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Gwag HB, Ko NG, Jin M. Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea. Korean J Intern Med 2024; 39:469-476. [PMID: 38632895 PMCID: PMC11076896 DOI: 10.3904/kjim.2023.479] [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: 11/06/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND/AIMS The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization. METHODS We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven. RESULTS Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later. CONCLUSION The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.
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Affiliation(s)
- Hye Bin Gwag
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Nak Gyeong Ko
- Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Mihyeon Jin
- Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
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2
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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.
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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.
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3
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Forzano I, Santulli G. Patent Foramen Ovale: The Unresolved Questions. TOP ITALIAN SCIENTISTS JOURNAL 2024; 1:10.62684/DMFZ6956. [PMID: 38585657 PMCID: PMC10995646 DOI: 10.62684/dmfz6956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Patent Foramen Ovale (PFO) is a remnant of fetal circulation that could be observed in the 25% of the population worldwide. PFO is associated to numerous clinical conditions as migraines, coronary embolization, transient ischemic attacks, and stroke. The main PFO concerns are related to its correlation to stroke, in particular in young adults. Despite the impact on morbidity that PFO could have, to date there is not clear evidence about its management and treatment. In this narrative review our aim is to summarize the more recent evidence in the literature dealing with PFO, in order to provide an updated overview on this topic.
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Affiliation(s)
- Imma Forzano
- Department of Advanced Biomedical Sciences, Division of Cardiology, "Federico II" University, International Translational Research and Medical Education (ITME) Consortium, Academic Research Unit, 80131, Naples, Italy
| | - Gaetano Santulli
- Department of Advanced Biomedical Sciences, Division of Cardiology, "Federico II" University, International Translational Research and Medical Education (ITME) Consortium, Academic Research Unit, 80131, Naples, Italy
- Department of Medicine (Division of Cardiology), Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, New York City, 10461, NY
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4
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Yamazaki N, Koga M, Doijiri R, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Ihara M, Toyoda K. Magnetic Resonance Imaging-Guided Intravenous Thrombolysis in Cardioembolic Stroke Patients With Unknown Time of Onset - Subanalysis of the THAWS Randomized Control Trial. Circ J 2024; 88:382-387. [PMID: 38220173 DOI: 10.1253/circj.cj-23-0662] [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] [Indexed: 01/16/2024]
Abstract
BACKGROUND We investigated the clinical effect of intravenous thrombolysis using a magnetic resonance imaging (MRI)-guided approach in cardioembolic stroke (CE) patients with unknown time of onset.Methods and Results: This subanalysis of the THAWS trial assessed the efficacy and safety of alteplase 0.6 mg/kg in CE patients with unknown time of onset and showing diffusion-weighted imaging-fluid-attenuated inversion recovery mismatch. Patients were classified as CE and non-CE using the SSS-TOAST classification system during the acute period. The efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days. In all, 126 patients from the THAWS trial were included in this study, of whom 45 (35.7%) were diagnosed with CE. In the CE group, a favorable outcome was numerically more frequent in the alteplase than control group (52% vs. 35%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 0.50-9.99). However, in the non-CE group, favorable outcomes were comparable between the alteplase and control groups (44% vs. 55%, respectively; aOR 0.39; 95% CI 0.12-1.21). Treatment-by-cohort interaction for a favorable outcome was modestly significant between the CE and non-CE groups (P=0.069). In the CE group, no patients experienced symptomatic intracranial hemorrhage (ICH) or parenchymal hematoma Type II following thrombolysis. CONCLUSIONS When an MRI-guided approach is used, CE patients with unknown time of onset appear to be suitable candidates for thrombolysis.
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Affiliation(s)
- Naoya Yamazaki
- Department of Neurology, Iwate Prefectural Central Hospital
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | | | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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5
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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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6
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Lee P, Dhillon G, Pourafkari M, DaBreo D, Jaff Z, Appireddy R, Jin A, Boissé Lomax L, Durafourt BA, Boyd JG, Nasirzadeh AR, Tampieri D, Jalini S. Non-ECG-gated cardiac CT angiography in acute stroke is feasible and detects sources of embolism. Int J Stroke 2024; 19:189-198. [PMID: 37515467 PMCID: PMC10811964 DOI: 10.1177/17474930231193335] [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: 04/25/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND A significant portion of cryptogenic stroke is hypothesized to be secondary to cardiac embolism. However, transthoracic echocardiogram is usually delayed after stroke, and more detailed cardiac imaging is not routinely done. AIMS This study aimed to determine whether non-ECG-gated cardiac CT angiography (cCTA) during hyperacute stroke would provide diagnostic quality images and act as an adjunct modality of cardiac imaging to detect sources of emboli. METHODS In this single-center prospective cohort study, modified Code Stroke imaging was implemented with a 64-slice CT scanner, where the longitudinal axis of CT angiography was extended from the carina to the diaphragm. The primary outcomes of image quality, recruitment feasibility, impact on hyperacute time metrics, and additional radiation dose were assessed. Secondary outcomes consisted of detection of high-risk cardiac sources of embolism, mediastinal or lung pathology, and impact on etiologic classification. RESULTS One hundred and twenty eligible patients were enrolled, of which 105 (87.5%) had good/moderate quality images for motion artifact and 119 (99.2%) for contrast opacification. Total CT time, door-to-needle time, and door-to-groin puncture time were unchanged with the addition of cCTA. Eighty-nine patients received a final diagnosis of ischemic stroke, of which 12/89 (13.5%) had high-risk cardioembolic findings on cCTA. Incidental findings, such as pulmonary embolism (PE) (7/89, 7.9%) and malignancy (6/89, 6.7%), were observed. cCTA led to changes in management for 19/120 (15.8%) of all patients, and reclassification of stroke etiology for 8/89 (9%) of patients. CONCLUSIONS Non-ECG-gated cCTA can be feasibly incorporated into Code Stroke and provide diagnostic quality images without delays in hyperacute time metrics. It can detect high-risk cardiac sources, and other findings impacting patient care. This may help reclassify a subset of cryptogenic stroke cases and improve secondary prevention.
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Affiliation(s)
- Peter Lee
- School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Gurmohan Dhillon
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Marina Pourafkari
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Dominique DaBreo
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Zardasht Jaff
- Division of Cardiology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Albert Jin
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Lysa Boissé Lomax
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Bryce A Durafourt
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - John Gordon Boyd
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Amir Reza Nasirzadeh
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Donatella Tampieri
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
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7
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Sposato LA, Albin CSW, Elkind MSV, Kamel H, Saver JL. Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence. Stroke 2024; 55:236-247. [PMID: 38134261 DOI: 10.1161/strokeaha.123.040546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
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Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry (L.A.S.), Western University, London, ON, Canada
- Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada (L.A.S.)
| | - Catherine S W Albin
- Department of Neurology & Neurosurgery, Emory University School of Medicine, Atlanta, GA (C.S.W.A.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
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8
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Villani LA, Guay M, DeDominicis M, Bharwani A, Xu R, Počuča N, Perera K. The Utility of Echocardiogram in the Workup of Ischemic Stroke Patients. Can J Neurol Sci 2024; 51:73-77. [PMID: 36691825 DOI: 10.1017/cjn.2023.11] [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: 01/25/2023]
Abstract
BACKGROUND Cardiac sources of emboli can be identified by transthoracic echocardiogram (TTE). The Canadian Best Practice Guidelines recommend routine use of TTE in the initial workup of ischemic stroke when an embolic source is suspected. However, TTEs are commonly ordered for all patients despite insufficient evidence to justify cost-effectiveness. We aim to evaluate the TTE ordering pattern in the initial workup of ischemic stroke at a regional Stroke Center in Central South Ontario and determine the proportion of studies which led to a change in management and affected length of stay (LOS). METHODS Hospital records of 520 patients with a discharge diagnosis of TIA or ischemic stroke between October 2016 and June 2017 were reviewed to gather information. RESULTS 477 patients admitted for TIA or ischemic stroke met inclusion criteria. 67.9% received TTE, out of which 6.0% had findings of cardiac sources of emboli including left ventricular thrombus, atrial septal aneurysm, PFO, atrial myxoma, and valvular vegetation. 2.5% of all TTE findings led to change in medical management. The median LOS of patients who underwent TTE was 2 days longer (p < 0.00001). CONCLUSION TTE in the initial workup of TIA or ischemic stroke remains common practice. The yield of TTEs is low, and the proportion of studies that lead to changes in medical management is minimal. TTE completion was associated with increased LOS and may result in increased healthcare spending; however, additional factors prolonging the LOS could not be excluded.
