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Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
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2
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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Austein F, Eden M, Both M, Salehi Ravesh M, Jansen O, Langguth P. In Reply: Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke. Clin Neuroradiol 2021; 31:923-924. [PMID: 34228139 PMCID: PMC8648679 DOI: 10.1007/s00062-021-01045-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Friederike Austein
- Department of Neuroradiological Intervention and Diagnostics, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias Eden
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Marcus Both
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Mona Salehi Ravesh
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Patrick Langguth
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany.,Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.,Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany.,University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany. .,Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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Predictive Value of Cardiac CTA, Cardiac MRI, and Transthoracic Echocardiography for Cardioembolic Stroke Recurrence. AJR Am J Roentgenol 2021; 217:336-346. [PMID: 32936016 DOI: 10.2214/ajr.20.23903] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Transthoracic echocardiography (TTE) is the standard of care for initial evaluation of patients with suspected cardioembolic stroke. Although TTE is useful for assessing certain sources of cardiac emboli, its diagnostic capability is limited in the detection of other sources, including left atrial thrombus and aortic plaques. OBJECTIVE. The purpose of this article was to investigate sensitivity, specificity, and predictive value of cardiac CTA (CCTA), cardiac MRI (CMRI), and TTE for recurrence in patients with suspected cardioembolic stroke. METHODS. We retrospectively included 151 patients with suspected cardioembolic stroke who underwent TTE and either CMRI (n = 75) or CCTA (n = 76) between January 2013 and May 2017. We evaluated for the presence of left atrial thrombus, left ventricular thrombus, vulnerable aortic plaque, cardiac tumors, and valvular vegetation as causes of cardioembolic stroke. The end point was stroke recurrence. Sensitivity, specificity, PPV, and NPV for recurrent stroke were calculated; the diagnostic accuracy of CMRI, CCTA, and TTE was compared between and within groups using AUC. RESULTS. Twelve and 14 recurrent strokes occurred in the CCTA and CMRI groups, respectively. Sensitivity, specificity, PPV, and NPV were 33.3%, 93.7%, 50.0%, and 88.2% for CCTA; 14.3%, 80.3%, 14.3%, and 80.3% for CMRI; 14.3%, 83.6%, 16.7%, and 80.9% for TTE in the CMRI group; and 8.3%, 93.7%, 20.0%, and 84.5% for TTE in the CCTA group. Accuracy was not different (p > .05) between CCTA (AUC = 0.63; 95% CI, 0.49-0.77), CMRI (0.53; 95% CI, 0.42-0.63), TTE in the CMRI group (0.51; 95% CI, 0.40-0.61), and TTE in the CCTA group (0.51; 95% CI, 0.42-0.59). In the CCTA group, atrial and ventricular thrombus were detected by CCTA in three patients and TTE in one patient; in the CMRI group, thrombus was detected by CMRI in one patient and TTE in two patients. CONCLUSION. CCTA, CMRI, and TTE showed comparably high specificity and NPV for cardioembolic stroke recurrence. CCTA and CMRI may be valid alternatives to TTE. CCTA may be preferred given potentially better detection of atrial and ventricular thrombus. CLINICAL IMPACT. CCTA and CMRI have similar clinical performance as TTE for predicting cardioembolic stroke recurrence. This observation may be especially important when TTE provides equivocal findings.
