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Sievering EMW, Grosshennig A, Kottas M, Ernst J, Ringlstetter R, Koch A, Weissenborn K, Grosse GM. Diagnostic value of carotid intima-media thickness and clinical risk scores in determining etiology of ischemic stroke. Eur Stroke J 2023; 8:738-746. [PMID: 37334932 PMCID: PMC10472955 DOI: 10.1177/23969873231182492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND In the general population, carotid intima-media thickness (CIMT) is associated with atherosclerosis as well as atrial fibrillation (AF). However, the extent to which CIMT might be of diagnostic value in clarifying stroke etiology is currently unclear. METHODS In this retrospective cohort study, we included 800 consecutive patients with acute ischemic stroke. We compared CIMT-values between stroke etiologies. The association between CIMT and cardioembolic stroke was investigated via logistic regression analysis adjusting for vascular risk factors. Receiver operating characteristic analyses were conducted to investigate the diagnostic value of CIMT in comparison to vascular risk factors and clinical AF risk scores (CHA2DS2VASc, HAVOC, and AS5F). RESULTS CIMT-values were highest in patients with cardioembolic or atherosclerotic stroke origin. CIMT was associated with newly diagnosed AF compared against cryptogenic strokes (crude odds ratio (OR) per 0.1 mm-increase of CIMT: 1.26 (95% confidence interval (CI): 1.13-1.41)). After adjustment for vascular risk factors, the effect of CIMT on AF-diagnosis, however, was weakened (adjusted OR: 1.10 (95% CI: 0.97-1.25)). The diagnostic value of CIMT for detection of AF (AUC: 0.60, 95% CI: 0.54-0.65) was outperformed by AF risk scores. Among the scores investigated, the AS5F-score yielded best accuracy and calibration to predict newly diagnosed AF (AUC: 0.71, 95% CI: 0.65-0.78). CONCLUSIONS CIMT may help in the diagnosis of stroke etiology. However, compared with vascular risk factors or clinical AF risk scores, CIMT does not provide substantial additional information on the risk of newly detected AF. Thus, stratification of AF risk based on scores, such as the AS5F, is advisable.
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Affiliation(s)
| | - Anika Grosshennig
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Martina Kottas
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Armin Koch
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | | | - Gerrit M Grosse
- Department of Neurology, Hannover Medical School, Hannover, Germany
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Barnea R, Agmon IN, Shafir G, Peretz S, Mendel R, Naftali J, Shiyovich A, Kornowski R, Auriel E, Hamdan A. Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS). Eur Stroke J 2022; 7:212-220. [PMID: 36082249 PMCID: PMC9446335 DOI: 10.1177/23969873221099692] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/22/2022] [Indexed: 10/17/2023] Open
Abstract
Introduction Embolic stroke of undetermined source (ESUS) is a common medical challenge regarding secondary prevention strategy. Cardiac imaging is the cornerstone of embolic stroke workup, in an effort to diagnose high risk cardio-embolic sources. Cardiac computed tomography angiography (CCTA) is an emerging imaging modality with high diagnostic performance for intra-cardiac thrombus detection. The yield of CCTA implementation in addition to standard care in ESUS workup is unknown. Thus, the aim of this study was to assess the utility of CCTA in detecting intra-cardiac thrombi in the routine ESUS workup. Patients and methods This is a retrospective observational analysis of ESUS cases managed in vascular neurology unit between 2019 and 2021. Within this ESUS registry, consecutive patients undergoing CCTA were included and carefully analyzed. Results During the study period 1066 Ischemic stroke (IS) cases were treated and evaluated. 266/1066 (25%) met ESUS criteria and 129/266 (48%) underwent CCTA. Intra-cardiac thrombus was detected by CCTA in 22/129 (17%; 95% CI, 11.5%-23.5%) patients: left ventricular thrombus (LVT) in 13 (10.1%) patients, left atrial appendage (LAA) thrombus in 8 (6.2%) patients, and left atrial (LA) thrombus in 1 (0.8%) patient. Only 5/22 (23%) of these thrombi were suspected, but could not be confirmed, in trans-thoracic echocardiogram (TTE). Among CCTA-undergoing patients, 27/129 (21%; 95% CI, 14%-28%) were found to have an indication (including pulmonary embolism) for commencing anticoagulation (AC) treatment, rather than anti-platelets. In favor of CCTA implementation, 22/266 (8.2%; 95% CI, 4.9%-11.5%) patients within the entire ESUS cohort were diagnosed with intra-cardiac thrombus, otherwise missed. Conclusion CCTA improves the detection of intra-cardiac thrombi in addition to standard care in ESUS patients. The implementation of CCTA in routine ESUS workup can change secondary prevention strategy in a considerable proportion of patients.
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Affiliation(s)
- Rani Barnea
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Inbar Nardi Agmon
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Gideon Shafir
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Shlomi Peretz
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Rom Mendel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Arthur Shiyovich
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Ran Kornowski
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Ashraf Hamdan
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
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Lattanzi S, Acampa M, Norata D, Broggi S, Caso V. A critical assessment of the current pharmacotherapy for the treatment of embolic strokes of undetermined source. Expert Opin Pharmacother 2022; 23:905-915. [PMID: 35470761 DOI: 10.1080/14656566.2022.2071125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION "Embolic stroke of undetermined source" (ESUS) is a term coined to identify non-lacunar stroke whose mechanism is likely to be embolic, and the source remains unidentified. The best antithrombotic treatment for preventing stroke recurrence in this population has not been delineated. AREAS COVERED The authors summarize and critically appraise the currently available evidence about the antithrombotic treatment for preventing stroke recurrence in patients with ESUS. Randomized trials addressing this topic were identified through MEDLINE (accessed by PubMed, as of November 2021, week 4). EXPERT OPINION Recent randomized trials have failed to demonstrate a significant benefit of direct oral anticoagulants over aspirin in reducing the recurrence of cerebral infarctions in unselected cohorts of patients with ESUS. The heterogeneity and often overlap of embolic sources may be possible explanations for the overall absence of a benefit of oral anticoagulants in ESUS as a single homogeneous entity. The results of these trials and their subgroup analyses have provided important cues to understand the pathophysiology of ESUS. They have, furthermore, increased in the interest in researchers in identifying distinct etiological phenotypes within this stroke population. There is a good rationale for ongoing and future investigations in order to tailor antithrombotic treatment according to individual features of patients with ESUS.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Davide Norata
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Serena Broggi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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