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Affiliation(s)
- Linda A Villani
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Meagan Guay
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | | | - Aadil Bharwani
- Temerty Faculty of Medicine, University of Toronto, Canada
| | - Richard Xu
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Nikola Počuča
- Faculty of Science, Department of Mathematics and Statistics, McMaster University, Canada
| | - Kanjana Perera
- Division of Neurology, Department of Medicine, McMaster University, Canada
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9
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Liu L, Li Z, Zhou H, Duan W, Huo X, Xu W, Li S, Nie X, Liu H, Liu J, Sun D, Wei Y, Zhang G, Yuan W, Zheng L, Liu J, Wang D, Miao Z, Wang Y. Chinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update. Stroke Vasc Neurol 2023; 8:e3. [PMID: 38158224 PMCID: PMC10800268 DOI: 10.1136/svn-2023-002998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND China is one of the countries with the highest burden of stroke. Implementing multidimensional management guidelines will help clinicians practise evidence-based care, improve patient outcomes and alleviate societal burdens. This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases. METHODS We conducted a comprehensive search on MEDLINE (via PubMed) up to 31 August 2023. The writing team established the recommendations through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association (CSA). The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee. RESULTS This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care: emergency assessment and diagnosis of ischaemic cerebrovascular disease, acute-phase reperfusion therapy, evaluation of underlying mechanisms, antithrombotic therapy, prevention and treatment of complications, and risk factor management. CONCLUSIONS This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Hongyu Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Cerebral Vascular Disease Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Weihai Xu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shujuan Li
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huihui Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinjie Liu
- Department of General Medicine, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Dapeng Sun
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guitao Zhang
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weizhuang Yuan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lina Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Zhongrong Miao
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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10
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Pandian JD, Padma Srivastava MV, Aaron S, Ranawaka UK, Venketasubramanian N, Sebastian IA, Injety RJ, Gandhi DB, Chawla NS, Vijayanand PJ, Rangamani S, Kalkonde YV. The burden, risk factors and unique etiologies of stroke in South-East Asia Region (SEAR). THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 17:100290. [PMID: 37849933 PMCID: PMC10577147 DOI: 10.1016/j.lansea.2023.100290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
The World Health Organization (WHO) South East Asia Region (SEAR) comprises 11 countries, which are one of the most culturally, topographically, and socially diverse areas worldwide, undergoing an epidemiological transition towards non-communicable diseases, including stroke and other cardiovascular diseases (CVDs). This region accounts for over 40% of the global stroke mortality. Few well-designed population-based epidemiological studies on stroke are available from SEAR countries, with considerable variations among them. Ischemic stroke, a common stroke subtype, has higher frequencies of intracerebral hemorrhage in many countries. Along with an aging population, the increased prevalence of risk factors such as hypertension, diabetes mellitus, tobacco and alcohol consumption, lack of physical activity, high ambient pollution, heat, and humidity contribute to the high burden of stroke in this region. SEAR's many unique and uncommon stroke etiologies include cerebral venous thrombosis, tuberculosis, dengue, scrub typhus, falciparum malaria, snake bite, scorpion sting, etc. Current data on stroke burden and risk factors is lacking, compelling an urgent need for high-quality hospital-level and population-level data in all SEAR countries. Strategies towards a consolidated approach for implementing improved stroke prevention measures, stroke surveillance, and established stroke systems of care are the path to bridging the gaps in stroke care.
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Affiliation(s)
- Jeyaraj D. Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | | | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, India
| | | | | | | | - Ranjit J. Injety
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Dorcas B.C. Gandhi
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Nistara S. Chawla
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Pranay J. Vijayanand
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Sukanya Rangamani
- National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bangalore, Karnataka, India
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11
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Huang W, Wang H. Predictive value of transesophageal echocardiography combined with contrast transthoracic echocardiography for embolic stroke of undetermined source. Perfusion 2023:2676591231198356. [PMID: 37657946 DOI: 10.1177/02676591231198356] [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: 09/03/2023]
Abstract
OBJECTIVE In this study, we aimed to assess the predictive value of transesophageal echocardiography (TEE) combined with contrast transthoracic echocardiography (cTTE) for embolic stroke of undetermined source (ESUS). METHODS A total of 52 patients with ESUS were examined by TEE and cTTE. The detection rate of patent foramen ovale (PFO) and right-to-left shunt (RLS) grade were compared in patients with ESUS between cTTE alone and cTTE combined with TEE. The Risk of Paradoxical Embolism (RoPE) score, PFO diameter, and PFO length of patients with PFO-associated ESUS and non-PFO-associated ESUS were compared by cTTE alone and cTTE combined with TEE. The receiver operating characteristic (ROC) curve was utilized to determine the effect of RoPE score and PFO diameter on patients with PFO-associated ESUS. RESULTS The positive rate of PFO detected by cTTE alone (46.15%) was lower than that detected by cTTE combined with TEE (69.23%). The proportion of patients with RLS grade I + II + III detected by cTTE combined with TEE (69.23%) was higher than that detected by cTTE alone (46.15%). Both the RoPE score and PFO diameter were significantly greater in the patients with PFO-associated ESUS than in the patients with non-PFO-associated ESUS (p < .05). The combination of RoPE score and PFO diameter had the largest area under the ROC curve (AUC = 0.875), which was larger than the AUC alone of RoPE score (AUC = 0.819) and PFO diameter (AUC = 0.783) (p < .05). CONCLUSION The combination of cTTE and TEE is helpful to the diagnosis of ESUS patients caused by PFO and to judge the degree of RLS.
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Affiliation(s)
- Wei Huang
- Department of Neurology, Hebei Medical University, Shijiazhuang, China
- Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Hebo Wang
- Department of Neurology, Hebei Medical University, Shijiazhuang, China
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
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12
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Goldschmied A, Geisler T. [Thromboembolic diseases from a cardiological point of view]. Dtsch Med Wochenschr 2023; 148:908-914. [PMID: 37493952 DOI: 10.1055/a-1825-7296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist's perspective.The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk.
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13
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Hull R, Carman N, Wilson A, Moulton M, Jordan MC, Stephens BD, Bush K. A Multidisciplinary Algorithm for the Evaluation of Acute Neurologic Deficits Improves Management of Cryptogenic Stroke or Transient Ischemic Attack. Cureus 2023; 15:e42728. [PMID: 37654966 PMCID: PMC10466960 DOI: 10.7759/cureus.42728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
The appropriate diagnosis and management of cryptogenic stroke and transient ischemic attack (TIA) is challenging and requires multidisciplinary involvement. Joint societal guidelines exist to guide the comprehensive evaluation of these entities. This study aimed to implement a standardized multidisciplinary diagnostic algorithm for cryptogenic stroke/TIA. We performed a retrospective analysis of patients admitted to the largest regional military healthcare center with stroke or TIA considered to be cryptogenic at the time of discharge. We abstracted baseline demographics and rates of extra- and intracranial imaging, transthoracic and transesophageal echocardiography, and event monitor orders at the time of discharge. The incidence of event monitor results at 30 days and six months were included. A diagnostic algorithm for evaluation of cryptogenic stroke/TIA was created and disseminated hospital-wide using increased compliance with neuroimaging, echocardiography, and cardiac rhythm monitoring as primary endpoints for our intervention. Post-intervention data abstraction revealed similar rates of extra- and intracranial imaging, but significantly greater rates of transthoracic echocardiography (70% vs. 87%, p 0.0073), inclusion of agitated saline study (41% vs. 65%, p 0.0024), and event monitors ordered at discharge (18% vs. 35%, p 0.0045). At six months there was a higher rate of event monitors obtained (24% vs. 45%, p 0.001). Our study showed implementation of an evidence-based diagnostic algorithm for evaluation of cryptogenic stroke/TIA increases appropriate use of echocardiography and event monitoring.