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Coronary CTA to Investigate Predictive Value of Left Atrial Appendage for Cardiogenic Stroke in Patients with Nonvalvular Atrial Fibrillation. BIOMED RESEARCH INTERNATIONAL 2021; 2020:7351876. [PMID: 33123585 PMCID: PMC7584971 DOI: 10.1155/2020/7351876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To investigate the predictive value of changes in LAA size and function for cardiogenic stroke (CS) in patients with NVAF by coronary CTA examination. Materials and Method. 179 patients with NVAF were selected and grouped according to the outbreak of acute ischemic stroke and TIA within 2 years after coronary CTA examination. Those who met the criteria for CS were selected as cases (87 patients), and those neither stroke nor TIA as controls (92 patients). LAA size of selected patients was measured and data postprocessing was performed. The differences of baseline data and LAA parameters between groups were analyzed. The impacts of BMI, hyperlipidemia, the duration of AF, the LAAOA Index, and the LAAEF on CS were assessed by binary logistic regression. The predictive abilities of LAAOA Index, LAAEF, and the combined predictor were assessed by ROC curves. RESULTS Proportions of BMI ≥ 25, prevalence of hyperlipidemia, duration of AF, and LAAODmax, LAAODmin, LAAOA, LAAVmax, and LAAVmin with their correction index were greater in cases than controls. The LAAEF was lower in cases than that in controls. The binary logistic regression model showed an increase in LAAOA Index (P = 0.005) and a decrease in LAAEF (P < 0.001) were independent risk factors for CS. ROC curve analysis showed that the optimal cutoff values of LAAOA Index and LAAEF to predict CS were 3.16 cm2/m2 and 38.71%, with AUC value of 0.712 and 0.734, respectively. The LAAOA Index-LAAEF combined predictor (AUC value = 0.786) was likely superior to either LAAOA Index or LAAEF. CONCLUSIONS Coronary CTA can provide additional valuable parameters, as a by-product of coronary artery assessment without additional radiation dose, for the risk assessment of CS in patients with NVAF. Coronary CTA may make up for the limitation of single indicator of CHA2DS2-VASc in guiding anticoagulation program, to reduce the incidence of embolism and bleeding events.
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Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke : A Proof of Concept Study. Clin Neuroradiol 2021; 31:911-920. [PMID: 33688981 PMCID: PMC8648696 DOI: 10.1007/s00062-021-01003-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/08/2021] [Indexed: 12/21/2022]
Abstract
Purpose Recurrent stroke is considered to increase the incidence of severe disability and death. For correct risk assessment and patient management it is essential to identify the origin of stroke at an early stage. Transthoracic echocardiography (TTE) is the initial standard of care for evaluating patients in whom a cardioembolic source of stroke (CES) is suspected but its diagnostic capability is limited. Transesophageal echocardiography (TEE) is considered as gold standard; however, this approach is time consuming, semi-invasive and not always feasible. We hypothesized that adding a delayed-phase cardiac computed tomography (cCT) to initial multimodal CT might represent a valid alternative to routine clinical echocardiographic work-up. Material and Methods Patients with suspected acute cardioembolic stroke verified by initial multimodal CT and subsequently examined with cCT were included. The cCT was evaluated for presence of major CES and compared to routine clinical echocardiographic work-up. Results In all, 102 patients with suspected acute CES underwent cCT. Among them 60 patients underwent routine work-up with echocardiography (50 TTE and only 10 TEE). By cCT 10/60 (16.7%) major CES were detected but only 4 (6.7%) were identified by echocardiography. All CES observed by echocardiography were also detected by cCT. In 8 of 36 patients in whom echocardiography was not performed cCT also revealed a major CES. Conclusion These preliminary results show the potential diagnostic yield of delayed-phase cCT to detect major CES and therefore could accelerate decision-making to prevent recurrence stroke. To confirm these results larger studies with TEE as the reference standard and also compared to TTE would be necessary.
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Markus A, Valerie S, Mira K. Promising Biomarker Candidates for Cardioembolic Stroke Etiology. A Brief Narrative Review and Current Opinion. Front Neurol 2021; 12:624930. [PMID: 33716927 PMCID: PMC7947187 DOI: 10.3389/fneur.2021.624930] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 01/09/2023] Open
Abstract
Determining the cause of stroke is considered one of the main objectives in evaluating a stroke patient in clinical practice. However, ischemic stroke is a heterogeneous disorder and numerous underlying disorders are implicated in its pathogenesis. Although progress has been made in identifying individual stroke etiology, in many cases underlying mechanisms still remain elusive. Since secondary prevention strategies are tailored toward individual stroke mechanisms, patients whose stroke etiology is unknown may not receive optimal preventive treatment. Cardioembolic stroke is commonly defined as cerebral vessel occlusion by distant embolization arising from thrombus formation in the heart. It accounts for the main proportion of ischemic strokes, and its share to stroke etiology is likely to rise even further in future decades. However, it can be challenging to distinguish cardioembolism from other possible etiologies. As personalized medicine advances, stroke researchers' focus is increasingly drawn to etiology-associated biomarkers. They can provide deeper insight regarding specific stroke mechanisms and can help to unravel previously undetected pathologies. Furthermore, etiology-associated biomarkers could play an important role in guiding future stroke prevention strategies. To achieve this, broad validation of promising candidate biomarkers as well as their implementation in well-designed randomized clinical trials is necessary. This review focuses on the most-promising candidates for diagnosis of cardioembolic stroke. It discusses existing evidence for possible clinical applications of these biomarkers, addresses current challenges, and outlines future perspectives.
