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Villani LA, Guay M, DeDominicis M, Bharwani A, Xu R, Počuča N, Perera K. The Utility of Echocardiogram in the Workup of Ischemic Stroke Patients. Can J Neurol Sci 2024; 51:73-77. [PMID: 36691825 DOI: 10.1017/cjn.2023.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cardiac sources of emboli can be identified by transthoracic echocardiogram (TTE). The Canadian Best Practice Guidelines recommend routine use of TTE in the initial workup of ischemic stroke when an embolic source is suspected. However, TTEs are commonly ordered for all patients despite insufficient evidence to justify cost-effectiveness. We aim to evaluate the TTE ordering pattern in the initial workup of ischemic stroke at a regional Stroke Center in Central South Ontario and determine the proportion of studies which led to a change in management and affected length of stay (LOS). METHODS Hospital records of 520 patients with a discharge diagnosis of TIA or ischemic stroke between October 2016 and June 2017 were reviewed to gather information. RESULTS 477 patients admitted for TIA or ischemic stroke met inclusion criteria. 67.9% received TTE, out of which 6.0% had findings of cardiac sources of emboli including left ventricular thrombus, atrial septal aneurysm, PFO, atrial myxoma, and valvular vegetation. 2.5% of all TTE findings led to change in medical management. The median LOS of patients who underwent TTE was 2 days longer (p < 0.00001). CONCLUSION TTE in the initial workup of TIA or ischemic stroke remains common practice. The yield of TTEs is low, and the proportion of studies that lead to changes in medical management is minimal. TTE completion was associated with increased LOS and may result in increased healthcare spending; however, additional factors prolonging the LOS could not be excluded.
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Affiliation(s)
- Linda A Villani
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Meagan Guay
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | | | - Aadil Bharwani
- Temerty Faculty of Medicine, University of Toronto, Canada
| | - Richard Xu
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Nikola Počuča
- Faculty of Science, Department of Mathematics and Statistics, McMaster University, Canada
| | - Kanjana Perera
- Division of Neurology, Department of Medicine, McMaster University, Canada
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Farinha JM, Parreira L, Marinheiro R, Fonseca M, Mesquita D, Gonçalves S, Miranda C, Silvestre I, Caria R. A lower left atrial appendage peak emptying velocity in the acute phase of cryptogenic stroke predicts atrial fibrillation occurrence during follow-up. Echocardiography 2019; 36:1859-1868. [PMID: 31503373 DOI: 10.1111/echo.14478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 08/20/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Silent atrial fibrillation is a frequent etiology of cryptogenic stroke. Spontaneous conversion of atrial fibrillation to sinus rhythm results in atrial stunning. OBJECTIVE To evaluate if the presence of a lower left atrial appendage peak emptying velocity (LAAV) after a cryptogenic stroke is associated with the occurrence of atrial fibrillation (AF). METHODS We retrospectively selected consecutive patients with an acute ischemic stroke that had a transoesophageal echocardiogram (TEE) performed in the first 30 days of the acute event. Documented AF or potential cardioembolic sources in the TEE were considered exclusion criteria. We assessed the LAAV. During follow-up, we evaluated the occurrence of new-onset AF and the combined endpoint of death or new ischemic stroke. RESULTS We studied 73 consecutive patients, during a mean follow-up period of 54.9 ± 19.3 months. Seven developed AF, and 13 had the combined endpoint. LAAV was independently associated with AF occurrence (HR: 0.93, 95% CI: 0.88-0.99; P = .016). Patients with a LAAV ≤ 46.5 cm/s (AUC: 0.766, 95% CI: 0.579-0.954; P = .021) had a lower survival rate free from AF occurrence (Log-rank, P < .001) and free from the combined endpoint of death or ischemic stroke (Log-rank, P = .010). CONCLUSION A lower LAAV was associated with AF occurrence and the combined endpoint of death or ischemic stroke after an initial episode of cryptogenic stroke. Patients with this finding could eventually benefit from long-term cardiac rhythm monitoring.
