1
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Jung JW, Baik M, Jeong J, Lee IH, Kim KH, Yun J, Shim CY, Hong GR, Kim YD, Heo JH, Nam HS. Prognosis of ischemic stroke patients with both aortic atheroma and cardioembolic sources. Sci Rep 2024; 14:12656. [PMID: 38825610 PMCID: PMC11144702 DOI: 10.1038/s41598-024-60294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/21/2024] [Indexed: 06/04/2024] Open
Abstract
This study aimed to investigate the relationship between complex aortic plaque (CAP) and short-term as well as long-term outcomes following cardioembolic stroke. CAP is a known risk factor for occurrence and recurrence of ischemic stroke. However, the association of CAP on cardioembolic stroke remains unclear. This was retrospective study using prospective cohort of consecutive patients with cardioembolic stroke who underwent transesophageal echocardiography. The functional outcome was evaluated using the modified Rankin Scale score at 3 months, and long-term outcomes were assessed by recurrence of ischemic stroke and occurrence of major adverse cardiovascular events (MACE). Among 759 patients with cardioembolic stroke, 91 (12.0%) had CAP. Early ischemic stroke recurrence within 3 months was associated with CAP (p = 0.025), whereas CAP was not associated with functional outcome at 3 months (odd ratio 1.01, 95% confidence interval [CI] 0.57-1.84, p = 0.973). During a median follow-up of 3.02 years, CAP was significantly associated with ischemic stroke recurrence (hazard ratio = 2.68, 95% CI 1.48-4.88, p = 0.001) and MACE occurrence (hazard ratio = 1.61, 95% CI 1.03-2.51, p = 0.039). In conclusion, CAP was associated with early ischemic stroke recurrence and poor long-term outcomes in patients with cardioembolic stroke. It might be helpful to consider transesophageal echocardiography for patients with cardioembolic stroke to identify CAP.
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Affiliation(s)
- Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Korea
| | - JaeWook Jeong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Kwang Hyun Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Jaeseob Yun
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Chi Young Shim
- Department of Cardiology, Yonsei University College of Medicine, Seoul, Korea
| | - Geu-Ru Hong
- Department of Cardiology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea.
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2
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Lee IH, Heo J, Lee H, Jeong J, Kim J, Han M, Yoo J, Kim J, Baik M, Park H, Jung JW, Kim YD, Nam HS. Long-term outcomes of patients with embolic stroke of undetermined source according to subtype. Sci Rep 2024; 14:9295. [PMID: 38653743 DOI: 10.1038/s41598-024-58292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024] Open
Abstract
The prognosis of patients with embolic stroke of undetermined source (ESUS) may vary according to the underlying cause. Therefore, we aimed to divide ESUS into subtypes and assess the long-term outcomes. Consecutive patients with acute ischemic stroke who underwent a comprehensive workup, including transesophageal echocardiography and prolonged electrocardiography monitoring, were enrolled. We classified ESUS into minor cardioembolic (CE) ESUS, arteriogenic ESUS, two or more causes ESUS, and no cause ESUS. Arteriogenic ESUS was sub-classified into complex aortic plaque (CAP) ESUS and non-stenotic (< 50%) relevant artery plaque (NAP) ESUS. A total of 775 patients were enrolled. During 1286 ± 748 days follow-up, 116 major adverse cardiovascular events (MACE) occurred (4.2 events/100 patient-years). Among the ESUS subtypes, CAP ESUS was associated with the highest MACE frequency (9.7/100 patient-years, p = 0.021). Cox regression analyses showed that CAP ESUS was associated with MACE (hazard ratio 2.466, 95% confidence interval 1.305-4.660) and any stroke recurrence (hazard ratio 2.470, 95% confidence interval, 1.108-5.508). The prognosis of ESUS varies according to the subtype, with CAP ESUS having the worst prognosis. Categorizing ESUS into subtypes could improve patient care and refine clinical trials.
