neurology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - JaeWook Jeong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonho Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Minho Han
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Jinkwon Kim
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| |
Collapse
|
3
|
Apostolos A, Drakopoulou M, Trantalis G, Ioakeimidis M, Koroboki E, Tsalamandris S, Aggeli C, Ntaios G, Tsioufis C, Tsivgoulis G, Toutouzas K. Management of patent foramen ovale; findings from a nationwide survey. J Stroke Cerebrovasc Dis 2024; 33:107551. [PMID: 38241951 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107551] [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: 09/21/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVES Several clinical trials have provided evidence supporting the transcatheter closure of patent foramen ovale (PFO) in selected patients following a cryptogenic stroke. However, it remains unknown to what extent these guidelines have been implemented in everyday clinical practice and the familiarity of physicians from different specialties with PFO closure. The aim of our nationwide survey is to explore the implementation of transcatheter PFO occlusion in Greek clinical practice. MATERIALS AND METHODS Attending level cardiologists, internal medicine physicians and neurologists involved in the management of PFO-related strokes working in Greece were invited to complete an online questionnaire. The questionnaire consisted of 19 questions and was designed to obtain comprehensive data on provider demographics, PFO characteristics, and specific clinical scenarios. RESULTS A total of 51 physicians (56.9 % cardiologists, 25.5 % neurologists and 17.6 % internal medicine physicians) completed the survey, resulting in a response rate of 53 %. Cardiologists, internal medicine physicians and neurologists agree on several issues regarding PFO closure, such as PFO closure as first line treatment, management of patients with DVT or prior decompression sickness, and post-closure antithrombotic treatment, but different approaches were reported regarding closure in patients with thrombophilia treated with oral anticoagulation (p=0.012) and implantable loop recorder placement for atrial fibrillation exclusion (p=0.029 and p=0.020). CONCLUSIONS Our findings show that cardiologists, internal medicine physicians and neurologists agree in numerous issues, but share different views in the management of patients with thrombophilia and rhythm monitoring duration. These results highlight the significance of collaboration among physicians from different medical specialties for achieving optimal results.
Collapse
Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Maria Drakopoulou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Georgios Trantalis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Michael Ioakeimidis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Eleni Koroboki
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Tsalamandris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Constantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Georgios Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Costas Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| |
Collapse
|
4
|
Han M, Heo J, Lee IH, Kim JH, Lee H, Jung JW, Lim IH, Hong SH, Kim YD, Nam HS. Prognostic value of central blood pressure on the outcomes of embolic stroke of undetermined source. Sci Rep 2023; 13:9550. [PMID: 37308509 DOI: 10.1038/s41598-023-36151-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
We investigated the prognostic impact of central blood pressure (BP) on outcomes in patients with embolic stroke of undetermined source (ESUS). The prognostic value of central BP according to ESUS subtype was also evaluated. We recruited patients with ESUS and data on their central BP parameters (central systolic BP [SBP], central diastolic BP [DBP], central pulse pressure [PP], augmentation pressure [AP], and augmentation index [AIx]) during admission. ESUS subtype classification was arteriogenic embolism, minor cardioembolism, two or more causes, and no cause. Major adverse cardiovascular event (MACE) was defined as recurrent stroke, acute coronary syndrome, hospitalization for heart failure, or death. Over a median of 45.8 months, 746 patients with ESUS were enrolled and followed up. Patients had a mean age of 62.8 years, and 62.2% were male. Multivariable Cox regression analysis showed that central SBP and PP were associated with MACE. All-cause mortality was independently associated with AIx. In patients with no cause ESUS, central SBP and PP, AP, and AIx were independently associated with MACE. AP and AIx were independently associated with all-cause mortality (all p < 0.05). We demonstrated that central BP can predict poor long-term prognosis in patients with ESUS, especially those with the no cause ESUS subtype.
Collapse
Affiliation(s)
- Minho Han
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Joon Ho Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - In Hwan Lim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Soon-Ho Hong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea.