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Affiliation(s)
- Arnold Markus
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Schütz Valerie
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Katan Mira
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
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9
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NODA R, TAMAI Y, INOUE M, HARA T. Cerebral Infarction Due to Aortic Mural Thrombus in a Non-atherosclerotic Ascending Aorta, Detected by Cardiac CT. NMC Case Rep J 2021; 8:325-330. [PMID: 35079483 PMCID: PMC8769395 DOI: 10.2176/nmccrj.cr.2020-0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/26/2020] [Indexed: 11/27/2022] Open
Abstract
Aortic mural thrombus (AMT) in the ascending aorta is a rare source of embolism. Recently, the usefulness of contrast computed tomography (CT) has been reported, and we sought to examine the differences between cardiac CT and CT angiography (CTA). A 58-year-old patient of acute embolic infarction was treated by endovascular thrombectomy. Postoperative cardiac CT revealed the AMT as an embolic source. The lesion was not detected by the CTA performed 2 days before. This is the first case report of AMT to highlight the apparent utility of cardiac CT. Although trans-esophageal echocardiogram (TEE) is still the first choice for routine embolic exploration, cardiac CT may play a role as an alternative tool aimed to detect small size AMT.
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Affiliation(s)
- Ryuichi NODA
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
- Department of Neurosurgery, NTT Medical Center, Tokyo, Japan
| | - Yuta TAMAI
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Masato INOUE
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Tetsuo HARA
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
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10
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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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11
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Lionnet A, Cueff C, de Gaalon S, Manigold T, Sévin M, Testard N, Guillon B. Cause cardiache di embolia cerebrale. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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12
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Hellwig S, Grittner U, Elgeti M, Wyschkon S, Nagel SN, Fiebach JB, Krause T, Herm J, Scheitz JF, Endres M, Nolte CH, Haeusler KG, Elgeti T. Evaluation of left ventricular function in patients with acute ischaemic stroke using cine cardiovascular magnetic resonance imaging. ESC Heart Fail 2020; 7:2572-2580. [PMID: 32667736 PMCID: PMC7524103 DOI: 10.1002/ehf2.12833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/05/2020] [Accepted: 05/27/2020] [Indexed: 01/09/2023] Open
Abstract
Aims Heart failure (HF) is frequent in patients with acute ischaemic stroke (AIS) and associated with higher morbidity and mortality. Assessment of cardiac function in AIS patients using cardiovascular MRI (CMR) may help to detect HF. We report the rate of systolic and diastolic dysfunction in a cohort of patients with AIS using CMR and compare cine real‐time (CRT) sequences with the reference of segmented cine steady‐state free precession sequences. Methods and results Patients with AIS without known atrial fibrillation were prospectively enrolled in the HEart and BRain Interfaces in Acute Ischemic Stroke (HEBRAS) study (NCT 02142413) and underwent CMR at 3 Tesla within 7 days after AIS. Validity of CRT sequences was determined in 50 patients. A total of 229 patients were included in the analysis (mean age 66 years; 35% women; HF 2%). Evaluation of cardiac function was successful in 172 (75%) patients. Median time from stroke onset to CMR was 82 h (interquartile range 56–111) and 54 h (interquartile range 31–78) from cerebral MRI to CMR. Systolic dysfunction was observed in 43 (25%) and diastolic dysfunction in 102 (59%) patients. Diagnostic yield was similar using CRT or segmented cine imaging (no significant difference in left ventricular ejection fraction, myocardial mass, time to peak filling rate, and peak filling rate ratio E/A). Intraobserver and interobserver agreement was high (κ = 0.78–1.0 for all modalities). Conclusions Cardiovascular MRI at 3 Tesla is an appropriate method for the evaluation of cardiac function in a selected cohort of patients with AIS. Systolic and diastolic dysfunction is frequent in these patients. CRT imaging allows reliable assessment of systolic and diastolic function.
