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Khenkina N, Aimo A, Fabiani I, Masci PG, Sagris D, Williams SE, Mavraganis G, Chen HS, Wintermark M, Michel P, Ntaios G, Georgiopoulos G. Magnetic resonance imaging for diagnostic workup of embolic stroke of undetermined source: A systematic review. Int J Stroke 2024; 19:293-304. [PMID: 37435743 DOI: 10.1177/17474930231189946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) refers to ischemic stroke where the underlying cause of thromboembolism cannot be found despite the recommended diagnostic workup. Unidentified source of emboli hinders clinical decision-making and patient management with detrimental consequences on long-term prognosis. The rapid development and versatility of magnetic resonance imaging (MRI) make it an appealing addition to the diagnostic routine of patients with ESUS for the assessment of potential vascular and cardiac embolic sources. AIMS To review the use of MRI in the identification of cardiac and vascular embolic sources in ESUS and to assess the reclassification value of MRI examinations added to the conventional workup of ESUS. SUMMARY OF REVIEW We reviewed the use of cardiac and vascular MRI for the identification of a variety of embolic sources associated with ESUS, including atrial cardiomyopathy, left ventricular pathologies, and supracervical atherosclerosis in carotid and intracranial arteries and in distal thoracic aorta. The additional reclassification after MRI examinations added to the workup of patients with ESUS ranged from 6.1% to 82.3% and varied depending on the combination of imaging modalities. CONCLUSION MRI techniques allow us to identify additional cardiac and vascular embolic sources and may further decrease the prevalence of patients with the diagnosis of ESUS.
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Affiliation(s)
- Natallia Khenkina
- Postgraduate School of Diagnostic and Interventional Radiology, University of Milan, Milan, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Pier Giorgio Masci
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Dimitrios Sagris
- Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | - George Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Georgios Georgiopoulos
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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Ischaemic events in hypertrophic cardiomyopathy patients with and without atrial fibrillation: a systematic review and meta-analysis. J Thromb Thrombolysis 2023; 55:83-91. [PMID: 36192663 DOI: 10.1007/s11239-022-02713-6] [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] [Accepted: 09/22/2022] [Indexed: 10/10/2022]
Abstract
Hypertrophic cardiomyopathy predisposes to acute cerebrovascular events including ischaemic stroke, transient ischaemic attack and systemic thromboembolism. Atrial fibrillation confers even higher risk. We aim to report the incidence of these complications and to investigate the impact of atrial fibrillation on the ischaemic risk in patients with hypertrophic cardiomyopathy. A literature search was performed on PubMed, Scopus, Embase/Ovid and Cochrane library from inception to 20th March 2021. We compared the incidence of ischaemic strokes, transient ischaemic attack, non-specified thromboembolism events and systemic thromboembolism in hypertrophic cardiomyopathy patients with or without atrial fibrillation. Non-specified thromboembolism events in our paper referred to thromboembolic events whereby types were not specified in the studies. Meta-analysis was performed using StataSE 16 software, and heterogeneity was assessed using I2 test. A total of 713 studies were identified. Thirty-five articles with 42,570 patients were included. The pooled incidence of stroke/ transient ischaemic attack was 7.45% (95% confidence interval [CI] 5.80-9.52, p < 0.001) across 24 studies with a total of 37,643 hypertrophic cardiomyopathy patients. Atrial fibrillation significantly increased the risk of total stroke/ transient ischaemic attack (Risk Ratio 3.26, 95% CI 1.75-6.08, p < 0.001, I2 = 76.0). The incidence of stroke/ transient ischaemic attack was 9.30% (95% CI 6.64-12.87, p = 0.316) in the apical hypertrophic cardiomyopathy subgroup. Concomitant atrial fibrillation in hypertrophic cardiomyopathy increases the risk of thromboembolic events including ischaemic stroke and transient ischaemic attack. The apical subgroup shows a similar risk of acute cerebrovascular events as the overall hypertrophic cardiomyopathy population.
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Komatsu J, Imai RI, Nakaoka Y, Nishida K, Seki SI, Kubo T, Yamasaki N, Kitaoka H, Kubokawa SI, Kawai K, Hamashige N, Doi YL. Importance of Paroxysmal Atrial Fibrillation and Sex Differences in the Prevention of Embolic Stroke in Hypertrophic Cardiomyopathy. Circ Rep 2021; 3:273-278. [PMID: 34007941 PMCID: PMC8099667 DOI: 10.1253/circrep.cr-20-0101] [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] [Indexed: 11/23/2022] Open
Abstract
Background:
Although atrial fibrillation (AF) is a well-known risk factor for embolic stroke in hypertrophic cardiomyopathy (HCM), there is a paucity of information derived from HCM patients who have experienced embolic stroke. Methods and Results:
From 141 consecutive HCM patients who had been hospitalized between 2000 and 2018, the clinical characteristics and management of 86 patients with AF were analyzed retrospectively. The incidence of embolic stroke was 36% (n=31 patients). The median (interquartile range) age of embolic stroke was younger in male than female HCM patients (71 [64–80] vs. 83 [77–87] years, respectively; P=0.009). The prevalence of paroxysmal AF (74%) was significantly higher than that of chronic AF (26%) in 31 patients with embolic stroke (P=0.007). The CHADS2
score in patients with embolic stroke was not particularly useful in predicting the occurrence of embolic stroke. Conclusions:
One-third of HCM patients with AF developed embolic stroke, and male HCM patients were younger at the time of the embolic stroke than female HCM patients. The prevalence of paroxysmal AF was significantly higher than that of chronic AF in patients with AF and embolic stroke. Early introduction of anticoagulation therapy is recommended at the first documentation of paroxysmal AF.