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemoon-Gu, Seoul, 03722, South Korea.
| |
Collapse
|
5
|
Jumah A, Aboul Nour H, Fana M, Choudhury O, Eltous L, Zoghoul S, Jumah F, Alsrouji OK, Alhajala H, Intikhab O, Marin H, Chebl A, Miller D. The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature. Interv Neuroradiol 2022:15910199221143172. [PMID: 36451548 DOI: 10.1177/15910199221143172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.
Collapse
Affiliation(s)
- Ammar Jumah
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Aboul Nour
- Department of Vascular Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Michael Fana
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Omar Choudhury
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Lara Eltous
- 37251Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Zoghoul
- Department of Radiology, 36977Hamad Medical Corporation, Doha, Qatar
| | - Fareed Jumah
- Department of Neurosurgery, University of Missouri Hospital, Columbia, MO, USA
| | - Owais K Alsrouji
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Hisham Alhajala
- Department of Vascular Neurology, University of Toledo, Toledo, OH, USA
| | - Osama Intikhab
- Department of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Horia Marin
- Department of Neuroradiology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Alex Chebl
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Daniel Miller
- Department of Neurology, 24016Henry Ford Hospital, Detroit, MI, USA
| |
Collapse
|
6
|
Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review. J Clin Med 2022; 11:jcm11206196. [PMID: 36294515 PMCID: PMC9604731 DOI: 10.3390/jcm11206196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.
Collapse
|
7
|
Dilaveris PE, Antoniou CK, Caiani EG, Casado-Arroyo R, Climent AΜ, Cluitmans M, Cowie MR, Doehner W, Guerra F, Jensen MT, Kalarus Z, Locati ET, Platonov P, Simova I, Schnabel RB, Schuuring M, Tsivgoulis G, Lumens J. ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients : In collaboration with the Council on Stroke, the European Heart Rhythm Association, and the Digital Health Committee. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:341-358. [PMID: 36712155 PMCID: PMC9707962 DOI: 10.1093/ehjdh/ztac026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method's pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.
Collapse
Affiliation(s)
| | - Christos Konstantinos Antoniou
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527 Athens, Greece,Electrophysiology and Pacing Laboratory, Athens Heart Centre, Athens Medical Center, Marousi, Attica, Greece
| | - Enrico G Caiani
- Politecnico di Milano, Department of Electronics, Information and Biomedical Engineering, Milan, Italy,National Council of Research, Institute of Electronics, Information and Telecommunication Engineering, Milan, Italy
| | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andreu Μ Climent
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Matthijs Cluitmans
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin R Cowie
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Wolfram Doehner
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, Germany,Department of Cardiology (Virchow Klinikum), and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti Umberto I—Lancisi—Salesi’, Ancona, Italy
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Hospital Amager & Hvidovre, Denmark
| | - Zbigniew Kalarus
- DMS in Zabrze, Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Emanuela Teresa Locati
- Arrhythmology & Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Pyotr Platonov
- Department of Cardiology, Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Iana Simova
- Cardiology Clinic, Heart and Brain Centre of Excellence—University Hospital, Medical University Pleven, Pleven, Bulgaria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany,German Center for Cardiovascular Research (DZHK) partner site, Hamburg/Kiel/Lübeck, Germany
| | - Mark Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Georgios Tsivgoulis
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
8
|
Rubiera M, Aires A, Antonenko K, Lémeret S, Nolte CH, Putaala J, Schnabel RB, Tuladhar AM, Werring DJ, Zeraatkar D, Paciaroni M. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7:VI. [PMID: 36082257 PMCID: PMC9446336 DOI: 10.1177/23969873221099478] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.
Collapse
Affiliation(s)
- Marta Rubiera
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt- Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Renate B. Schnabel
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck Germany
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neurosciences, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Dena Zeraatkar
- Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| |
Collapse
|
9
|
Rakhimova I, Semenova Y, Khaibullin T, Kuanysheva A, Kovalchuk V, Abdrakhmanov A. Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e211221199213. [PMID: 34939547 PMCID: PMC9893140 DOI: 10.2174/1573403x18666211221145714] [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: 06/15/2021] [Revised: 08/17/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. PURPOSE The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. PROCEDURES In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. FINDINGS Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. . CONCLUSION After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.