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Affiliation(s)
- Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Matthias Elgeti
- Jules Stein Eye Institute and Department for Chemistry and Biochemistry, University of California, Los Angeles, CA, USA
| | - Sebastian Wyschkon
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian N Nagel
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Juliane Herm
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Diseases (DZHK), partner site Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Diseases (DZHK), partner site Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Diseases (DZHK), partner site Berlin, Berlin, Germany
| | | | - Thomas Elgeti
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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13
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Aljizeeri A, Small G, Malhotra S, Buechel R, Jain D, Dwivedi G, Al-Mallah MH. The role of cardiac imaging in the management of non-ischemic cardiovascular diseases in human immunodeficiency virus infection. J Nucl Cardiol 2020; 27:801-818. [PMID: 30864047 DOI: 10.1007/s12350-019-01676-1] [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: 02/04/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
Infection with human immunodeficiency virus (HIV) has become the pandemic of the new century. About 36.9 million people are living with HIV worldwide. The introduction of antiretroviral therapy in 1996 has dramatically changed the global landscape of HIV care, resulting in significantly improved survival and changing HIV to a chronic disease. With near-normal life expectancy, contemporary cardiac care faces multiple challenges of cardiovascular diseases, disorders specific to HIV/AIDS, and those related to aging and higher prevalence of traditional risk factors. Non-ischemic cardiovascular diseases are major components of cardiovascular morbidity and mortality in HIV/AIDS. Non-invasive cardiac imaging plays a pivotal role in the management of these diseases. This review summarizes the non-ischemic presentation of the HIV cardiovascular spectrum focusing on the role of cardiac imaging in the management of these disorders.
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Affiliation(s)
- Ahmed Aljizeeri
- King Abdulaziz Cardiac Center, Ministry of National Guard-Health Affaire, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Gary Small
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Ronny Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Diwakar Jain
- Division of Cardiology and Nuclear Medicine, New York Medical College/Westchester Medical Center, Hawthorne, NY, USA
| | - Girish Dwivedi
- Fiona Stanley Hospital, Murdoch, WA, Australia
- Harry Perkins Institute of Medical Research, Murdoch, WA, Australia
- The University of Western Australia, Crawley, WA, Australia
| | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, 6565 Fannin Street, Smith-19, Houston, TX, 77030, USA.
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14
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Groeneveld NS, Guglielmi V, Leeflang MMG, Matthijs Boekholdt S, Nils Planken R, Roos YBWEM, Majoie CBLM, Coutinho JM. CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis. J Neurol 2020; 267:1793-1801. [PMID: 32140869 PMCID: PMC7293690 DOI: 10.1007/s00415-020-09766-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac thrombi are an important cause of embolic stroke. We studied the diagnostic yield and diagnostic accuracy of cardiac CT angiography (CTA) compared to echocardiography for detection of cardiac thrombi in ischemic stroke patients. METHODS We performed a systematic review and meta-analysis of the literature on cardiac CTA versus echocardiography for detection of cardiac thrombi in ischemic stroke patients. We included studies (N ≥ 20) in which both cardiac CTA (index test) and echocardiography (reference test) were performed and data on cardiac thrombi were reported. Results were stratified for type of echocardiography: transesophageal (TEE) vs transthoracic (TTE). RESULTS Out of 1530 studies, 14 were included (all single center cohort studies), with data on 1568 patients. Mean age varied between 52 and 69 years per study and 66% were men. Reported time intervals ranged from 0 to 21 days between stroke and first test, and from 0 to 199 days between tests. In ten studies that compared CTA to TEE, CTA detected cardiac thrombi in 87/1385 (6.3%) patients versus 68/1385 (4.9%) on TEE (p < 0.001). In four studies comparing CTA to TTE, CTA detected thrombi in 23/183 (12.5%) patients versus 12/183 (6.6%) on TTE (p = 0.010). Pooled sensitivity and specificity of CTA versus TEE were 86.0% (95% CI 65.6-95.2) and 97.4% (95% CI 95.0-98.7), respectively. CONCLUSIONS CTA may be a promising alternative to echocardiography for detection of cardiac thrombi in patients with ischemic stroke, especially now that CTA is standard care for patient selection for endovascular treatment. However, studies were too heterogeneous and of insufficient methodological quality to draw firm conclusions. Large, prospective studies on this topic are warranted.