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Affiliation(s)
| | - Leonor Parreira
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Rita Marinheiro
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Marta Fonseca
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Dinis Mesquita
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Sara Gonçalves
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Carla Miranda
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Isabel Silvestre
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Rui Caria
- Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
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Cardio-embolic stroke: Lessons from a single centre in Sub-Saharan Africa. Rev Neurol (Paris) 2019; 175:544-551. [PMID: 31155304 DOI: 10.1016/j.neurol.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/05/2019] [Accepted: 02/13/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Limited information is available about cardio-embolic stroke (CES) in sub-Saharan Africa. The aim of this study was to describe the epidemiology, clinical features, etiology, the management and outcome of CES in our setting. METHODS A retrospective cohort study was carried out in the Douala General Hospital (DGH), using files of ischemic stroke patients admitted in the Neurological Unit and the Intensive Care Unit. Socio-demographic, clinical and paraclinical data were collected. After hospitalization, follow-up was performed with focus on mortality, stroke recurrence and the functional outcome assessed with Barthel score. Multivariate analysis was performed to determine the factors associated with death. RESULTS Of the 704 stroke cases included, 368 were ischemic with 86 (23.4%) of them being cardio-embolic. The mean age of patient with CES was 67±13.3 years. The main etiologies of CES were: atrial fibrillation (82.1%), dilated cardiomyopathy (12.8%), and rheumatic mitral stenosis (5.1%). Anti-platelet agents were the most prescribed anti-thrombotic drugs (50.7%). The in-hospital mortality rate was 23.3% with lesion in both internal carotid arteries [OR=110.3; 95% CI: 1.2-1040.7; P=0.043] and heart disease [OR=46.9; 95% CI: 1.2-1789.9; P=0.038] appeared to be predictive of this. Stroke recurrence was observed in 8 patients (12.1%) and the survival probability in 5 years was 10%. Functional outcome was progressively worse with the systolic blood pressure>140mmHg (P=0.025) been the associated factor. CONCLUSION CES accounted for 1/4 of ischemic stroke with a high risk of early death and long-term recurrence. Atrial fibrillation was the leading cause of CES. The association of VKA and anti-platelet agent should be avoided to reduce early death during acute stroke.
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Komarova IB, Zykov VP, Ushakova LV, Novikova EB, Shuleshko OV, Nazarova EK, Samigulina MG. [Clinical and neuroimaging signs of cardioembolic stroke in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:13-22. [PMID: 29359715 DOI: 10.17116/jnevro201711711213-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children. MATERIAL AND METHODS A group of 100 patients with arterial ischemic stroke (AIS), aged from 1 month to 15 years, was stratified into the main group (10 patients with CES) and the comparison group (90 patients with other subtypes of AIS). CT and MRI, MR-angiography, ultrasound study as well as assessment of clinical symptoms on PedNIHSS were performed. The duration of follow-up was from 2 month to 14 years. The follow-up allowed the assessment of occurrence of secondary strokes, severity of residual neurological symptoms on the PSOM and fatal outcomes. Special attention was drawn to the use of CASSADE criteria for CES. RESULTS AND CONCLUSION Clinical features that help to diagnose CES, even in the absence of adequate neuroimaging, in patients with heart disease, which is a potential high risk factor for cardioembolia, were established. These factors include early disease onset, acute development and progression of neurological deficit to the maximal level in the first 5 min., marked severity of the acute period (PedNIHSS > 15), early recovery of neurological functions, significant residual neurological symptoms (PSOM > 2). These symptoms should be used in addition to the CASCADE criteria in the diagnosis of CES of AIS type in children.