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Affiliation(s)
- Il Hyung Lee
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyungwoo Lee
- Department of Neurology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - JaeWook Jeong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonho Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Minho Han
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Jinkwon Kim
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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3
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van der Maten G, Meijs MFL, Timmer JR, Brouwers PJAM, von Birgelen C, Coutinho JM, Bouma BJ, Kerkhoff H, Helming AM, van Tuijl JH, van der Meer NA, Saxena R, Ebink C, van der Palen J, den Hertog HM. Routine transthoracic echocardiography in ischaemic stroke or transient ischaemic attack of undetermined cause: a prospective multicentre study. Neth Heart J 2024; 32:91-98. [PMID: 37870709 PMCID: PMC10834921 DOI: 10.1007/s12471-023-01819-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Guidelines recommend routine transthoracic echocardiography (TTE) after ischaemic stroke or transient ischaemic attack of undetermined cause; yet, only limited scientific evidence exists. Therefore, we aimed to determine in these patients the prevalence of TTE-detected major cardiac sources of embolism (CSE), which are abnormalities leading to therapeutic changes. METHODS Six Dutch hospitals conducted a prospective observational study that enrolled patients with ischaemic stroke or transient ischaemic attack of undetermined cause. Patients underwent TTE after comprehensive diagnostic evaluation on stroke units, including blood chemistry, 12-lead electrocardiogram (ECG), ≥ 24 h continuous ECG monitoring, brain imaging and cervical artery imaging. Primary outcome measure was the proportion of patients with TTE-detected major CSE. RESULTS From March 2018 to October 2020, 1084 patients, aged 66.6 ± 12.5 years, were enrolled; 456 (42.1%) patients were female and 869 (80.2%) had ischaemic stroke. TTE detected major CSE in only 11 (1.0%) patients. Ten (90.9%) of these patients also had major ECG abnormalities (previous infarction, major repolarisation abnormalities, or previously unknown left bundle branch block) that would have warranted TTE assessment regardless of stroke evaluation. Such ECG abnormalities were present in 11.1% of the total study population. A single patient (0.1%) showed a major CSE despite having no ECG abnormality. CONCLUSIONS This multicentre cross-sectional study in patients who-after workup on contemporary stroke units-were diagnosed with ischaemic stroke or transient ischaemic attack of undetermined cause found TTE-detected major CSE in only 1% of all patients. Most of these patients also had major ECG abnormalities. These findings question the value of routine TTE assessment in this clinical setting.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Jorik R Timmer
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Anne Mijn Helming
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Ritu Saxena
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Corné Ebink
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Job van der Palen
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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Yaghi S, Albin C, Chaturvedi S, Savitz SI. Roundtable of Academia and Industry for Stroke Prevention: Prevention and Treatment of Large-Vessel Disease. Stroke 2024; 55:226-235. [PMID: 38134259 DOI: 10.1161/strokeaha.123.043910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Shadi Yaghi
- Alpert Medical School at Brown University, Providence, RI (S.Y.)
| | | | | | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston (S.I.S.)
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5
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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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6
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Sakai Y, Cao Q, Rubin J, Witsch J, Cohen‐Addad D, de Macedo Rodrigues K, Coco‐Martin MB, Pasyar P, Juega J, Fan Z, Kasner SE, Cucchiara BL, Song JW. Imaging Biomarkers and Prevalence of Complex Aortic Plaque in Cryptogenic Stroke: A Systematic Review. J Am Heart Assoc 2023; 12:e031797. [PMID: 38014682 PMCID: PMC10727354 DOI: 10.1161/jaha.123.031797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Complex aortic plaque (CAP) is a potential embolic source in patients with cryptogenic stroke (CS). We review CAP imaging criteria for transesophageal echocardiogram (TEE), computed tomography angiography (CTA), and magnetic resonance imaging and calculate CAP prevalence in patients with acute CS. METHODS AND RESULTS PubMed and EMBASE databases were searched up to December 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Two independent reviewers extracted data on study design, imaging techniques, CAP criteria, and prevalence. The Cochrane Collaboration tool and Guideline for Reporting Reliability and Agreement Studies were used to assess risk of bias and reporting completeness, respectively. From 2293 studies, 45 were reviewed for CAP imaging biomarker criteria in patients with acute CS (N=37 TEE; N=9 CTA; N=6 magnetic resonance imaging). Most studies (74%) used ≥4 mm plaque thickness as the imaging criterion for CAP although ≥1 mm (N=1, CTA), ≥5 mm (N=5, TEE), and ≥6 mm (N=2, CTA) were also reported. Additional features included mobility, ulceration, thrombus, protrusions, and assessment of plaque composition. From 23 prospective studies, CAP was detected in 960 of 2778 patients with CS (0.32 [95% CI, 0.24-0.41], I2=94%). By modality, prevalence estimates were 0.29 (95% CI, 0.20-0.40; I2=95%) for TEE; 0.23 (95% CI, 0.15-0.34; I2=87%) for CTA and 0.22 (95% CI, 0.06-0.54; I2=92%) for magnetic resonance imaging. CONCLUSIONS TEE was commonly used to assess CAP in patients with CS. The most common CAP imaging biomarker was ≥4 mm plaque thickness. CAP was observed in one-third of patients with acute CS. However, high study heterogeneity suggests a need for reproducible imaging methods.