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Affiliation(s)
| | - Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariska M G Leeflang
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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15
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Understanding Atrial Cardiopathy: an Under-Recognized Contributor to Cardioembolic Stroke. Curr Treat Options Neurol 2019; 21:32. [DOI: 10.1007/s11940-019-0571-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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16
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What is Clinical Efficacy of Transesophageal Echocardiography in Patients With Cryptogenic Stroke? Neurologist 2018; 23:30-33. [DOI: 10.1097/nrl.0000000000000155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Liberman AL, Kalani RE, Aw-Zoretic J, Sondag M, Daruwalla VJ, Mitter SS, Bernstein R, Collins JD, Prabhakaran S. Cardiac magnetic resonance imaging has limited additional yield in cryptogenic stroke evaluation after transesophageal echocardiography. Int J Stroke 2017; 12:946-952. [DOI: 10.1177/1747493017706242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The use of cardiac magnetic resonance imaging is increasing, but its role in the diagnostic work-up following ischemic stroke has received limited study. We aimed to explore the added yield of cardiac magnetic resonance imaging to identify cardio-aortic sources not detected by transesophageal echocardiography among patients with cryptogenic stroke. Methods A retrospective single-center cohort study was performed from 01 January 2009 to 01 March 2013. Consecutive patients who had both a stroke protocol cardiac magnetic resonance imaging and a transesophageal echocardiography preformed during a single hospitalization were included. All cardiac magnetic resonance imaging studies underwent independent, blinded review by two investigators. We applied the causative classification system for ischemic stroke to all patients, first blinded to cardiac magnetic resonance imaging results; we then reapplied the causative classification system using cardiac magnetic resonance imaging. Standard statistical tests to evaluate stroke subtype reclassification rates were used. Results Ninety-three patients were included in the final analysis; 68.8% were classified as cryptogenic stroke after initial diagnostic evaluation. Among patients with cryptogenic stroke, five (7.8%) were reclassified due to cardiac magnetic resonance imaging findings: one was reclassified as “cardio-aortic embolism evident” due to the presence of a patent foramen ovale and focal cardiac infarct and four were reclassified as “cardio-aortic embolism possible” due to mitral valve thickening (n = 1) or hypertensive cardiomyopathy (n = 3). Overall, findings on cardiac magnetic resonance imaging reduced the percentage of patients with cryptogenic stroke by slightly more than 1%. Conclusion Our stroke subtype reclassification rate after the addition of cardiac magnetic resonance imaging results to a diagnostic work-up which includes transesophageal echocardiography was very low. Prospective studies evaluating the role of cardiac magnetic resonance imaging and transesophageal echocardiography among patients with cryptogenic stroke should be considered.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rizwan E Kalani
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Jessie Aw-Zoretic
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew Sondag
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vistasp J Daruwalla
- Department of Radiology, Conemaugh Memorial Medical Center, Temple University, Johnstown, PA, USA
| | - Sumeet S Mitter
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard Bernstein
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeremy D Collins
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Impact of Implementing Cardiac CT in Evaluating Patients Suspected of Cardioembolic Stroke. J Comput Assist Tomogr 2017; 40:380-6. [PMID: 26854417 DOI: 10.1097/rct.0000000000000369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES In practice, clinical and logistic hurdles may hamper performing transesophageal echocardiography in stroke patients. Cardiac computed tomography (CT) is a recently introduced noninvasive modality able to detect various embolic causes. Thus, we retrospectively assessed possible added values of applying cardiac CT in the real-world work-up of suspected cardioembolic stroke cases. METHODS Forty-seven patients were neurology service referrals for suspected cardioembolic stroke. The CT images and clinical reports of our cardiac CT radiologists were retrospectively evaluated. Cardiac CT was assessed in terms of detecting major embolic potential findings, potentially significant stroke-unrelated findings, and coronary arterial disease (CAD). Computed tomography results were correlated with echocardiographic reports. RESULTS Cardiac CT showed findings of major embolic potential in 10 patients (21%, 5 thrombi cases, 2 vasculitis cases, 1 case of metastasis invading the left superior pulmonary artery, 1 myocardial infarction case, and 1 pulmonary arteriovenous malformations case), none of which were documented in echocardiography reports. Two cases (4%) with findings of major embolic potential where identified on echocardiography but not on CT (1 left atrial appendage thrombus and 1 mitral valve vegetation). Computed tomography of 13 patients (28%) showed 16 potentially significant stroke-unrelated findings. Twenty-one patients (47%) had unexpected CAD on CT, 11 (52%) of which were obstructive. CONCLUSIONS Implementing cardiac CT in assessing patients suspected of cardioembolic stroke added value to echocardiographic evaluation, by detecting major embolic potential findings. In addition, cardiac CT revealed additional potentially significant stroke-unrelated findings and CAD.