Collapse
Affiliation(s)
- Idaliya Rakhimova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Yuliya Semenova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Talgat Khaibullin
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Anargul Kuanysheva
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Vitalii Kovalchuk
- Department of Semashko City Hospital, Saint Petersburg, Russian Federation
| | - Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Nur-Sultan 010000, Kazakhstan
| |
Collapse
|
10
|
Aubry P, Hamidouche F, Alqudwa A, Naoum-Nehme A, Maiga B, Camara N, Manchon E, Poulos N. [Cryptogenic stroke management : where are we ?]. Ann Cardiol Angeiol (Paris) 2021; 70:373-379. [PMID: 34742466 DOI: 10.1016/j.ancard.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/02/2021] [Indexed: 10/19/2022]
Abstract
Cryptogenic stroke is an old definition that designates an ischemic stroke with no identifiable cause. The term of the embolic stroke of undetermined source was then introduced to identify non-lacunar strokes in whom thromboembolism was the likely mechanism. This subgroup of cryptogenic strokes remains heterogeneous with many potential and possibly associated embolic causes. Covert atrial fibrillation is probably less often involved than initially expected, in contrast to intracranial and extracranial atherosclerosis. The cardiologist should be involved in the search of underlying causes of ischemic stroke by helping the neurologist to identify the most likely diagnosis. Further research is necessary to select populations that may benefit from more effective and individualized treatment.
Collapse
Affiliation(s)
- P Aubry
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse; Département de cardiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Bichat-Claude-Bernard, 75018 Paris.
| | - F Hamidouche
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - A Alqudwa
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - A Naoum-Nehme
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - B Maiga
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - N Camara
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - E Manchon
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - N Poulos
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| |
Collapse
|
11
|
Kamtchum-Tatuene J, Nomani AZ, Falcione S, Munsterman D, Sykes G, Joy T, Spronk E, Vargas MI, Jickling GC. Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source. Front Neurol 2021; 12:719329. [PMID: 34630291 PMCID: PMC8492999 DOI: 10.3389/fneur.2021.719329] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 01/01/2023] Open
Abstract
Embolic stroke of unknown source (ESUS) represents one in five ischemic strokes. Ipsilateral non-stenotic carotid plaques are identified in 40% of all ESUS. In this narrative review, we summarize the evidence supporting the potential causal relationship between ESUS and non-stenotic carotid plaques; discuss the remaining challenges in establishing the causal link between non-stenotic plaques and ESUS and describe biomarkers of potential interest for future research. In support of the causal relationship between ESUS and non-stenotic carotid plaques, studies have shown that plaques with high-risk features are five times more prevalent in the ipsilateral vs. the contralateral carotid and there is a lower incidence of atrial fibrillation during follow-up in patients with ipsilateral non-stenotic carotid plaques. However, non-stenotic carotid plaques with or without high-risk features often coexist with other potential etiologies of stroke, notably atrial fibrillation (8.5%), intracranial atherosclerosis (8.4%), patent foramen ovale (5-9%), and atrial cardiopathy (2.4%). Such puzzling clinical associations make it challenging to confirm the causal link between non-stenotic plaques and ESUS. There are several ongoing studies exploring whether select protein and RNA biomarkers of plaque progression or vulnerability could facilitate the reclassification of some ESUS as large vessel strokes or help to optimize secondary prevention strategies.
Collapse
Affiliation(s)
- Joseph Kamtchum-Tatuene
- Faculty of Medicine and Dentistry, Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Ali Z Nomani
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarina Falcione
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Danielle Munsterman
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gina Sykes
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Twinkle Joy
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Elena Spronk
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Maria Isabel Vargas
- Division of Neuroradiology, Department of Radiology and Medical Imaging, Geneva University Hospital, Geneva, Switzerland
| | - Glen C Jickling
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
12
|
Zhu Y, Zhang J, Huang B, Liu Y, Deng Y, Weng Y, Sun R. Impact of Patent Foramen Ovale Anatomic Features on Right-to-Left Shunt in Patients with Cryptogenic Stroke. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1289-1298. [PMID: 33541750 DOI: 10.1016/j.ultrasmedbio.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/24/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
The purpose of this study was to investigate the impact of the morphologic characteristics of patent foramen ovale (PFO) on right-to-left shunt (RLS) in patients with PFO and cryptogenic stroke using transesophageal echocardiography and saline contrast transthoracic echocardiography (c-TTE). Of the 165 patients with PFO stroke, both the height and the length of PFO in the provoked RLS group were smaller than those in the constant RLS group. PFO height, interatrial septum mobility and proportion of atrial septal aneurysms were greater in the severe RLS group than in the mild and moderate RLS groups. Multivariate analysis revealed that PFO height and interatrial septum mobility were independent predictors of severe RLS. Multiple territorial ischemic lesions were more common in the severe RLS or constant RLS group. Our findings indicated that the severity of RLS was related to the anatomic features in PFO, inducing different cerebral ischemia lesion patterns in cryptogenic stroke patients with PFO.