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Affiliation(s)
- Robert Hull
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
| | | | - Andrew Wilson
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Michael Moulton
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Morgan C Jordan
- Neurology, Brooke Army Medical Center, Fort Sam Houston, USA
| | | | - Kelvin Bush
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
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14
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López-Dequidt I, Martínez-Monzonis A, Peña-Gil C, González-Maestro A, González-Salvado V, Rodríguez-Castro E, Santamaría-Cadavid M, Arias-Rivas S, Rodríguez-Yáñez M, Prieto González JM, González-Juanatey JR. Results of a focused cardiac ultrasound program conducted by neurologists within a stroke care network with cardiac imaging units. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:103-111. [PMID: 36038123 DOI: 10.1016/j.rec.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/14/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION AND OBJECTIVES Recently, neurologists have begun to perform focused cardiac ultrasound for the detection of a cardiac source of embolism in stroke patients, requiring them to undergo a prior accredited training process. We designed a prospective study to analyze the incidence of heart disease detected by a focused cardiac ultrasound program within a stroke care network with cardiac imaging units and to identify the outcomes of detected structural heart disease at 1 year of follow-up. METHODS We included patients admitted to a university hospital for ischemic stroke or a transient ischemic attack between 2017 and 2021 who were evaluated by focused cardiac ultrasound. We studied the presence of structural heart disease and cardioembolic sources. We analyzed cardiovascular events (CVE) during the first year of follow-up. RESULTS Focused cardiac ultrasound was performed in 706 patients. Structural heart disease was detected in 52.1% and a cardioembolic source in 31.9%. Adverse CVE occurred in 5.49% of the patients in the first year of follow-up. The presence of de novo structural heart disease was independently associated with a higher probability of adverse CVE (HR, 1.72; 95%CI, 1.01- 2.91; P=.046). CONCLUSIONS Focused cardiac ultrasound within a stroke care network with cardiac imaging units is an accessible technique with high diagnostic yield. Its use allows clinical and therapeutic actions in the prevention of stroke recurrences and other CVEs in this group of patients.
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Affiliation(s)
- Iria López-Dequidt
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Amparo Martínez-Monzonis
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Carlos Peña-Gil
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Adrián González-Maestro
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Violeta González-Salvado
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Emilio Rodríguez-Castro
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain
| | - María Santamaría-Cadavid
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Susana Arias-Rivas
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Manuel Rodríguez-Yáñez
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain
| | - José María Prieto González
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain
| | - José Ramón González-Juanatey
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain.
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15
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Hira K, Ueno Y, Watanabe M, Shimura H, Kurita N, Miyamoto N, Haginiwa H, Yamashiro K, Hattori N, Urabe T. Impact of D-dimer for pathologic differentiation on transesophageal echocardiography in embolic stroke of undetermined source: a single-center experience. BMC Neurol 2022; 22:338. [PMID: 36076175 PMCID: PMC9454212 DOI: 10.1186/s12883-022-02867-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background Embolic stroke of undetermined source (ESUS) encompasses diverse embologenic mechanisms, which transesophageal echocardiography (TEE) is critical to detect. Specific markers related to each embolic source in ESUS is not fully studied. We focused on D-dimer levels, and explored the association of D-dimer with potential embolic sources (PES) identified on TEE in ESUS. Methods Consecutive patients with ESUS were included in this study. Clinical characteristics including D-dimer levels were compared between ESUS patients with and without TEE, and among none of, one, and at least two PES in ESUS patients undergoing TEE. Factors related to elevation of D-dimer were analyzed. Results A total of 211 patients (age, 69.3 ± 13.2 years; 149 males) with ESUS were enrolled. Of these, 115 received TEE, displaying significantly younger age and lower D-dimer levels than patients without TEE (P < 0.05), and 20 (17%), 61 (53%), and 34 (30%) patients were classified into none of, one, and ≥ two PES, respectively. On multiple logistic regression analysis, D-dimer levels were related to one PES (odds ratio [OR]: 9.01; 95% confidence interval [CI]: 1.00–81.51; P = 0.050) and PES ≥ two (OR: 9.76; 95% CI: 1.07–88.97; P = 0.043). Right-to-left shunt (RLS) with deep venous thrombosis (DVT)(OR: 13.94; 95% CI: 1.77–109.99; P = 0.012) and without DVT (OR: 3.90; 95% CI: 1.20–12.70; P = 0.024) were associated with elevation of D-dimer. Conclusions D-dimer levels were higher in patients with PES. Among PES, RLS, with and without DVT, were associated with increase of D-dimer in ESUS.
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Affiliation(s)
- Kenichiro Hira
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.,Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Masao Watanabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Hideki Shimura
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Naohide Kurita
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Haruna Haginiwa
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
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16
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Robertson DM, Wright MA, Ostrander B, Tani LY. Child Neurology: Case Report of Lambl Excrescences in a Pediatric Patient With Multifocal Strokes. Neurology 2022; 99:73-76. [PMID: 35584923 DOI: 10.1212/wnl.0000000000200747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/04/2022] [Indexed: 11/15/2022] Open
Abstract
Lambl excrescences are fibrinous connective tissue strands found predominantly on left-sided cardiac valves. These valvular strands are typically benign, but have been implicated as a potential etiology of embolic strokes in adult patients. The significance of Lambl excrescences in pediatric stroke cases is unclear and not previously reported in the literature. In this study, we describe a 10-year-old boy who presented with acute-onset right-sided hemiplegia, found to have multifocal embolic strokes of various ages. Extensive stroke workup was unrevealing, aside from the presence of small, filamentous, strand-like densities associated with the mitral and aortic valves noted on a transesophageal echocardiogram consistent with Lambl excrescences. In this case report, we review Lambl excrescences and their significance in acute stroke and management options for the prevention of future ischemia in these patients.
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Affiliation(s)
- Dwight M Robertson
- From the Division of Pediatric Cardiology (D.M.R., L.Y.T.), Department of Pediatrics, University of Utah, Salt Lake City; United States Air Force (D.M.R.), Washington, DC; and Division of Pediatric Neurology (M.A.W., B.O.), Department of Pediatrics, University of Utah, Salt Lake City
| | - Melissa A Wright
- From the Division of Pediatric Cardiology (D.M.R., L.Y.T.), Department of Pediatrics, University of Utah, Salt Lake City; United States Air Force (D.M.R.), Washington, DC; and Division of Pediatric Neurology (M.A.W., B.O.), Department of Pediatrics, University of Utah, Salt Lake City.
| | - Betsy Ostrander
- From the Division of Pediatric Cardiology (D.M.R., L.Y.T.), Department of Pediatrics, University of Utah, Salt Lake City; United States Air Force (D.M.R.), Washington, DC; and Division of Pediatric Neurology (M.A.W., B.O.), Department of Pediatrics, University of Utah, Salt Lake City
| | - Lloyd Y Tani
- From the Division of Pediatric Cardiology (D.M.R., L.Y.T.), Department of Pediatrics, University of Utah, Salt Lake City; United States Air Force (D.M.R.), Washington, DC; and Division of Pediatric Neurology (M.A.W., B.O.), Department of Pediatrics, University of Utah, Salt Lake City
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17
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Resultados de un programa de ecocardioscopia realizada por neurólogos en el proceso integrado en red de atención al ictus en unidades de imagen cardiaca. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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18
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Association between Low Ankle-Brachial Index and Poor Outcomes in Patients with Embolic Stroke of Undetermined Source. J Clin Med 2022; 11:jcm11113073. [PMID: 35683461 PMCID: PMC9181204 DOI: 10.3390/jcm11113073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023] Open
Abstract
We investigated the association of low ankle-brachial index (ABI < 0.9) with major adverse cardiovascular events (MACE) and all-cause mortality in patients with embolic stroke of undetermined source (ESUS) as well as whether the association differed by ESUS subtype. This retrospective single-center study included ESUS patients who underwent transesophageal echocardiography and ABI during hospitalization. ESUS was classified as ESUS with minor cardioembolic source, arteriogenic embolism, two or more causes, or no cause. Arteriogenic embolism was defined and classified as complex aortic or non-stenotic relevant artery plaque. MACE was defined as stroke recurrence, acute coronary syndrome, hospitalization for heart failure, or death. Overall, 829 patients were included, with a median follow-up of 45.8 months. Of these, 42 (5.1%) and 370 (44.6%) had low ABI and arteriogenic embolism, respectively. ABI < 0.9 was independently associated with MACE (hazard ratio [HR]: 2.038, 95% confidence interval [CI]: 1.093−3.801) and all-cause mortality (HR: 3.608, 95% CI: 1.538−8.465) according to the multivariable Cox regression analysis. Between ESUS subtypes, low ABI was independently associated with MACE (HR: 2.513, 95% CI: 1.257−5.023) and all-cause mortality (HR: 5.681, 95% CI: 2.151−15.008) in arteriogenic embolism patients, especially in those with complex aortic plaque. However, in non-arteriogenic embolism patients, low ABI was not related to MACE and mortality. In ESUS patients, low ABI was linked to MACE and all-cause mortality, especially in those with arteriogenic embolisms from complex aortic plaque.