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Affiliation(s)
- I B Komarova
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - V P Zykov
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - L V Ushakova
- Kulakov Research Center of Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - E B Novikova
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - O V Shuleshko
- Bashlyaeva City Child Clinical Hospital, Moscow, Russia
| | - E K Nazarova
- Moscow Regional Consultating and Diagnostic Center, Moscow, Russia
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Komarova IB, Zykov VP, Ushakova LV, Nazarova EK, Novikova EB, Shuleshko OV, Samigulina MG. [Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:11-19. [PMID: 28665364 DOI: 10.17116/jnevro20171173211-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children. MATERIAL AND METHODS Ten children (mean age 3.5±3.5 years) were examined. Eight children met the diagnostic criteria of CES CASCADE, two children were diagnosed with CES based on the complex of symptoms. A comparison group consisted of 90 children with other subtypes of ischemic stroke (IS). The diagnosis was confirmed by MRI and magnetic-resonance angiography; symptom severity was assessed with PedNIHSS and PSOM. RESULTS AND CONCLUSION The PedNIHSS score in the acute stage of CES was higher (18.4±9.34) compared to patients with other subtypes of IS (12.6±6.2; p=0.0065). Six patients had large cerebral infarctions with the involvement of basal ganglia, internal capsule, white matter and cerebral cortex. In two patients, the infarction affected the cerebral cortex and underlying white matter, in one patient it affected the cortex from one side and the basal ganglia from the other. A damage of the cortex was noted in one patient. The frequency of recurrent CES was 30%, of fatal cases 20%. Recurrent IS and severe residual neurological deficit were more frequent in CES. CONCLUSION Early disease onset, acute development and progression of neurological deficit up to the maximal level in the first 5 min, marked severity of the acute stage (PedNIHSS score >15), early onset of neurological function recovery, marked residual neurological deficit (PSOM score >2) are the additional signs of CES.
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Affiliation(s)
- I B Komarova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - V P Zykov
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - L V Ushakova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - E K Nazarova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - E B Novikova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - O V Shuleshko
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - M G Samigulina
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
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Radu RA, Terecoasă EO, Băjenaru OA, Tiu C. Etiologic classification of ischemic stroke: Where do we stand? Clin Neurol Neurosurg 2017; 159:93-106. [PMID: 28609703 DOI: 10.1016/j.clineuro.2017.05.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/06/2017] [Accepted: 05/18/2017] [Indexed: 12/25/2022]
Abstract
Despite major technological advances in ischemic stroke diagnostic techniques, our current understanding of stroke mechanisms and etiology continues to remain unclear in a significant percent of patients. As a result, several etiological ischemic stroke classifications have emerged during the last two decades but their reliability and validity is far from perfect and further world-wide research is needed in order to achieve the so much needed "standard reference language". An ideal ischemic stroke classification should both comprise all underlying pathologies that could potentially concur to an index event and emphasize the most likely etiological and pathophysiological mechanism. Currently available approaches to ischemic stroke classification are either phenotypic or causative in nature, a multitude of criteria being published by different authors. Phenotypic classifications are targeted towards describing the concurring underlying pathologies, without highlighting the most probable ischemic stroke etiology, while causative classifications focus on establishing the most likely cause, neglecting other associated diseases. A judicious use of this two different concepts might improve clinical research as well as daily clinical practice.
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Affiliation(s)
- Răzvan Alexandru Radu
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania
| | - Elena Oana Terecoasă
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Ovidiu Alexandru Băjenaru
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Tiu
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Şenadim S, Bozkurt D, Çabalar M, Bajrami A, Yayla V. The Role of Patent Foramen Ovale in Cryptogenic Stroke. Noro Psikiyatr Ars 2016; 53:63-66. [PMID: 28360768 DOI: 10.5152/npa.2015.10034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/11/2014] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Almost one-third of ischemic strokes has an unknown etiology and are classified as cryptogenic stroke. Paradoxical embolism because of a patent foramen ovale (PFO) is detected in 40%-50% of these patients. Recently, PFO has been reported as a risk factor for patients of all age groups. METHODS In this study, 1080 ischemic stroke patients admitted to our clinic (2011-2013) were retrospectively evaluated. Age, sex, risk factors, complete blood count, vasculitis, biochemical and hypercoagulability tests, magnetic resonance imaging, magnetic resonance angiography, transthoracic echocardiography, transeosophageal echocardiography (TEE) findings, and therapeutic approaches were evaluated. RESULTS The age range of the participants (seven male and four female patients) was 20-60 years (mean=43.09±11.13 years). Hemiparesis (n=10), diplopia (n=2), hemianopsia (n=2), and dysarthria (n=2) were the main findings of the neurological examinations. Patient medical history revealed hypertension (n=3), asthma (n=1), deep venous thrombosis (n=1), and smoking (n=4). Diffusion-weighted imaging showed middle cerebral artery (n=8) and posterior cerebral artery (n=3) infarctions. In one case, symptomatic severe carotid stenosis was detected. In eight cases, TEE showed PFO without any other abnormalities, but PFO was associated with atrial septal aneurysm in two cases, and in one case it was associated with ventricular hypokinesia and pulmonary arterial hypertension. Antiplatelet therapy was applied to nine patients and percutaneous PFO closure operation to two patients. In a 2-year follow-up, no recurrent ischemic stroke was recorded. CONCLUSION PFO, especially in terms of the etiology of cryptogenic stroke in young patients, should not be underestimated. We want to emphasize the importance of TEE in identifying potential cardioembolic sources not only in young but also in all ischemic stroke patients with unknown etiology; we also discuss the controversial management options of PFO.