Collapse
Affiliation(s)
- Ying Zhu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Zhang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Huang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yani Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Youbin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yahui Weng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiying Sun
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
13
|
Witte KK, Tsivgoulis G, Reynolds MR, Tsintzos SI, Eggington S, Ismyrloglou E, Lyon J, Huynh M, Egea M, de Brouwer B, Ziegler PD, Franco N, Joglekar R, Rosemas SC, Liu S, Thijs V. Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation. BMC Cardiovasc Disord 2021; 21:160. [PMID: 33789592 PMCID: PMC8015049 DOI: 10.1186/s12872-021-01967-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/23/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. Methods CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. Results Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953–£7018 per patient (UK), €6683–€7368 (Netherlands), €4933–€9378 (Spain), AUD$5353–6539 (Australia) and $26,768–$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468–$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). Conclusions Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-01967-x.
Collapse
Affiliation(s)
- Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, LIGHT Building, Clarendon Way, Leeds, LS2 9JT, UK.
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, National & Kapodistrian University of Athens Medical School, Athens, Greece
| | | | | | - Simon Eggington
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | | | | | | | | | - Paul D Ziegler
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
| | - Noreli Franco
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
| | - Rashmi Joglekar
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | - Shufeng Liu
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
| | - Vincent Thijs
- Florey Institute of Neuroscience, Melbourne, Australia
| |
Collapse
|
14
|
Psychogios K, Magoufis G, Kargiotis O, Safouris A, Bakola E, Chondrogianni M, Zis P, Stamboulis E, Tsivgoulis G. Ultrasound Assessment of Extracranial Carotids and Vertebral Arteries in Acute Cerebral Ischemia. ACTA ACUST UNITED AC 2020; 56:medicina56120711. [PMID: 33353035 PMCID: PMC7765801 DOI: 10.3390/medicina56120711] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/25/2022]
Abstract
Assessing ischemic etiology and mechanism during the acute phase of an ischemic stroke is crucial in order to tailor and monitor appropriate treatment and determine prognosis. Cervical Duplex Ultrasound (CDU) has evolved since many years as an excellent screening tool for the evaluation of extracranial vasculature. CDU has the advantages of a low cost, easily applicable, bed side examination with high temporal and spatial resolution and without exposing the patients to any significant complications. It represents an easily repeatable test that can be performed in the emergency room as a first-line examination of cervical artery pathology. CDU provides well validated estimates of the type of the atherosclerotic plaque, the degree of stenosis, as well as structural and hemodynamic information directly about extracranial vessels (e.g., subclavian steal syndrome) and indirectly about intracranial circulation. CDU may also aid the diagnosis of non-atherosclerotic lesions of vessel walls including dissections, arteritis, carotid-jugular fistulas and fibromuscular dysplasias. The present narrative review outlines all potential applications of CDU in acute stroke management and also highlights its potential therapeutic implications.
Collapse
Affiliation(s)
- Klearchos Psychogios
- Acute Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (K.P.); (O.K.); (A.S.); (E.S.)
- Second Department of Neurology, Attikon University Hospital, 15772 Athens, Greece; (E.B.); (M.C.)