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19
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Stalikas N, Doundoulakis I, Karagiannidis E, Kartas A, Gavriilaki M, Sofidis G, Panteris E, Papazoglou AS, Haidich AB, Sianos G, Giannakoulas G. Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: A systematic review. Eur J Intern Med 2022; 99:38-44. [PMID: 35065879 DOI: 10.1016/j.ejim.2022.01.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emerging evidence suggests the potential role of atrial cardiomyopathy (AC) as a direct thromboembolic determinant in embolic stroke of undetermined source (ESUS). OBJECTIVE We aimed to quantify the prevalence of potential AC markers among ESUS, non-cardioembolic (NCE) and cardioembolic (CE) stroke patients. METHODS PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for publications from inception to October 2021, with duplicate data extraction and risk of bias assessment. The Newcastle-Ottawa assessment scale was used to evaluate study quality. RESULTS Among 398 screened studies, 11 observational studies with 2009 ESUS patients (mean age 66.5 years) fulfilled the inclusion criteria. Of electrocardiographic markers, increased P-wave terminal force in lead V1 was more prevalent in ESUS vs NCE (OR=2.26, 95%CI: 1.40-3.66). Of imaging markers, left atrial volume index (LAVI) and left atrial diameter (LAd) were higher in ESUS vs NCE (OR=1.04, 95%CI: 1.02-1.06 and OR=3.41, 95%CI: 1.35-8.61 respectively). Non-chicken wing morphology of the left atrial appendage was more frequent in ESUS compared to NCE patients in the majority of studies. Of serum biomarkers, the prevalence of NT-proBNP >250 pg/ml did not differ among ESUS vs NCE (OR=0.73, 95%CI: 0.39 -1.35). CONCLUSIONS Electrocardiographic, echocardiographic markers and advanced imaging modalities able to assess the morphologic characteristics of left atrial appendage and left atrial function may be important tools to discriminate AC among ESUS vs NCE stroke patients. Prospective studies exploring the association of potential AC markers with ESUS occurrence are warranted to validate their clinical utility.
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Key Words
- AC, Atrial Cardiomyopathy
- Atrial cardiomyopathy
- CE, cardioembolic
- CS, Cryptogenic Stroke
- ESUS, Embolic Strokes of Undetermined Source
- Embolic strokes of undetermined source
- Epidemiology
- LAA, Left atrial appendage
- LAE, Left atrial enlargement
- LAVI, Left Atrial Volume Index
- LAd, Left atrial diameter
- Markers
- NCE, non-cardioembolic
- NCW, non-chicken wing
- Nonstandard Abbreviations and Acronyms
- PTFV1, P-wave terminal force in V1
- Systematic review
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Affiliation(s)
- Nikolaos Stalikas
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios Kartas
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Gavriilaki
- First Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Sofidis
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftherios Panteris
- Biomic_Auth, Bioanalysis and Omics Lab, Centre for Interdisciplinary Research of Aristotle University of Thessaloniki, Innovation Area of Thessaloniki, Greece
| | - Andreas S Papazoglou
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, Greece
| | - Georgios Sianos
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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20
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Grory BM, Yaghi S, Cordonnier C, Sposato LA, Romano JG, Chaturvedi S. Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies. Circ Res 2022; 130:1075-1094. [PMID: 35420910 PMCID: PMC9015232 DOI: 10.1161/circresaha.121.319947] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
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Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
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21
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Mbonde AA, O'Carroll CB, Dulamea OA, Anghel D, Chong BW, Dumitrascu OM. Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks. Asia Pac J Ophthalmol (Phila) 2022; 11:168-176. [PMID: 35213421 DOI: 10.1097/apo.0000000000000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.
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Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Cumara B O'Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Octaviana A Dulamea
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Daniela Anghel
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Brian W Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US
| | - Oana M Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
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22
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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23
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Heslin ME, Thon JM, Caruso E, Romiyo P, Rana A, Yu S, Thau L, Rana A, Kamen S, Siegler JE. Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction. J Clin Neurosci 2021; 95:31-37. [PMID: 34929648 DOI: 10.1016/j.jocn.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022]
Abstract
Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015-8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46-57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.
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Affiliation(s)
- Mark E Heslin
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA.
| | - Jesse M Thon
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Evan Caruso
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Prasanth Romiyo
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ankit Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - James E Siegler
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
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24
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Nguyen HT, Nguyen HVB, Nguyen HQ, Le HQ. Prevalence of left atrial appendage thrombus in patients with acute ischaemic stroke and sinus rhythm: a cross-sectional study. BMJ Open 2021; 11:e051563. [PMID: 34921077 PMCID: PMC8685935 DOI: 10.1136/bmjopen-2021-051563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Thrombi originating in the left atrial appendage (LAA) mainly form because of atrial fibrillation (AF) and are a known cause of cardioembolic stroke. We aimed to investigate the prevalence of LAA thrombus in patients with acute ischaemic stroke (AIS) and sinus rhythm on 12-lead ECG. METHODS From June 2019 to February 2021, we conducted a cross-sectional study wherein we performed transoesophageal echocardiography (TEE) in patients with AIS and sinus rhythm on 12-lead ECG who were referred for detection of LAA thrombus. After TEE, all patients underwent 24-hour ECG monitoring to screen for paroxysmal AF. Predictors of LAA thrombus were determined using logistic regression analysis. RESULTS Overall, 223 patients (age: 66.2±11.3 years, men: 61.4%) were included in the study. LAA thrombus was detected in 15 patients (6.7%). Paroxysmal AF was detected in 14 of the 15 patients during 24-hour ECG monitoring. Compared with the non-thrombus group, the thrombus group had a statistically significant higher rate of spontaneous echo contrast (SEC), longer LAA, lower peak LAA emptying velocity and predominantly bilateral stroke. In the adjusted model, the presence of SEC increased the probability of LAA thrombus (OR 9.04; 95% CI 2.12 to 38.54; p=0.003). CONCLUSIONS In patients with AIS and sinus rhythm on 12-lead ECG, our study revealed that the prevalence of LAA thrombus was 6.7% with the most prevalent aetiology being paroxysmal AF. The presence of SEC can be a predictor of LAA thrombus in these patients.
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Affiliation(s)
- Huan Thanh Nguyen
- Department of Geriatrics and Gerontology, University of Medicine and Pharmacy at Ho Chi Minh city, Ho Chi Minh City, Vietnam
- Department of Cardiology, Thong Nhat Hospital, Ho Chi Minh, Vietnam
| | | | - Huy Quang Nguyen
- Department of Cardiology, Thong Nhat Hospital, Ho Chi Minh, Vietnam
| | - Hung Quoc Le
- Department of Cardiology, Thong Nhat Hospital, Ho Chi Minh, Vietnam
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25
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Van Herck J, Thoen H, Delens C, Voet J. Multi-territory stroke preceded by pulmonary embolism with asymptomatic coronavirus disease 2019: a case report. Eur Heart J Case Rep 2021; 5:ytab471. [PMID: 34993406 PMCID: PMC8728730 DOI: 10.1093/ehjcr/ytab471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/12/2021] [Accepted: 11/15/2021] [Indexed: 01/19/2023]
Abstract
Background Non-bacterial thrombotic endocarditis is characterized by the presence of sterile vegetations on a cardiac valve. We present a case of multi-territory stroke caused by embolism of a non-bacterial thrombotic aortic valve endocarditis, leading to the diagnosis of a prostate adenocarcinoma with bone metastases. Case summary A 66-year-old patient was diagnosed with pulmonary embolism, first attributed to an asymptomatic coronavirus disease 2019 infection. Edoxaban was started, which was discontinued by the patient. Four weeks later, he presented with subacute vertigo and balance disorders. Magnetic resonance imaging showed a multi-territory stroke. A transoesophageal echocardiogram demonstrated a small vegetation on the aortic valve with moderate aortic insufficiency. Blood cultures remained negative. Malignancy screening showed a markedly elevated prostate-specific antigen. Prostate adenocarcinoma was confirmed on biopsy. A positron emission tomography revealed metastatic disease. A diagnosis of non-bacterial thrombotic endocarditis and paraneoplastic pulmonary embolism secondary to prostate cancer was made. Edoxaban was restarted and the patient was referred for treatment of the prostate adenocarcinoma. Follow-up after 5 months showed no evidence of aortic valve vegetations. Discussion Coronavirus disease 2019 in ambulatory patients may be insufficient as a predisposing factor for venous thrombo-embolism and these patients, especially the elderly, should undergo a screening for malignancy. Non-bacterial thrombotic endocarditis is a rare cause of multi-territory stroke. When related to cancer, the prostate can be the primary tumour.