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Affiliation(s)
- Songül Şenadim
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Dilek Bozkurt
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Murat Çabalar
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Arsida Bajrami
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Vildan Yayla
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
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Ustrell X, Pellisé A. Cardiac workup of ischemic stroke. Curr Cardiol Rev 2011; 6:175-83. [PMID: 21804776 PMCID: PMC2994109 DOI: 10.2174/157340310791658721] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 12/31/2022] Open
Abstract
Stroke is the leading cause of disability in developed countries and the third cause of mortality. Up to 15-30% of ischemic strokes are caused by cardiac sources of emboli being associated with poor prognosis and high index of fatal recurrence. In order to establish an adequate preventive strategy it is crucial to identify the cause of the embolism. After a complete diagnostic workup up to 30% of strokes remain with an undetermined cause, and most of them are attributed to an embolic mechanism suggesting a cardiac origin.There is no consensus in the extent and optimal approach of cardiac workup of ischemic stroke. Clinical features along with brain imaging and the study of the cerebral vessels with ultrasonography or MRI/CT based angiography can identify other causes or lead to think about a possible cardioembolic origin.Atrial fibrillation is the most common cause of cardioembolic stroke. Identification of occult atrial fibrillation is essential. Baseline ECG, serial ECG('s), cardiac monitoring during the first 48 hours, and Holter monitoring have detection rates varying from 4 to 8% each separately. Extended cardiac monitoring with event loop recorders has shown higher rates of detection of paroxysmal atrial fibrillation.Cardiac imaging with echocardiography is necessary to identify structural sources of emboli. There is insufficient data to determine which is the optimal approach. Transthoracic echocardiography has an acceptable diagnostic yield in patients with heart disease but transesophageal echocardiography has a higher diagnostic yield and is necessary if no cardiac sources have been identified in patients with cryptogenic stroke with embolic mechanism.
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Affiliation(s)
- Xavier Ustrell
- Stroke Unit, Neurology Department, Joan XXIII University Hospital, Tarragona, Catalonia, Spain
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Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JVI, Pearson TA. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 42:517-84. [PMID: 21127304 DOI: 10.1161/str.0b013e3181fcb238] [Citation(s) in RCA: 1017] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. CONCLUSIONS Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.
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Mattioli AV, Aquilina M, Oldani A, Longhini C, Mattioli G. Frequency of atrial septal aneurysm in patients with recent stroke: preliminary results from a multicenter study. Clin Cardiol 2009; 24:297-300. [PMID: 11303697 PMCID: PMC6655053 DOI: 10.1002/clc.4960240408] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The role of atrial septal aneurysm (ASA) as a risk factor for cerebral ischemia of unknown etiology is controversial. Recent studies have found an association between ASA and focal ischemic events, while results from other studies suggest a low incidence of embolism in patients with ASA. HYPOTHESIS The present study was designed to evaluate the frequency of ASA, a minor cardioembolic source, in patients with a recent stroke presenting with normal carotid arteries. METHODS In all, 394 patients with cerebral ischemic stroke were referred to our institutions. Patients underwent transthracic and transesophageal echocardiography and carotid artery ultrasound examination. The study population included 215 patients without significant arterial disease. Frequency and morphologic characteristics of ASA were evaluated. RESULTS Transthoracic examination showed ASA in 39 patients (18%), while transesophageal echocardiography showed ASA in 61 patients (28%). A patent foramen ovale was found in 47 patients (21.8%) and was associated with ASA in 40 patients (65.5%). We observed an increased thickness of the aneurysmatic wall (3.80 +/- 1.7 mm) in all patients with ASA. CONCLUSIONS The present study confirms the relationship between ASA and stroke in patients with normal carotid arteries. The most common abnormality associated with ASA was patent foramen ovale. We suggest that patients who have a stroke in the absence of significant carotid disease undergo transesophageal echocardiography to identify possible underlying septal abnormalities.