- School of Medicine, University of Athens, 15772 Athens, Greece
| | - Georgios Magoufis
- Department of Interventional Neuroradiology, Metropolitan Hospital, 18547 Piraeus, Greece;
| | - Odysseas Kargiotis
- Acute Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (K.P.); (O.K.); (A.S.); (E.S.)
| | - Apostolos Safouris
- Acute Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (K.P.); (O.K.); (A.S.); (E.S.)
| | - Eleni Bakola
- Acute Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (K.P.); (O.K.); (A.S.); (E.S.)
| | - Maria Chondrogianni
- Acute Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (K.P.); (O.K.); (A.S.); (E.S.)
| | - Panagiotis Zis
- Medical School, University of Cyprus, 1678 Nicosia, Cyprus;
| | - Elefterios Stamboulis
- Acute Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (K.P.); (O.K.); (A.S.); (E.S.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, 15772 Athens, Greece; (E.B.); (M.C.)
- Correspondence:
| |
Collapse
|
15
|
Fuentes B, Gutiérrez-Zúñiga R, Díez-Tejedor E. It's Time to Say Goodbye to the ESUS Construct. Front Neurol 2020; 11:653. [PMID: 32733368 PMCID: PMC7358305 DOI: 10.3389/fneur.2020.00653] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/02/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital Universitario La Paz, Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Raquel Gutiérrez-Zúñiga
- Department of Neurology and Stroke Center, Hospital Universitario La Paz, Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Exuperio Díez-Tejedor
- Department of Neurology and Stroke Center, Hospital Universitario La Paz, Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| |
Collapse
|
16
|
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.
Collapse
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
| | | |
Collapse
|
17
|
Ravikanth R. Role of 18F-FDG positron emission tomography in carotid atherosclerotic plaque imaging: A systematic review. World J Nucl Med 2020; 19:327-335. [PMID: 33623500 PMCID: PMC7875029 DOI: 10.4103/wjnm.wjnm_26_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 12/22/2022] Open
Abstract
Stroke and other thromboembolic events in the brain are often due to carotid artery atherosclerosis, and atherosclerotic plaques with inflammation are considered particularly vulnerable, with an increased risk of becoming symptomatic. Positron emission tomography (PET) with 2-deoxy-2-[Fluorine-18] fluoro-D-glucose (18F-FDG) provides valuable metabolic information regarding arteriosclerotic lesions and may be applied for the detection of vulnerable plaque. At present, however, patients are selected for carotid surgical intervention on the basis of the degree of stenosis alone, and not the vulnerability or inflammation of the lesion. During the past decade, research using PET with the glucose analog tracer 18F-fluor-deoxy-glucose, has been implemented for identifying increased tracer uptake in symptomatic carotid plaques, and tracer uptake has been shown to correlate with plaque inflammation and vulnerability. These findings imply that 18F-FDG PET might hold the promise for a new and better diagnostic test to identify patients eligible for carotid endarterectomy. The rationale for developing diagnostic tests based on molecular imaging with 18F-FDG PET, as well as methods for simple clinical PET approaches, are discussed. This is a systematic review, following Preferred Reporting Items for Systematic Reviews guidelines, which interrogated the PUBMED database from January 2001 to November 2019. The search combined the terms, “atherosclerosis,” “inflammation,” “FDG,” and “plaque imaging.” The search criteria included all types of studies, with a primary outcome of the degree of arterial vascular inflammation determined by 18F-FDG uptake. This review examines the role of 18F-FDG PET imaging in the characterization of atherosclerotic plaques.