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Affiliation(s)
- Jakob Van Herck
- Department of Cardiology, General Hospital AZ Nikolaas, Moerlandstraat 1, 9100 Sint-Niklaas, Belgium.,Department of General Internal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Hendrik Thoen
- Department of Cardiology, General Hospital AZ Nikolaas, Moerlandstraat 1, 9100 Sint-Niklaas, Belgium.,Department of Cardiology, University Hospital Ghent, Ghent, Belgium
| | - Christophe Delens
- Department of Cardiology, General Hospital AZ Nikolaas, Moerlandstraat 1, 9100 Sint-Niklaas, Belgium
| | - Joeri Voet
- Department of Cardiology, General Hospital AZ Nikolaas, Moerlandstraat 1, 9100 Sint-Niklaas, Belgium
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26
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Angelini F, Bocchino PP, Peyracchia M, Saglietto A, Magnano M, Patanè N, D’Ascenzo F, Giustetto C, Anselmino M, Gaita F, Toso E. Prevalence and predictors of left atrial thrombosis in atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants. Acta Cardiol 2021; 78:290-297. [PMID: 34821203 DOI: 10.1080/00015385.2021.2005307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Few data are available regarding the prevalence of left atrium (LA) thrombi in atrial fibrillation (AF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods: We evaluated the prevalence and predictors of LA/LA appendage (LAA) thrombi in non-valvular AF patients treated with NOACs referring to a single centre for a scheduled electrical cardioversion (ECV) or catheter ablation (CA). Transesophageal echocardiography (TEE) was performed within 12 h prior to the index procedure. RESULTS A total of 352 consecutive patients with non-valvular AF treated with NOACs were included in this analysis (ECV group n = 176 and CA group n = 176) between 2013 and 2018. 85 patients (24.2%) were on dabigatran, 150 (42.7%) on rivaroxaban, 104 (29.6%) on apixaban and 13 (3.7%) on edoxaban. A LA/LAA thrombus was detected by TEE in 27 (7.7%) patients, 18 in the ECV group and nine in the ablation group; 18 (5.1%) patients presented dense LA/LAA spontaneous echo contrast (SEC). Predictors of LA/LAA thrombi were a CHA2DS2-VASc score > 3 (OR 4.54, 95% CI 1.50 - 13.70, p value = .007) and obesity (OR 6.01, 95% CI 1.95 - 18.50, p value = .001). CONCLUSIONS Among real-world patients with non-valvular AF treated with NOACs, we found a high incidence of LA/LAA thrombi compared to previous reports. The main predictors of LA/LAA thrombosis were a CHA2DS2-VASc score > 3 and obesity.
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Affiliation(s)
- Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Mattia Peyracchia
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Massimo Magnano
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Nicolò Patanè
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Carla Giustetto
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Elisabetta Toso
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
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27
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Abstract
This article focuses on the inpatient evaluation and management of ischemic stroke and transient ischemic attack (TIA). We describe foundational principles including quality metrics, TIA, and stroke as emergencies, TIA/minor stroke management, and standard assessments before discussing tailored evaluation and management strategies by stroke type.
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Affiliation(s)
- Lauren Patrick
- Department of Neurology, Division of Neurovascular, University of California San Francisco, 505 Parnassus Avenue, M-830, San Francisco, CA 94143, USA; Weill Institute for Neuroscience, San Francisco, CA, USA
| | - Cathra Halabi
- Department of Neurology, Division of Neurovascular, University of California San Francisco, 505 Parnassus Avenue, M-830, San Francisco, CA 94143, USA; Weill Institute for Neuroscience, San Francisco, CA, USA.
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28
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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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29
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Yang X, Jing J, Meng X, Li Z, Pan Y, Jiang Y, Xiang X, Liu H, Chen Y, Liu L, Zhao X, Wang Y, Li H, Wang Y. Characteristics and prognosis of patients with embolic stroke of undetermined source in China. Int J Stroke 2021; 17:526-535. [PMID: 34125633 DOI: 10.1177/17474930211028040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to explore the frequencies, risk factors, and natural history of embolic stroke of undetermined source (ESUS) through a national prospective registry in China. METHODS Between August 2015 and March 2018, the Third China National Stroke Registry recruited consecutive patients with ischemic stroke or transient ischemic attack in China. The baseline characteristics, risks of stroke, and prognosis in patients with embolic stroke of undetermined source were described and compared with that in patients with other causative subtypes. RESULTS A total of 15,166 transient ischemic attack and ischemic stroke patients were enrolled in the Third China National Stroke Registry. Among 8528 ischemic stroke with standard diagnostic work-up, 2415 (28.3%) patients were diagnosed with embolic stroke of undetermined source. The mean age was 61 years and 70% of them were male. Compared to patients with cardioembolic strokes and small vessel disease, patients with embolic stroke of undetermined source had higher prevalence of nonstenosing large artery atherosclerosis (37.93% vs. 31.26%, P = 0.008 and 37.93% vs. 34.40%, P = 0.044 respectively). The cumulative probability of stroke recurrence in patients with embolic stroke of undetermined source at three months and one year was 5.59% and 8.74%. Compared with embolic stroke of undetermined source patients (0.70% and 1.99%), patients with the large artery atherosclerosis and cardioembolic strokes had higher cumulative probability of death at three months (1.94% and 3.22%) and one year (4.17% and 7.39%). CONCLUSIONS Embolic stroke of undetermined source is a common cause of ischemic stroke in Chinese population with a higher stroke recurrence than previously reported. It was more likely to have nonstenosing large artery atherosclerosis in patients with embolic stroke of undetermined source than with cardioembolic strokes and small vessel disease.
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Affiliation(s)
- Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Project Management, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xianglong Xiang
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huan Liu
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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30
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1032] [Impact Index Per Article: 344.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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van der Maten G, Dijkstra S, Meijs MFL, von Birgelen C, van der Palen J, den Hertog HM. Cardiac imaging in ischemic stroke or transient ischemic attack of undetermined cause: Systematic review & meta-analysis. Int J Cardiol 2021; 339:211-218. [PMID: 34197841 DOI: 10.1016/j.ijcard.2021.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with "cryptogenic stroke or TIA" the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT). METHODS AND RESULTS We performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3-71.2 years, 49.2-59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies. CONCLUSIONS TTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands; Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands.
| | - Saskia Dijkstra
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands
| | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands; Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands; Department of Research Methodology, Measurement and Data Analysis, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, the Netherlands
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Ahmed MK, Kamal H, Weiss JL, Crumlish A, Shirani P, Sawyer RN, Mowla A. Transesophageal echocardiogram in the evaluation of acute ischemic stroke of young adults. Brain Circ 2021; 7:85-91. [PMID: 34189351 PMCID: PMC8191534 DOI: 10.4103/bc.bc_68_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/06/2021] [Accepted: 02/22/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION: Acute ischemic stroke (AIS) in the young age (≤50 years) is a major cause of disability. The underlying mechanism of AIS in this age group is usually different from elderly. Transthoracic echocardiography (TTE) is used to detect the potential cardiac sources of embolism in AIS patients. Transthoracic echocardiogram (TEE) is superior to detect specific underlying cardio-aortic source of embolism when compared to TTE. We aim to evaluate the diagnostic yield and therapeutic impact of TEE in AIS of young adults. METHODS: We retrospectively reviewed the consecutive patients with AIS in our comprehensive center in a 5-year period from our prospectively collected registry. We selected patients with age ≤50 years who had acute infarcts on brain magnetic resonance imaging or head computed tomography and underwent TEE as part of their diagnostic workup. Demographic details including, age, gender, body mass index, cardiovascular risk factors profile, and TEE findings were collected. RESULTS: Among a total 7,930 patients, 876 (11.04%) were found to be ≤50 years old. Among those, TEE was done in 113 patients (12.8%) in addition to TTE. Those who underwent TEE had a mean age of 40.4 ± 7.9 years, 60 were male (53%), 7 (6.2%) had a history of coronary artery disease, 38 (33%) had a history of diabetes, and 45 (40%) had a history of smoking. TEE showed new abnormal findings in a total of 15 patients (13.2%) that were not reported in their TTEs. Out of these, left atrial appendage thrombus was found in 5, infective endocarditis in 4, atrial septal aneurysms associated with patent foramen ovale (PFO) in 3, and spontaneous mobile echo density in three patients. Overall, new findings from TEE resulted in change in the secondary stroke prevention strategy in 14 patients of those who underwent TEE (12.3%). TEE also confirmed the presence of PFO, which was present on TTE with bubble study in 20 (17.6%) patients. CONCLUSION: TEE may provide additional information in the evaluation of the AIS in young adults, which could lead to change of the secondary stroke prevention strategy.