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Affiliation(s)
- Yu Sakai
- Department of RadiologyUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Quy Cao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jeremy Rubin
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jens Witsch
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Dan Cohen‐Addad
- Department of Radiology and Imaging SciencesEmory UniversityAtlantaGAUSA
| | | | | | - Pouyan Pasyar
- Department of RadiologyUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jesús Juega
- Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | - Zhaoyang Fan
- Departments of Radiology, Biomedical Engineering, and Radiation OncologyUniversity of Southern CaliforniaLos AngelesCAUSA
| | - Scott E. Kasner
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Jae W. Song
- Department of RadiologyUniversity of PennsylvaniaPhiladelphiaPAUSA
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Saldaña-Inda I, Garcés-Antón E, Navasa-Melado JM, Bernal-Lafuente C, Tejada-Meza H. Direct carotid puncture for the endovascular treatment of acute ischaemic stroke associated to aortic arch atheroma. Neurologia 2023; 38:606-607. [PMID: 37802553 DOI: 10.1016/j.nrleng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 12/18/2022] [Indexed: 10/10/2023] Open
Affiliation(s)
- I Saldaña-Inda
- Stroke Unit - Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - E Garcés-Antón
- Stroke Unit - Department of Neurology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - J M Navasa-Melado
- Interventional Neuroradiology Unit - Department of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - C Bernal-Lafuente
- Department of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - H Tejada-Meza
- Stroke Unit - Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain; Interventional Neuroradiology Unit - Department of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón. Universidad de Zaragoza, Spain
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8
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Kumar H, Boini A, Tshibangu M, Ghosh B, Shaheen F, Joseph AM, Cazzaniga J, Karas M, Jara Silva CE, Quinonez J, Ruxmohan S. Anticoagulation Options for Cranial Procedures: A Comparative Review of Aspirin, Plavix, and Aggrastat. Cureus 2023; 15:e43899. [PMID: 37746498 PMCID: PMC10512101 DOI: 10.7759/cureus.43899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Anticoagulation therapy is critical to avoiding thrombotic events in patients following cranial surgery. Although Aspirin, Plavix, and Aggrastat are used as anticoagulants for this purpose, there is no consensus on which agent is the most effective and safe. In this comparative study, we analyze the current evidence on the efficacy and safety of these three anticoagulants in the context of cranial surgeries. This review focuses on the advantages and disadvantages of each anticoagulant, such as its pharmacokinetics, indications, contraindications, and possible consequences. The outcomes of this study will help physicians choose the best anticoagulant for their patients based on individual patient characteristics and the kind of cranial procedure. Aggrastat's potential to be included as a recommended anticoagulant for cranial procedures warrants further study.