Collapse
Affiliation(s)
- Reddy Ravikanth
- Department of Radiology, St. John's Hospital, Kattappana, Kerala, India
| |
Collapse
|
18
|
Qawasmeh MA, Aldabbour B, Momani A, Obiedat D, Alhayek K, Kofahi R, Yassin A, El-Salem K. Epidemiology, Risk Factors, and Predictors of Disability in a Cohort of Jordanian Patients with the First Ischemic Stroke. Stroke Res Treat 2020; 2020:1920583. [PMID: 32566121 PMCID: PMC7292978 DOI: 10.1155/2020/1920583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/17/2020] [Accepted: 05/23/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To identify the risk factors, etiologies, length of stay, severity, and predictors of disability among patients with the first ischemic stroke in Jordan. METHODS A retrospective cohort study of 142 patients who were admitted to the Neurology Department at King Abdullah University Hospital between July/2017 and March/2018 with a first ischemic stroke. Etiology was classified according to the TOAST criteria. Severity was represented by NIHSS score, disability by mRS score, and prolonged length of stay as hospitalizations more than 75th percentile of the cohort's median length of stay. Analysis of the sample demographics and descriptive statistics were done, including frequencies of prevalence of independent variables (risk factors) and frequencies of stroke and etiology work-up. Chi-square and univariate analysis of variance "ANOVA" were used to investigate the relationship between risk factors and type of stroke. Finally, logistic regression analysis was used to measure the contribution of each of the independent variables. IRB approval was obtained as necessary. RESULTS The mean age for the cohort was 66.5 years. The most common risk factors were hypertension (78.8%), diabetes mellitus (60.5%), and ischemic heart disease (29.4%). The most common stroke etiology was small-vessel occlusion (54.2%). Median length of stay was 4 days. Prolonged length of stay was observed in 23.23% of patients, which was associated with several factors, the most common of which were persistent dysphagia (57.5%), nosocomial infection (39.3%), and combined dysphagia and nosocomial infection (21.2%). The mean admission NIHSS score was 7.94, and on discharge was 5.76. In-hospital mortality was 2.81%, while 50% of patients had a favorable outcome on discharge (mRS score between 0-2). The mean discharge mRS score for the cohort was 2.47 (SD ± 1.79). Large artery atherosclerosis was associated with the highest residual disability with a mean score of 3.67 (SD ± 1.88), while the stroke of undetermined etiology was associated with the lowest residual disability with a mean score of 1.60 (SD ± 1.78). Significant predictors of mRS score were smoking (t 3.24, P < 0.001), age (t 1.98, P < 0.049), and NIHSS score (t 9.979, P 0.000). CONCLUSION Ischemic strokes have different etiologies that are associated with different levels of impact on the patient's clinical status and prognosis. Large artery atherosclerosis was associated with the highest residual disability. Regarding predictors of prognosis, current smoking status, age above 50, gender, and NIHSS on admission appear to be the strongest predictors of prognosis. Finally, higher NIHSS score on admission resulted in a longer hospital stay.
Collapse
Affiliation(s)
- Majdi Al Qawasmeh
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Belal Aldabbour
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Aiman Momani
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Deema Obiedat
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Kefah Alhayek
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Raid Kofahi
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Ahmed Yassin
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Khalid El-Salem
- Department of Neurology, King Abdullah University Hospital (KAUH) of Jordan University of Science and Technology (JUST), Irbid, Jordan
| |
Collapse
|
19
|
Maestrini I, Altieri M, Di Piero V. Letter by Maestrini et al Regarding Article, “Classification of Covert Brain Infarct Subtype and Risk of Death and Vascular Events”. Stroke 2020; 51:e81. [DOI: 10.1161/strokeaha.119.028835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ilaria Maestrini
- Department of Human Neurosciences, ‘Sapienza’ University of Rome, Italy
| | - Marta Altieri
- Department of Human Neurosciences, ‘Sapienza’ University of Rome, Italy
| | - Vittorio Di Piero
- Department of Human Neurosciences, ‘Sapienza’ University of Rome, Italy
| |
Collapse
|
20
|