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Affiliation(s)
- Muhammad K Ahmed
- Department of Neurology, Georgia School of Medicine, HCA Education Consortium, Rome, GA, USA.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Haris Kamal
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Jessica L Weiss
- Department of Medicine, Division of Cardiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Annemarie Crumlish
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Robert N Sawyer
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Ashkan Mowla
- Department of Neurological Surgery, Division of Endovascular Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Danese A, Mugnai G, Prevedello F, Morra M, Bilato C. The role of echocardiography in the embolic stroke of undetermined source. J Cardiovasc Med (Hagerstown) 2021; 21:547-555. [PMID: 32628421 DOI: 10.2459/jcm.0000000000001023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: Echocardiography plays an important role both in the diagnosis and the treatment/prevention of embolic stroke of undetermined source and should be performed as soon as possible for preventing ischemic stroke recurrencies, which occur more frequently during the first week after the first ischemic event. Early identification of the cause of a transient ischemic attack or stroke is indeed a primary goal for the neurologist in the Stroke Unit and requires specific diagnostic strategies. Echocardiography, together with other diagnostic tools such as carotid and transcranial ultrasounds, provides this information promptly. In particular, echocardiography might be able to detect the main sources of the embolic stroke, such as atrial fibrillation, ventricular akinesia, aortic atheroma plaques and/or cardiac shunts. The present review discusses the importance and the practical role of echocardiography as a crucial diagnostic tool for detecting the main source of emboli in the setting of the acute stroke.
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Affiliation(s)
| | - Giacomo Mugnai
- Division of Cardiology, West Vicenza General Hospitals, Vicenza, Italy
| | | | | | - Claudio Bilato
- Division of Cardiology, West Vicenza General Hospitals, Vicenza, Italy
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Different aspects of early and late development of atrial fibrillation during hospitalization in cryptogenic stroke. Sci Rep 2021; 11:7127. [PMID: 33782508 PMCID: PMC8007744 DOI: 10.1038/s41598-021-86620-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/17/2021] [Indexed: 12/04/2022] Open
Abstract
The detection of underlying atrial fibrillation (AF) has become increasingly possible by insertable cardiac monitoring (ICM). During hospitalization for cryptogenic stroke, factors related to the early and late development of AF have not been studied. CHALLENGE ESUS/CS is a multicenter registry of cryptogenic stroke patients undergoing transesophageal echocardiography. Twelve-lead electrocardiogram, continuous cardiac monitoring, and 24-h Holter electrocardiogram were all used for the detection of AF. Early and late detection of AF was determined with an allocation ratio of 1:1 among patients with AF. A total of 677 patients (68.7 ± 12.8 years; 455 men) were enrolled, and 64 patients developed AF during hospitalization. Four days after admission was identified as the approximate median day to classify early and late phases to detect AF: ≤ 4 days, 37 patients; > 4 days, 27 patients. Multiple logistic regression analysis showed that spontaneous echo contrast (SEC) (OR 5.91; 95% CI 2.19–15.97; p < 0.001) was associated with AF ≤ 4 days, whereas a large infarction > 3 cm in diameter (OR 3.28; 95% CI 1.35–7.97; p = 0.009) was associated with AF > 4 days. SEC and large infarctions were important predictors of in-hospital AF detection, particularly in the early and late stages, respectively; thus, they could serve as indications for recommending ICM.
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Johansen MC, Doria de Vasconcellos H, Nazarian S, Lima JAC, Gottesman RF. The Investigation of Left Atrial Structure and Stroke Etiology: The I-LASER Study. J Am Heart Assoc 2021; 10:e018766. [PMID: 33442991 PMCID: PMC7955322 DOI: 10.1161/jaha.120.018766] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Left atrial (LA) function is important in stroke, but often poorly characterized. We evaluated the association of 2-dimensional speckle tracking echocardiography LA variables with stroke subtype (cardioembolic stroke [CS] or cryptogenic stroke versus other). The hypothesis is worse LA active function is associated with CS, but not cryptogenic strokes. Methods and Results In this prospective cohort (2017-2019), left ventricular/LA structure and function were quantified by 2-dimensional and speckle tracking echocardiography in 151 patients with stroke. Strain/strain rate curves for the 3 components of the LA cycle, ie, (1) Reservoir (global longitudinal strain [Srmax]), (2) Conductive (early LA Sr [Sre]), and (3) Active (late LA strain [Sra]) were evaluated, masked to stroke subtype. Associations of cardiac features with stroke subtype were tested using multivariable logistic regressions. Odds of CS were increased in patients with a larger LA systolic diameter (odds ratio [OR], 2.96, 95% CI, 1.14-7.69) but reduced in patients with a higher Srmax (better reservoir) (OR, 0.80, 95% CI, 0.67-0.97). Lower Sra (worse function) was associated with an increased odds of CS (OR, 1.72, 95% CI, 1.07-2.76) but not independent of atrial fibrillation. Higher active LA emptying fraction (better active phase) was associated with reduced odds of CS (OR, 0.74, 95% CI, 0.57-0.95) or cryptogenic stroke (OR, 0.82, 95% CI, 0.68-0.98) versus other subtypes; other associations between cryptogenic stroke and speckle tracking echocardiography were not found. Conclusions Markers of LA structure and function were associated with CS. Similar associations were not found for cryptogenic stroke, which might suggest different underlying mechanisms, given study limitations. Further understanding could aid stroke diagnosis and secondary stroke prevention research.
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Affiliation(s)
- Michelle C Johansen
- Department of Neurology The Johns Hopkins University School of Medicine Baltimore MD
| | | | - Saman Nazarian
- Department of Cardiology The University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Joao A C Lima
- Department of Cardiology The Johns Hopkins University School of Medicine Baltimore MD
| | - Rebecca F Gottesman
- Department of Neurology The Johns Hopkins University School of Medicine Baltimore MD
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Abstract
PURPOSE OF REVIEW This article reviews current knowledge on epidemiology, risk factors and causes, diagnostic considerations, management, and prognosis of ischemic stroke in young adults (those 55 years old and younger). RECENT FINDINGS The incidence of ischemic stroke in young adults has been increasing since the 1980s, which has occurred in parallel with increasing prevalence of vascular risk factors and substance abuse among the younger population. Young adults have a considerably wider range of risk factors than older patients, including age-specific factors such as pregnancy/puerperium and oral contraceptive use. Behavioral risk factors such as low physical activity, excess alcohol consumption, and smoking are factors as well. More than 150 identified causes of early-onset ischemic stroke exist, including rare monogenic disorders. Several recent advances have been made in diagnosis and management of stroke in young adults, including molecular characterization of monogenic vasculitis due to deficiency of adenosine deaminase 2 and transcatheter closure of patent foramen ovale for secondary prevention. Compared with the background population of the same age and sex, long-term mortality in patients remains fourfold higher with cardiovascular causes underlying most of the deaths. The cumulative rate of recurrent stroke extends up to 15% at 10 years. Patients with atherosclerosis, high-risk sources of cardioembolism, and small vessel disease underlying their stroke seem to have the worst prognosis regarding survival and recurrent vascular events. Young stroke survivors also often have other adverse outcomes in the long term, including epilepsy, pain, cognitive problems, and depression. SUMMARY Systematic identification of risk factors and causes and the motivation of patients for long-term prevention and lifestyle changes are of utmost importance to improve the prognosis of early-onset ischemic stroke.