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Affiliation(s)
- Harendra Kumar
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Aishwarya Boini
- Medicine, Government Medical College and Hospital, Siddipet, IND
- Medicine, Davao Medical School Foundation, Davao, PHL
| | | | - Bikona Ghosh
- Medicine and Surgery, Dhaka Medical College, Dhaka, BGD
| | - Fatima Shaheen
- Medicine, M. N. Raju (MNR) Medical College, Hyderabad, IND
| | - Andrew M Joseph
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Juliana Cazzaniga
- Herbert Wertheim College of Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Monica Karas
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Cesar E Jara Silva
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Jonathan Quinonez
- Neurology/Osteopathic Neuromuscular Medicine, Larkin Community Hospital, Miami, USA
| | - Samir Ruxmohan
- Division of Neurocritical Care, University of Texas (UT) Southwestern Medical Center, Dallas, USA
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9
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Yaghi S. Diagnosis and Management of Cardioembolic Stroke. Continuum (Minneap Minn) 2023; 29:462-485. [PMID: 37039405 DOI: 10.1212/con.0000000000001217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke. LATEST DEVELOPMENTS Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy. ESSENTIAL POINTS A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.
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10
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Hoshino T, Mizuno T, Nishimura A, Ishizuka K, Toi S, Takahashi S, Wako S, Kitagawa K. Reclassification and risk stratification of embolic stroke of undetermined source by ASCOD phenotyping. Int J Stroke 2023; 18:322-330. [PMID: 35422186 DOI: 10.1177/17474930221096953] [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: 11/15/2022]
Abstract
BACKGROUND Common vascular diseases underlying stroke, including atherosclerosis, small-vessel disease (SVD), and cardioembolic pathology, can be present in patients with embolic stroke of undetermined source (ESUS), although these are not direct causes of stroke. AIMS To describe the frequency and degree of the three major diseases using atherosclerosis, SVD, cardiac pathology, other causes, and dissection (ASCOD) phenotyping and to assess their prognostic implications in ESUS. METHODS In this prospective observational study, 221 patients with ESUS within 1 week of onset were consecutively enrolled and followed up for 1 year. Vascular diseases associated with stroke were assessed using the ASCOD classification. The primary outcome was a composite of nonfatal stroke, nonfatal acute coronary syndrome, and vascular death. RESULTS Among 221 patients (mean age, 69.6 years; male, 59.7%), 135 (61.1%), 102 (46.2%), and 107 (48.4%) had any grade of atherosclerosis (A2 or A3), SVD (S3), and cardiac pathology (C2 or C3), respectively. ESUS patients graded as A2 or A3 (i.e. ipsilateral atherosclerotic plaque, contralateral ⩾ 50% stenosis, or aortic arch plaque) were at a significantly higher risk of composite vascular events than those graded as A0 (i.e. no atherosclerotic disease) (adjusted hazard ratio (95% confidence interval), 2.40 (1.01-5.72). No differences were observed in the event risk between patients with S3 (i.e. magnetic resonance imaging evidence of SVD) and S0 (i.e. no SVD) and between those with C2 or C3 (i.e. presence of any cardiac pathology) and C0 (i.e. no cardiac abnormalities). CONCLUSIONS Atherosclerotic diseases corresponding to ASCOD grade A2 or A3 were predictive of recurrent vascular events in ESUS patients. Reclassification of ESUS using ASCOD phenotyping provides important clues for risk prediction and may guide optimal management strategies.
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Affiliation(s)
- Takao Hoshino
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Takafumi Mizuno
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Ayako Nishimura
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kentaro Ishizuka
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Sono Toi
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Shuntaro Takahashi
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Sho Wako
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
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11
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Yang D, Elkind MSV. Current perspectives on the clinical management of cryptogenic stroke. Expert Rev Neurother 2023; 23:213-226. [PMID: 36934333 PMCID: PMC10166643 DOI: 10.1080/14737175.2023.2192403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/20/2023]
Abstract
INTRODUCTION Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology. AREAS COVERED In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022. EXPERT OPINION Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.
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Affiliation(s)
- Dixon Yang
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- American Heart Association
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12
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Fan ZX, Liu RX, Liu GZ. Development and refinement of diagnostic and therapeutic strategies for managing patients with cardiogenic stroke: An arduous journey. World J Clin Cases 2023; 11:719-724. [PMID: 36818629 PMCID: PMC9928701 DOI: 10.12998/wjcc.v11.i4.719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
Cardioembolic stroke, referred to as cardiogenic stroke, is a clinical syndrome in which emboli from the heart pass through the circulatory system and cause cerebral artery embolism and corresponding brain dysfunction. Compared to other subtypes of ischemic stroke, cardiogenic stroke presents with more etiologies, greater severity, worse prognosis, and a higher recurrence rate. In this minireview, we provide new insights into the etiological classification, diagnostic methods, and interventions of cardiogenic stroke.