Palà E, Bustamante A, Clúa-Espuny JL, Acosta J, Gonzalez-Loyola F, Ballesta-Ors J, Gill N, Caballero A, Pagola J, Pedrote A, Muñoz MA, Montaner J. N-Terminal Pro B-Type Natriuretic Peptide's Usefulness for Paroxysmal Atrial Fibrillation Detection Among Populations Carrying Cardiovascular Risk Factors. Front Neurol 2019; 10:1226. [PMID: 31849809 PMCID: PMC6896906 DOI: 10.3389/fneur.2019.01226] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/04/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Atrial fibrillation (AF) systematic screening studies have not shown a clear usefulness in stroke prevention, as AF might present as paroxysmal and asymptomatic. This study aims to determine the usefulness of some blood-biomarkers to identify paroxysmal atrial fibrillation in the context of a screening programme. Methods: A total of 100 subjects aged 65-75 years with hypertension and diabetes were randomly selected. AF was assessed by conventional electrocardiogram (ECG) and 4 weeks monitoring with a wearable Holter device (Nuubo™). N-terminal pro B-type natriuretic peptide (NT-proBNP), apolipoprotein CIII (ApoC-III), von Willebrand factor (vWF), ADAMTS13, urokinase plasminogen activator surface receptor (uPAR), and urokinase plasminogen activator (uPA) were determined in serum/plasma samples and the levels were compared depending on AF presence and mode of detection. Results: The AF prevalence in the studied population was found to be 20%. In seven subjects, AF was only detected after 1 month of Holter monitoring (hAF group). NT-proBNP levels were higher in subjects with AF compared with subjects with no AF (p < 0.0001), even when only taking into account the hAF group (p = 0.031). No significant differences were found in the other biomarkers. The NT-proBNP >95 pg/ml cut-off showed high sensitivity and specificity to detect AF (95%, 66.2%) or hAF (85.72%, 66.2%) and was found to be an independent predictor of AF and hAF in a logistic regression analysis. NT-proBNP correlated with AF burden (r = 0.597, p = 0.024). Conclusion: NT-proBNP was elevated in AF cases not identified by ECG; thus, it may be used as a screening biomarker in asymptomatic high-risk populations, with a promising cut-off point of 95 pg/ml that requires further validation.
Collapse
Affiliation(s)
- Elena Palà
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR)-Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR)-Universitat Autónoma de Barcelona, Barcelona, Spain.,Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Josep Lluis Clúa-Espuny
- Equip d'Atenció Primària Tortosa Est, SAP Terres de l'Ebre, Institut Català de la Salut, Tortosa, Spain.,Unitat de Suport a la Recerca de Barcelona, Institut d'Investigació en Atenció Primària IDIAP Jordi Gol, Barcelona, Spain
| | - Juan Acosta
- Department of Cardiology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Felipe Gonzalez-Loyola
- Unitat de Suport a la Recerca de Barcelona, Institut d'Investigació en Atenció Primària IDIAP Jordi Gol, Barcelona, Spain.,Gerència Atenció Primària de Barcelona, Institut Català de la Salut, Barcelona, Spain
| | - Juan Ballesta-Ors
- Equip d'Atenció Primària Tortosa Est, SAP Terres de l'Ebre, Institut Català de la Salut, Tortosa, Spain.,Unitat de Suport a la Recerca de Barcelona, Institut d'Investigació en Atenció Primària IDIAP Jordi Gol, Barcelona, Spain
| | - Natalia Gill
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR)-Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Andrea Caballero
- Biochemical Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jorge Pagola
- Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alonso Pedrote
- Department of Cardiology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Miguel Angel Muñoz
- Unitat de Suport a la Recerca de Barcelona, Institut d'Investigació en Atenció Primària IDIAP Jordi Gol, Barcelona, Spain.,Gerència Atenció Primària de Barcelona, Institut Català de la Salut, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR)-Universitat Autónoma de Barcelona, Barcelona, Spain
| |
Collapse
|
21
|
Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke. J Clin Med 2019; 8:jcm8112002. [PMID: 31744102 PMCID: PMC6912531 DOI: 10.3390/jcm8112002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Occult paroxysmal atrial fibrillation (PAF) is a common and potential treatable cause of cryptogenic stroke (CS). We sought to prospectively identify independent predictors of atrial fibrillation (AF) detection in patients with CS and sinus rhythm on baseline electrocardiogram (ECG), without prior AF history. We had hypothesized that cardiac arrhythmia detection during neurosonology examinations (Carotid Duplex (CDU) and Transcranial Doppler (TCD)) may be associated with higher likelihood of AF detection. Methods: Consecutive CS patients were prospectively evaluated over a six-year period. Demographics, clinical and imaging characteristics of cerebral ischemia were documented. The presence of arrhythmia during spectral waveform analysis of CDU/TCD was recorded. Left atrial enlargement was documented during echocardiography using standard definitions. The outcome event of interest included PAF detection on outpatient 24-h Holter ECG recordings. Statistical analyses were performed using univariate and multivariate logistic regression models. Results: A total of 373 patients with CS were evaluated (mean age 60 ± 11 years, 67% men, median NIHSS-score 4 points). The rate of PAF detection of any duration on Holter ECG recordings was 11% (95% CI 8%–14%). The following three variables were independently associated with the likelihood of AF detection on 24-h Holter-ECG recordings in both multivariate analyses adjusting for potential confounders: age (OR per 10-year increase: 1.68; 95% CI: 1.19–2.37; p = 0.003), moderate or severe left atrial enlargement (OR: 4.81; 95% CI: 1.77–13.03; p = 0.002) and arrhythmia detection during neurosonology evaluations (OR: 3.09; 95% CI: 1.47–6.48; p = 0.003). Conclusion: Our findings underline the potential utility of neurosonology in improving the detection rate of PAF in patients with CS.
