Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

INTRODUCTION

Different mechanisms may underlie cryptogenic stroke, including subclinical atrial fibrillation (AF), nonstenotic carotid plaques (NCP), and aortic arch atherosclerosis (AAA). In a cohort of cryptogenic stroke patients, we aimed to: (1) evaluate the prevalence of subclinical AF, NCP, and AAA, and reclassify the etiology accordingly; (2) compare the clinical features of patients with reclassified etiology with those with confirmed cryptogenic stroke.

METHODS

Data of patients hospitalized for cryptogenic stroke between January 2018 and February 2021 were retrospectively analyzed. Patients were included if they received implantable cardiac monitoring (ICM) to detect subclinical AF. Baseline computed tomography angiography (CTA) was re-evaluated to assess NCP and AAA. Since aortic plaques with ulceration/intraluminal thrombus were considered pathogenetic during the initial workup, only patients with milder AAA were included. Stroke etiology was reclassified as "cardioembolic", "atherosclerotic", or "mixed" based on the detection of AF and NCP/AAA. Patients with "true cryptogenic" stroke (no AF, ipsilateral NCP, or AAA detected) were compared with those with reclassified etiology.

RESULTS

Among 63 patients included, 21 (33%) were diagnosed with AF (median follow-up time of 15 months), 12 (19%) had ipsilateral NCP, and 6 (10%) had AAA. Stroke etiology was reclassified in 30 patients (48%): cardioembolic in 14 (22%), atherosclerotic in 9 (14%), and mixed in 7 (11%). Patients with true cryptogenic stroke were younger compared to those with reclassified etiology (p = 0.001).

DISCUSSION

One or more potential covert stroke sources can be recognized in half of the patients with a cryptogenic stroke through long-term cardiac monitoring and focused CTA re-assessment.

Assessment of self-reported and objective daytime sleepiness in adult-onset myotonic dystrophy type 1

STUDY OBJECTIVES

Excessive daytime sleepiness (EDS) in myotonic dystrophy type 1 (DM1) is mostly of central origin but it may coexist with sleep-related breathing disorders. However, there is no consensus on the sleep protocols to be used, assessments vary and only a minority of patients are regularly tested or are on treatment for EDS. Our study presents data on self-reported and objective EDS in adult-onset DM1.

METHODS

63 adult-onset DM1 patients were subjected to EDS-sleep assessments (polysomnography, PSG; Multiple Sleep Latency Test, MSLT; Epworth Sleepiness Scale, ESS. Correlation coefficients were computed to assess the relationship between sleep and sleepiness test results, fatigue, quality of life.

RESULTS

33% and 48% of patients had EDS based respectively on the ESS and the MSLT with a low concordance between these tests (k = 0.19). Thirteen patients (20%) displayed 2 or more sleep-onset REM periods on MSLT. Patients having EDS by MSLT had a shorter disease duration (p<0.05), higher total sleep time, sleep efficiency and lower WASO (Wake After Sleep Onset) on PSG. Patients with self-reported EDS reported significantly higher fatigue score compared to patients without EDS (p<0.05). No other difference was found in demographic, clinical and respiratory features.

CONCLUSIONS

EDS test results are contradictory making treatment options difficult. Combining quantitative tests and self-reported scales may facilitate physicians in planning EDS care with patients and families.