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Affiliation(s)
- Junya Komatsu
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoko Nakaoka
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Koji Nishida
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shu-Ichi Seki
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Toru Kubo
- Department of Cardiology and Aging Science, Kochi Medial School Kochi Japan
| | - Naohito Yamasaki
- Department of Cardiology and Aging Science, Kochi Medial School Kochi Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Aging Science, Kochi Medial School Kochi Japan
| | | | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoshinori L Doi
- Department of Cardiology, Chikamori Hospital Kochi Japan.,Cardiomyopathy Institute, Chikamori Hospital Kochi Japan
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Cardiovascular magnetic resonance imaging and its role in the investigation of stroke: an update. J Neurol 2021; 268:2597-2604. [PMID: 33439327 DOI: 10.1007/s00415-020-10393-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 01/17/2023]
Abstract
Recent advances in complementary diagnostic exams have helped to clarify stroke etiology, not only by helping to confirm established stroke causes but also by unveiling new possible stroke mechanisms. Etiological investigation for cardioembolic stroke has benefited in the last years from information provided by studies analysing serum biomarkers, heart rhythm monitoring and imaging methods like cardiovascular magnetic resonance (CMR) imaging. CMR has been particularly important for the characterization of possible new cardioembolic stroke mechanisms including atrial cardiomyopathy, silent myocardial infarction and cardiomyopathies.
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Fonseca AC, Almeida AG, Santos MO, Ferro JM. Neurological complications of cardiomyopathies. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:91-109. [PMID: 33632460 DOI: 10.1016/b978-0-12-819814-8.00001-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
There is a multifaceted relationship between the cardiomyopathies and a wide spectrum of neurological disorders. Severe acute neurological events, such as a status epilepticus and aneurysmal subarachnoid hemorrhage, may result in an acute cardiomyopathy the likes of Takotsubo cardiomyopathy. Conversely, the cardiomyopathies may result in a wide array of neurological disorders. Diagnosis of a cardiomyopathy may have already been established at the time of the index neurological event, or the neurological event may have prompted subsequent cardiac investigations, which ultimately lead to the diagnosis of a cardiomyopathy. The cardiomyopathies belong to one of the many phenotypes of complex genetic diseases or syndromes, which may also involve the central or peripheral nervous systems. A number of exogenous agents or risk factors such as diphtheria, alcohol, and several viruses may result in secondary cardiomyopathies accompanied by several neurological manifestations. A variety of neuromuscular disorders, such as myotonic dystrophy or amyloidosis, may demonstrate cardiac involvement during their clinical course. Furthermore, a number of genetic cardiomyopathies phenotypically incorporate during their clinical evolution, a gamut of neurological manifestations, usually neuromuscular in nature. Likewise, neurological complications may be the result of diagnostic procedures or medications for the cardiomyopathies and vice versa. Neurological manifestations of the cardiomyopathies are broad and include, among others, transient ischemic attacks, ischemic strokes, intracranial hemorrhages, syncope, muscle weakness and atrophy, myotonia, cramps, ataxia, seizures, intellectual developmental disorder, cognitive impairment, dementia, oculomotor palsies, deafness, retinal involvement, and headaches.
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Affiliation(s)
- Ana Catarina Fonseca
- Neurology Service, Hospital Santa Maria, Centro Hospitalar Lisboa Norte and Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Ana G Almeida
- Cardiology Service, Hospital Santa Maria, Centro Hospitalar Lisboa Norte and Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Miguel Oliveira Santos
- Neurology Service, Hospital Santa Maria, Centro Hospitalar Lisboa Norte and Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - José M Ferro
- Neurology Service, Hospital Santa Maria, Centro Hospitalar Lisboa Norte and Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
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Liu L, Liu Z, Chen X, He S. Thromboembolism in Patients with Hypertrophic Cardiomyopathy. Int J Med Sci 2021; 18:727-735. [PMID: 33437207 PMCID: PMC7797548 DOI: 10.7150/ijms.50167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/18/2020] [Indexed: 02/05/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is an inherited cardiac disease, which has a marked heterogeneity in clinical expression, natural history, and prognosis. HCM is associated with a high prevalence of thromboembolic events (stroke and systemic embolic events), even if taking no account of atrial fibrillation (AF), leading to unexpected disability and death in patients of all ages. Several risk factors of thromboembolism such as AF, greater age, left atrial diameter, heart failure and others have been confirmed in patients with HCM. Conventional thromboembolic predictive models were estimated by several trials in HCM population but it turned out to be unsatisfactory. Based on those previous explorations, researchers tried to modify or develop novel models suitable for HCM population in thromboembolism prediction. In consideration of catastrophic advent events of thromboembolism, current guidelines have recommended life-long anticoagulant therapy after a single short AF. Therefore, early identification of risk factors for thromboembolism, accurate risk stratification, timely preventive measures and aggressive management may help to avoid serious adverse thromboembolic events in HCM population.
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Affiliation(s)
- Lu Liu
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Zheng Liu
- Nursing Department, West China School of Nursing, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoping Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Sen He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
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Okumura T, Kimura Y, Murohara T. Prediction of Thromboembolism in Patients With Hypertrophic Cardiomyopathy. Circ J 2020; 84:700-701. [PMID: 32281558 DOI: 10.1253/circj.cj-20-0250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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