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19
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Yaghi S, Liberman AL, Atalay M, Song C, Furie KL, Kamel H, Bernstein RA. Cardiac magnetic resonance imaging: a new tool to identify cardioaortic sources in ischaemic stroke. J Neurol Neurosurg Psychiatry 2017; 88:31-37. [PMID: 27659922 DOI: 10.1136/jnnp-2016-314023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/19/2016] [Accepted: 09/06/2016] [Indexed: 12/27/2022]
Abstract
Stroke of undetermined aetiology or 'cryptogenic' stroke accounts for 30-40% of ischaemic strokes despite extensive diagnostic evaluation. The role and yield of cardiac imaging is controversial. Cardiac MRI (CMR) has been used for cardiac disorders, but its use in cryptogenic stroke is not well established. We reviewed the literature (randomised trials, exploratory comparative studies and case series) on the use of CMR in the diagnostic evaluation of patients with ischaemic stroke. The literature on the use of CMR in the diagnostic evaluation of ischaemic stroke is sparse. However, studies have demonstrated a potential role for CMR in the diagnostic evaluation of patients with cryptogenic stroke to identify potential aetiologies such as cardiac thrombi, cardiac tumours, aortic arch disease and other rare cardiac anomalies. CMR can also provide data on certain functional and structural parameters of the left atrium and the left atrial appendage which have been shown to be associated with ischaemic stroke risk. CMR is a non-invasive modality that can help identify potential mechanisms in cryptogenic stroke and patients who may be targeted for enrolment into clinical trials comparing anticoagulation to antiplatelet therapy in secondary stroke prevention. Prospective studies are needed to compare the value of CMR as compared to transthoracic and transesophageal echocardiography in the diagnostic evaluation of cryptogenic stroke.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ava L Liberman
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Atalay
- Department of Radiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher Song
- Division of Cardiology, Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hooman Kamel
- Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York, USA
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
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20
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Katsanos AH, Bhole R, Frogoudaki A, Giannopoulos S, Goyal N, Vrettou AR, Ikonomidis I, Paraskevaidis I, Pappas K, Parissis J, Kyritsis AP, Alexandrov AW, Triantafyllou N, Malkoff MD, Voumvourakis K, Alexandrov AV, Tsivgoulis G. The value of transesophageal echocardiography for embolic strokes of undetermined source. Neurology 2016; 87:988-95. [PMID: 27488602 DOI: 10.1212/wnl.0000000000003063] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/18/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Our aim was to evaluate the diagnostic yield of transesophageal echocardiography (TEE) in consecutive patients with ischemic stroke (IS) fulfilling the diagnostic criteria of embolic strokes of undetermined source (ESUS). METHODS We prospectively evaluated consecutive patients with acute IS satisfying ESUS criteria who underwent in-hospital TEE examination in 3 tertiary care stroke centers during a 12-month period. We also performed a systematic review and meta-analysis estimating the cumulative effect of TEE findings on therapeutic management for secondary stroke prevention among different IS subgroups. RESULTS We identified 61 patients with ESUS who underwent investigation with TEE (mean age 44 ± 12 years, 49% men, median NIH Stroke Scale score = 5 points [interquartile range: 3-8]). TEE revealed additional findings in 52% (95% confidence interval [CI]: 40%-65%) of the study population. TEE findings changed management (initiation of anticoagulation therapy, administration of IV antibiotic therapy, and patent foramen ovale closure) in 10 (16% [95% CI: 9%-28%]) patients. The pooled rate of reported anticoagulation therapy attributed to abnormal TEE findings among 3,562 acute IS patients included in the meta-analysis (12 studies) was 8.7% (95% CI: 7.3%-10.4%). In subgroup analysis, the rates of initiation of anticoagulation therapy on the basis of TEE investigation did not differ (p = 0.315) among patients with cryptogenic stroke (6.9% [95% CI: 4.9%-9.6%]), ESUS (8.1% [95% CI: 3.4%-18.1%]), and IS (9.4% [95% CI: 7.5%-11.8%]). CONCLUSIONS Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.