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Eun MY, Sung JH, Lee SH, Jung I, Park MH, Kim YH, Jung JM. Predictive value of free fatty acid levels in embolic stroke of undetermined source: A retrospective observational study. Medicine (Baltimore) 2020; 99:e22465. [PMID: 33019438 PMCID: PMC7535631 DOI: 10.1097/md.0000000000022465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The present study aimed to investigate the predictive value of free fatty acid (FFA) in embolic stroke of undetermined source (ESUS) according to the presence of potential embolic sources (PES) after extensive etiologic evaluation.This was a retrospective observational study based on a single-center registry from January 2011 to July 2017. Stroke subtypes were determined through laboratory findings, brain, and angiographic imaging, carotid ultrasonography, transthoracic echocardiography, and 24-hour Holter monitoring. If ESUS was suspected, transesophageal echocardiography was additionally performed. Patients were classified into ESUS with PES and ESUS without PES. PES included mitral annular calcification, mitral valve prolapse, patent foramen ovale, atrial septal aneurysm, spontaneous echo contrast, ventricular aneurysm, and high-risk plaques of aortic arch, or carotid bulb. We compared clinical and laboratory findings between the two groups.Of a total of 110 ESUS patients, 61 patients (55.5%) had no PES. Patients with ESUS without PES had higher levels of serum FFA, systolic blood pressure, diastolic blood pressure (DBP), and left atrial (LA) enlargement compared with those of ESUS with PES. Multivariable analysis demonstrated that the FFA level, DBP, and LA volume index were associated with ESUS without PES [odds ratio (OR) 1.038, 95% confidence interval (CI) 1.019-1.058 for FFA/10 μEq/L, OR 1.414, 95% CI 1.037-1.928 for DBP/10 mm Hg, and OR 1.073, 95% CI 1.009-1.141 for LA volume index].Higher levels of FFA, DBP, and LA volume index are associated with ESUS without PES, highlighting the need to identify the role of these markers in ESUS through further large-scale, multi-center and prospective studies.
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Affiliation(s)
- Mi-Yeon Eun
- Department of Neurology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu
| | - Joo Hye Sung
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul
| | - Sang-Hun Lee
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine
| | - Ileok Jung
- Department of Neurology, Ho-one Geriatric Hospital
| | - Moon-Ho Park
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul
| | - Yong-Hyun Kim
- Department of Cardiology, Korea University Ansan Hospital, Korea University College of Medicine
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine
- Korea University Zebrafish Translational Medical Research Center, Ansan, Republic of Korea
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38
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Park S, Oh JK, Song JK, Kwon B, Kim BJ, Kim JS, Kang DW, Chang JY, Lee JS, Kwon SU. Transcranial Doppler as a Screening Tool for High-Risk Patent Foramen Ovale in Cryptogenic Stroke. J Neuroimaging 2020; 31:165-170. [PMID: 32896963 DOI: 10.1111/jon.12783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/29/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The identification of high-risk patent foramen ovale (PFO) is important for selecting suitable patients for PFO closure to prevent recurrent stroke in those with cryptogenic stroke. We aimed to evaluate the predictability of transcranial Doppler (TCD) in diagnosing high-risk PFO compared with that of transesophageal echocardiography (TEE), which is not feasible for some stroke patients. METHODS We retrospectively reviewed the data of 461 cryptogenic stroke patients who underwent TEE and TCD for PFO evaluation. High-risk PFO on TEE was defined as PFO with atrial septal aneurysm (phasic septal excursion ≥10 mm) or large PFO (≥2 mm). Spencer grading of right-to-left shunt was used to classify the amount of shunt on TCD. RESULTS PFO on TEE was observed for 242 (52.5%) patients, and high-risk PFO was detected for 123 (26.7%) patients. However, PFO on TCD was observed for 336 (72.9%) patients. Among patients with significant shunt (Spencer grade III or higher) who underwent TCD after Valsalva maneuver (VM), 60.0% of patients had high-risk PFO. However, only 5.3% of patients had high-risk PFO among those without significant shunt. Receiver operating characteristic curves showed that significant shunt after VM had higher predictability (AUC = .876, 95% CI: .843-.905) for detecting the high-risk PFO compared with the predictability based on significant shunt at rest (AUC = .718, 95% CI: .674-.759). (P<.0001 for the differences between two AUCs). CONCLUSIONS TCD is a good screening tool for evaluating high-risk PFO. VM is important for the evaluation of PFO. Patients with minimal or no shunt on TCD after VM are unlikely to have high-risk PFO.
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Affiliation(s)
- Seongho Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Kyung Oh
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Division of Cardiology, Department of Internal Medicine, Sejong Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boseong Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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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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Fralick M, Goldberg N, Rohailla S, Guo Y, Burke MJ, Lapointe-Shaw L, Kwan JL, Weinerman AS, Rawal S, Tang T, Razak F, Verma AA. Value of routine echocardiography in the management of stroke. CMAJ 2020; 191:E853-E859. [PMID: 31387955 DOI: 10.1503/cmaj.190111] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention. METHODS We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression. RESULTS Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram. INTERPRETATION Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke.
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Affiliation(s)
- Mike Fralick
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont.
| | - Nicola Goldberg
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Sagar Rohailla
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Yishan Guo
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Matthew J Burke
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Janice L Kwan
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Adina S Weinerman
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Shail Rawal
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Terence Tang
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Fahad Razak
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Amol A Verma
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
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Rosol ZP, Kopecky KF, Minehart BR, Tecson KM, Vasudevan A, McCullough PA, Grayburn PA, Schussler JM. Limitations of transoesophageal echocardiogram in acute ischaemic stroke. Open Heart 2020; 7:e001176. [PMID: 32257245 PMCID: PMC7103838 DOI: 10.1136/openhrt-2019-001176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/06/2020] [Accepted: 02/24/2020] [Indexed: 01/01/2023] Open
Abstract
Objective The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.
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Affiliation(s)
- Zachary P Rosol
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Kathleen F Kopecky
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Bailey R Minehart
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anupama Vasudevan
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Peter A McCullough
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.,Department of Cardiology, The Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, TX, United States
| | - Paul A Grayburn
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.,Department of Cardiology, The Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, TX, United States
| | - Jeffrey M Schussler
- Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.,Department of Cardiology, The Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, TX, United States
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Characteristics and Outcomes of Younger Adults with Embolic Stroke of Undetermined Source (ESUS): A Retrospective Study. Stroke Res Treat 2019; 2019:4360787. [PMID: 31885851 PMCID: PMC6914878 DOI: 10.1155/2019/4360787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/24/2019] [Accepted: 09/06/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Embolic stroke of undetermined source (ESUS) in younger adults may have different risk factors compared with ESUS in elderly, and the approach to ESUS in young adults may require new therapies. We aimed to investigate the characteristics and outcomes in younger adults with ESUS at a single centre in Saudi Arabia. Patients and Methods A retrospective study was conducted using the medical records of younger adults with ESUS according to the criteria of the Cryptogenic Stroke/ESUS International Working Group. Younger adults (aged ≤50 years) with ESUS were compared with older patients, on admission and discharge from hospital, using the modified Rankin scale (mRS) and the National Institute of Health Stroke Scale (NIHSS). Results Among 147 patients with ESUS, 39 (26.5%) were younger adults. Younger adults compared with older adults with ESUS had fewer vascular risk factors, including lower rates of hypertension (43.6% vs. 70.3%; P = 0.004), diabetes (35.9% vs. 57.4%; P = 0.03), and dyslipidaemia (12.8% vs. 28.7%; P = 0.05). There was no significant difference in poor outcome at discharge (defined as mRS > 2), which was observed in 17.9% of younger adults and 28.7% of older adults. Further, there were no significant differences in stroke severity at discharge (NIHSS score ≤5) or median length of stay. Discussion Although the outcomes of ESUS do not differ between younger and older patients, younger patients have fewer identified risk factors. Conclusion This study showed that 26.5% of patients with ESUS were aged ≤50 years. Although younger adults with ESUS had fewer risk factors, there were no significant differences in neurologic disability or mortality at discharge, stroke severity, or median length of stay.
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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.