Collapse
|
22
|
Tsivgoulis G, Kargiotis O, Katsanos AH, Patousi A, Pikilidou M, Birbilis T, Mantatzis M, Palaiodimou L, Triantafyllou S, Papanas N, Skendros P, Terzoudi A, Georgiadis GS, Maltezos E, Piperidou C, Serdari A, Theodorou A, Ikonomidis I, Heliopoulos I, Vadikolias K. Clinical and Neuroimaging Characteristics in Embolic Stroke of Undetermined versus Cardioembolic Origin: A Population-Based Study. J Neuroimaging 2019; 29:737-742. [PMID: 31463999 DOI: 10.1111/jon.12660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/13/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Evidence suggests that cardioembolism represents the underlying mechanism in the minority of embolic strokes of undetermined source (ESUS). In this population-based study, we sought to compare the clinical and imaging characteristics as well as outcomes in patients with ESUS and cardioembolic stroke (CE). METHODS We included consecutive patients with first-ever ischemic stroke (IS) from the previously published population-based Evros-Stroke-Registry identified as ESUS or CE according to standardized criteria. Baseline characteristics, admission NIHSS scores, cerebral edema, hemorrhagic transformation, stroke recurrence, functional outcomes (determined by modified Rankin Scale [mRS] scores), and mortality rates were recorded during the 1-year follow-up period. RESULTS We identified 21 ESUS (3.7% of IS) and 211 CE (37.1% of IS) cases. Patients with ESUS were younger (median age: 68 years [interquartile range [IQR]: 61-75] vs 80 years [IQR: 75-84]; P < .001), had lower median admission NIHSS scores (4 points [IQR: 2-8] vs 10 points [IQR: 5-17]; P < .001), and lower prevalence of cerebral edema on neuroimaging studies (0 vs. 33.3%, P = .002). Functional outcomes were more favorable in ESUS at 28 (median mRS score: 2 [IQR: 1-3] vs 4 [IQR: 4-5]; P < .001), 90 (median mRS score: 1 [IQR: 0-2] vs 4 [IQR: 3-5]; P < .001), and 365 days (median mRS score: 1 [IQR: 0-2] vs 4 [IQR: 2-4]; P < 0.001). At 1-year, the mortality rate was lower in ESUS (0% [95% confidence interval [CI]: 0-13.5%] vs 34.6% [95% CI: 28.2-41.0%]; P < .001); the 1-year recurrent rate was also lower numerically (0% [95% CI: 0-13.5%] vs 9.5% [95% CI: 5.5-13.4%]; P = .140) but this difference failed to reach statistical significance due to the small study population. CONCLUSIONS The clinical and neuroimaging profiles as well as clinical outcomes vary substantially between ESUS and CE indicating different underlying mechanisms.
Collapse
Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.,Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.,Department of Neurology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Athanasia Patousi
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Maria Pikilidou
- Excellence Center, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodosis Birbilis
- Department of Neurosurgery, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Sokratis Triantafyllou
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Panagiotis Skendros
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Aikaterini Terzoudi
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Charitomeni Piperidou
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Aspasia Serdari
- Department of Child and Adolescent Psychiatry, Democritus University of Thrace, University Hospital of Alexandroupolis
| | - Aikaterini Theodorou
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ignatios Ikonomidis
- Second Department of Cardiology, "Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Heliopoulos
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| |
Collapse
|