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Affiliation(s)
- Aristeidis H Katsanos
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Rohini Bhole
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Alexandra Frogoudaki
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Sotirios Giannopoulos
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Nitin Goyal
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Agathi-Rosa Vrettou
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Ignatios Ikonomidis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Ioannis Paraskevaidis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Konstantinos Pappas
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - John Parissis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Athanassios P Kyritsis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Anne W Alexandrov
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Nikos Triantafyllou
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Marc D Malkoff
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Konstantinos Voumvourakis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Andrei V Alexandrov
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - Georgios Tsivgoulis
- From the Department of Neurology (A.H.K., S.G., A.P.K.) and Second Department of Cardiology (K.P.), University Hospital of Ioannina, School of Medicine, University of Ioannina; Second Department of Neurology (A.H.K., K.V., G.T.) and Second Department of Cardiology (A.F., A.-R.V., I.I., I.P., J.P.), Attikon University Hospital, School of Medicine, University of Athens, Greece; Department of Neurology (R.B., N.G., A.W.A., M.D.M., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Australian Catholic University (A.W.A.), Sydney, Australia; First Department of Neurology (N.T.), Eginition University Hospital, School of Medicine, University of Athens, Greece; and International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic.
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Haeusler KG, Grittner U, Fiebach JB, Endres M, Krause T, Nolte CH. HEart and BRain interfaces in Acute ischemic Stroke (HEBRAS)--rationale and design of a prospective oberservational cohort study. BMC Neurol 2015; 15:213. [PMID: 26490042 PMCID: PMC4618534 DOI: 10.1186/s12883-015-0458-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/03/2015] [Indexed: 11/17/2022] Open
Abstract
Background An effective diagnostic work-up in hospitalized patients with acute ischemic stroke is vital to optimize secondary stroke prevention. The HEart and BRain interfaces in Acute ischemic Stroke (HEBRAS) study aims to assess whether an enhanced MRI set-up and a prolonged Holter-ECG monitoring yields a higher rate of pathologic findings as compared to diagnostic procedures recommended by guidelines (including stroke unit monitoring for at least 24 h, echocardiography and ultrasound of brain-supplying arteries). Methods/Design Prospective observational single-center study in 475 patients with acute ischemic stroke and without known atrial fibrillation. Patients will receive routine diagnostic care in hospital as wells as brain MRI, cardiac MRI, MR angiography of the brain-supplying arteries and Holter-monitoring for up to 10 days. Study patients will be followed up for cardiovascular outcomes at 3 and 12 months after enrolment. Discussion By comparing the results of routine diagnostic care to the study-specific MRI/ECG approach, the primary outcome of HEBRAS is the proportion of stroke patients with pathologic diagnostic findings. Predefined secondary outcomes are the association of stroke localization, autonomic dysbalance and cardiac dysfunction as well as the effect of impaired heart-rate-variability on long-term clinical outcome. The investigator-initiated HEBRAS study will assess whether an enhanced MRI approach and a prolonged ECG monitoring yield a higher rate of pathological findings than current standard diagnostic care to determine stroke etiology. These findings might influence current diagnostic recommendations after acute ischemic stroke. Moreover, HEBRAS will determine the extent and clinical impact of stroke-induced cardiac damage. Trial registration Clinicaltrials.gov NCT02142413.
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Affiliation(s)
- Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Ulrike Grittner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Department for Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany. .,Excellence Cluster NeuroCure, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,German Center for Neurodegenerative Diseases, Berlin, Germany. .,German Center for Cardiovascular Diseases, Partner Site Berlin, Berlin, Germany. .,Berlin Institute of Health, Berlin, Germany.
| | - Thomas Krause
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
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