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Arauz A, Serrano F, Pearce LA, Kasner SE, Ameriso SF, Toni D, Bereczki D, Siegler J, Ruiz-Franco A, Cantú-Brito C, Czlonkowska A, Lang W, Berkowitz SD, Mundl H, Hart RG. Regional, sex, and age differences in diagnostic testing among participants in the NAVIGATE-ESUS trial. Int J Stroke 2019; 16:55-62. [PMID: 31631796 DOI: 10.1177/1747493019884523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM The diagnosis of embolic stroke of undetermined source (ESUS) is based on excluding other more likely stroke etiologies, and therefore diagnostic testing plays an especially crucial role. Our objective was to compare the diagnostic testing by region, sex, and age among the participants of NAVIGATE-ESUS trial. METHODS Participants were grouped according to five global regions (North America, Latin America, Western Europe, Eastern Europe and East Asia), age (<60, 60-74, and >75 years), and sex. Frequencies of each diagnostic test within areas of echocardiography, cardiac rhythm monitoring, and arterial imaging were described and compared across groups. A multivariable logistic regression model for each diagnostic test was fit to assess the independent influence of each of region, age, and sex and likelihood of testing. RESULTS We included 6985 patients in the analysis (918 from North America; 746 from Latin America; 2853 from Western Europe; 1118 from Eastern Europe; 1350 from East Asia). Average age (highest in Western Europe (69 years), lowest in Eastern Europe (65 years)), % females (highest in Latin America (44%) and lowest in East Asia (31%)), and use of each diagnostic test varied significantly across regions. Region, but not sex, was independently associated with use of each diagnostic test examined. Transesophageal echocardiography and either CT or MR angiogram were more often used in younger patients. CONCLUSION Diagnostic testing differed by region, and less frequently by age, but not by sex. Our findings reflect the existing variations in global practice in diagnostic testing in ESUS patients.
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Affiliation(s)
- Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, México City, México
| | - Fabiola Serrano
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, México City, México
| | | | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, PA, USA
| | | | - Danilo Toni
- Department of Human Neurosciences, 9311Sapienza University of Rome, Rome, Italy
| | - Daniel Bereczki
- Department of Neurology, 37637Semmelweis University, Budapest, Hungary
| | - James Siegler
- Department of Neurology, University of Pennsylvania, PA, USA
| | | | - Carlos Cantú-Brito
- Department of Neurology. Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Anna Czlonkowska
- Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Wilfried Lang
- Department of Neurology, Sigmund Freud University Vienna, Medical Faculty and Hospital St. John of God, Beaconsfield, Australia
| | | | | | - Robert G Hart
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Canada
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Al Khathaami AM, Al Bdah B, Alnosair A, Alrebdi R, Alwayili S, Alhamzah S, Al Turki A, Alotaibi N. Embolic Stroke of Undetermined Source in Saudi Arabia: Prevalence, Patient Characteristics, and Outcomes. J Stroke Cerebrovasc Dis 2019; 28:104390. [PMID: 31607440 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 08/24/2019] [Accepted: 08/31/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) is a newly introduced clinical construct to better characterize cryptogenic stroke. It is associated with considerable morbidity and mortality and a high recurrence rate. It has not previously been investigated in Saudi stroke patients. We aimed to conduct a descriptive analysis of ESUS in Saudi Arabia, including its frequency among patients with acute stroke, characteristics, and outcomes. METHODS We reviewed all ischemic stroke patients admitted to the stroke unit at King Abdulaziz Medical City-Riyadh, Saudi Arabia, from February 2016 to July 2018. We applied the criteria proposed by the Cryptogenic Stroke/ESUS International Working Group, which defines ESUS as a radiologically confirmed nonlacunar brain infarct without (a) extracranial or intracranial atherosclerosis causing ≥50% stenosis in arteries supplying the ischemic area, (b) a major-risk cardioembolic source, (c) any other specific cause of stroke. We compared ESUS patients with the other stroke patients. Study was approved by local institutional review board. RESULTS Of the 736 patients admitted with ischemic stroke, 147 (20%) had ESUS. Patients with ESUS had fewer vascular risk factors compared to patients without ESUS. Nearly third were either dead or dependent at discharge. There were no significant differences between ESUS and other types of ischemic strokes in mortality rate and independence at discharge. CONCLUSION ESUS is common in Saudi stroke patients. Despite of the lack of definite etiology, it is associated with considerable morbidity and mortality.
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Affiliation(s)
- Ali M Al Khathaami
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Bayan Al Bdah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Rayan Alrebdi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Shorug Alwayili
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Sulaiman Alhamzah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Nasser Alotaibi
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Ohya Y, Osaki M, Fujimoto S, Jinnouchi J, Matsuki T, Mezuki S, Kumamoto M, Kanazawa M, Tagawa N, Ago T, Kitazono T, Arakawa S. Usefulness of Transesophageal Echocardiography for Predicting Covert Paroxysmal Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source. Cerebrovasc Dis Extra 2019; 9:98-106. [PMID: 31542780 PMCID: PMC6787416 DOI: 10.1159/000502713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/13/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Covert paroxysmal atrial fibrillation (CPAF) is a major cause of embolic stroke of undetermined source (ESUS). However, detecting PAF during hospitalization in these patients is difficult. OBJECTIVES This study aimed to determine whether findings of transesophageal echocardiography (TEE) during hospitalization are associated with later detection of PAF in patients with ESUS. METHOD We retrospectively studied 348 patients with ESUS who were admitted to our hospital within 1 week of onset. These patients met the criteria of ESUS, underwent TEE during hospitalization, and were followed up for at least 1 year. RESULTS We found PAF in 35 (10.0%) patients. In patients with PAF, spontaneous echo contrast (SEC) and low left atrial appendage flow (LAAF) by TEE and enlargement of the left atrial dimension (LAD) by transthoracic echocardiography were identified more frequently compared with those who did not have PAF. In multivariate analysis, SEC and an LAD ≥42 mm were independently associated with later detection of PAF (p < 0.05). An association of LAAF <46.9 cm/s and PAF was marginal (p = 0.09). The specificity of the combined finding of SEC and/or LAAF with that of LAD increased up to 90%, while that of LAD alone was 70%. CONCLUSIONS The findings of TEE during hospitalization may be useful for identifying patients at increased risk of CPAF in patients with ESUS.
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Affiliation(s)
- Yuichiro Ohya
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan,
| | - Masato Osaki
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Juro Jinnouchi
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Takayuki Matsuki
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Satomi Mezuki
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Masaya Kumamoto
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Makoto Kanazawa
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Naoki Tagawa
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shuji Arakawa
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
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Tsivgoulis G, Katsanos AH, Köhrmann M, Caso V, Perren F, Palaiodimou L, Deftereos S, Giannopoulos S, Ellul J, Krogias C, Mavridis D, Triantafyllou S, Alexandrov AW, Schellinger PD, Alexandrov AV. Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis. J Stroke 2019; 21:302-311. [PMID: 31590474 PMCID: PMC6780018 DOI: 10.5853/jos.2019.01067] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/04/2019] [Accepted: 06/14/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Current guidelines do not provide firm directions on atrial fibrillation (AF) screening after ischemic stroke (IS). We sought to investigate the association of implantable cardiac monitoring (ICM) duration with the yield of AF detection in IS patients. METHODS We included studies reporting AF detection rates by ICM in IS patients with negative initial AF screening. We excluded studies reporting prolonged cardiac monitoring with devices other than ICM, not providing AF detection rates or monitoring duration, and reporting overlapping data for the same population. The random-effects model was used for all pooled estimates and meta-regression analyses. RESULTS We included 28 studies (4,531 patients, mean age 65 years). In meta-regression analyses, the proportion of AF detection by ICM was independently associated with monitoring duration (coefficient=0.015; 95% confidence interval [CI], 0.005 to 0.024) and mean patient age (coefficient=0.009; 95% CI, 0.003 to 0.015). No associations were detected with other patient characteristics, including IS subtype (cryptogenic vs. embolic stroke of undetermined source) or time from IS onset to CM implantation. In subgroup analyses, significant differences (P<0.001) in the AF detection rates were found for ICM duration (<6 months: 5% [95% CI, 3% to 6%]; ≥6 and ≤12 months: 21% [95% CI, 16% to 25%]; >12 and ≤24 months: 26% [95% CI, 22% to 31%]; >24 months: 34% [95% CI, 29% to 39%]). CONCLUSION s Extended duration of ICM monitoring and increased patient age are factors that substantially increase AF detection in IS patients with initial negative AF screening.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H. Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Valeria Caso
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Fabienne Perren
- Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Deftereos
- Second Department of Cardiology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Sokratis Triantafyllou
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anne W. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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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.
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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
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Abdelghani M, El-Shedoudy SAO, Nassif M, Bouma BJ, de Winter RJ. Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update. Cardiology 2019; 143:62-72. [PMID: 31307049 DOI: 10.1159/000501028] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
Abstract
Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.
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Affiliation(s)
- Mohammad Abdelghani
- Heart Center, Segeberger Kliniken, Bad Segeberg, Germany, .,Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands, .,Department of Cardiology, Al-Azhar University, Cairo, Egypt,
| | | | - Martina Nassif
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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