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Affiliation(s)
- A V Mattioli
- Department of Cardiology, Pierantoni Hospital, Forli, Italy
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Doufekias E, Segal AZ, Kizer JR. Cardiogenic and Aortogenic Brain Embolism. J Am Coll Cardiol 2008; 51:1049-59. [DOI: 10.1016/j.jacc.2007.11.053] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 11/12/2007] [Accepted: 11/14/2007] [Indexed: 01/02/2023]
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Martignoni A, Sartori M, Lanzarini L, Negri M, Martino I, Benedicti E, Marchesi E, Bertone G, Tinelli C, Falaschi F. Improved aetiological diagnosis of ischaemic stroke in a Vascular Medicine Unit--the significance of transesophageal echocardiogram. Int J Clin Pract 2008; 62:394-9. [PMID: 18261074 DOI: 10.1111/j.1742-1241.2007.01672.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The TOAST study estimates that 34% of ischaemic strokes are of undetermined aetiology. Improvements in the diagnosis of the pathogenetic mechanism of ischaemic stroke would translate into a better care, in analogy to other fields of vascular and internal medicine. OBJECTIVE To measure the reduction of undetermined aetiology strokes performing a set of additional diagnostic tests. DESIGN Consecutive case series with historical controls. SETTING Internal Medicine Ward with a stroke area (SA) admitting most stroke patients of a large hospital in Italy. SUBJECTS A total of 179 ischaemic stroke patients admitted to SA in 2004-2005 compared with 105 ischaemic stroke patients admitted to the whole department in 2001. INTERVENTION To perform more diagnostic tests, including transesophageal echocardiography (TEE), in the greatest possible number of ischaemic stroke inpatients admitted in SA of the Internal Medicine Department, in the years 2004-2005. RESULTS More diagnostic tests were performed during the study period than in 2001, especially TEE (56% of patients in 2004-2005 vs. 3% of patients in 2001). We observed a significant reduction of undetermined aetiology from 38% in 2001 to 16% in 2004-2005 (p < 0.0001), largely for an increased identification of cases of cardio-embolic mechanism (from 18% to 40%, p = 0.0002). In the years 2004-2005 the fraction of patients on anticoagulant treatment at discharge was 21% vs. 12% in 2001 (p = 0.041). CONCLUSION Performing more tests, particularly TEE, brought improvements in the aetiological diagnosis of stroke, increasing cardio-embolism diagnosis and anticoagulant treatment.
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Affiliation(s)
- A Martignoni
- Department of Internal Medicine, Vascular and Metabolic Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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Ghosh S, Ghosh AK, Ghosh SK. Patent foramen ovale and atrial septal aneurysm in cryptogenic stroke. Postgrad Med J 2007; 83:173-7. [PMID: 17344571 PMCID: PMC2599987 DOI: 10.1136/pgmj.2006.051094] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Up to 40% of acute ischaemic strokes in young adults are cryptogenic in nature, that is, no cause is determined. In more than half of these patients, patent foramen ovale (PFO) is seen along with an increased incidence of atrial septal aneurysm. The commonest method of investigation is echocardiography (preferably transoesophageal echocardiography). On the basis of available evidence, low risk patients are treated with antiplatelet agents and high risk patients with warfarin. There are inconclusive data on the efficacy of PFO closure to prevent stroke recurrence. However, if there is recurrent stroke or intolerance to medical therapy, percutaneous closure is carried out.
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Affiliation(s)
- Sujoy Ghosh
- Ayr Hospital, Dalmellington Road, Ayr, Ayrshire, UK
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Affiliation(s)
- Jorge R Kizer
- Department of Medicine, Weill Medical College of Cornell University, New York, USA.
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