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Affiliation(s)
- Ze-Xin Fan
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
| | - Ri-Xia Liu
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
| | - Guang-Zhi Liu
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
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13
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Vassiliki’ Coutsoumbas G, Di Pasquale G. Ischaemic stroke in the absence of documented atrial fibrillation: is there who could benefit from anticoagulant therapy? Eur Heart J Suppl 2022; 24:I89-I95. [DOI: 10.1093/eurheartjsupp/suac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
About 25% of ischaemic strokes are of cryptogenic origin and a significant proportion of them has a certain embolic nature, and for these patients the term embolic stroke of undetermined source (ESUS) has been coined. In the absence of subclinical atrial fibrillation (AF) identifiable through prolonged electrocardiogram monitoring, atrial cardiomyopathy, demonstrable through non-invasive cardiac imaging, aortic plaques and heart failure with preserved sinus rhythm, have been recognized among the potential causes of ESUS. In patients with ESUS, randomized clinical trials performed so far have failed to demonstrate a benefit of therapy with direct oral anticoagulants (DOACs). However, it is possible that in patients in whom the presence of atrial cardiomyopathy is ascertained there may be a benefit of anticoagulant therapy in secondary prevention after ESUS. In patients with aortic plaques associated with a thrombotic component and in those with heart failure and preserved sinus rhythm in the absence of AF but with a high congestive heart failure, hypertension age, diabetes, stroke, vascular disease (CHA2DS2-VASc) score, the decision on anticoagulant therapy with DOACs could be made in the individual patient even in the absence of evidence from clinical trials.
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Alghamdi FA, AlShehri SA, Maghraby NH, Shaib M, Alfaraj D. A Cerebrovascular Incident Secondary to Extensive Aortic Arch Atheroma. Cureus 2022; 14:e28954. [PMID: 36237761 PMCID: PMC9547671 DOI: 10.7759/cureus.28954] [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] [Accepted: 09/08/2022] [Indexed: 11/23/2022] Open
Abstract
Plaques can form across different parts of the aorta, from the aortic arch to the thoracic and abdominal aorta. Aortic arch atheroma, however, is highly associated with cerebrovascular insults due to their dislodgement. Although no concise management protocol has been defined for dealing with such presentations, antiplatelet agents and anticoagulants are most frequently used. In this case, we present a 78-year-old male with a known case of diabetes mellitus type 2, hypertension, and dyslipidemia who presented to the emergency department with acute onset of slurred speech. A CT angiography was performed that revealed extensive plaque formations across the aortic arch with a 90% occlusion of the distal left common carotid artery and carotid bifurcation along with 99% stenosis of the internal carotid artery. The patient underwent aspiration thrombectomy and was started on dual antiplatelets but passed away after developing decompensated heart failure.
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15
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Arnautu SF, Arnautu DA, Lascu A, Hajevschi AA, Rosca CII, Sharma A, Jianu DC. A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke. MEDICAL SCIENCE MONITOR : INTERNATIONAL MEDICAL JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022; 28:e936365. [PMID: 35729858 PMCID: PMC9235914 DOI: 10.12659/msm.936365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Stroke is a major source of morbidity and mortality worldwide, accounting for the second largest cause of mortality and the third greatest cause of disability. Stroke is frequently preceded by a transient ischemic attack (TIA). The etiologies of 20-30% of ischemic strokes are unknown, and thus are termed "cryptogenic strokes". About 25% of ischemic strokes are cardioembolic. Strokes occur at a rate of around 2% per year in individuals with heart failure with reduced ejection fraction (HFrEF), with a strong correlation between stroke risk and the degree of ventricular impairment. Furthermore, stroke risk is augmented in the absence of anticoagulation therapy. Cardioembolic strokes, when treated inadequately, have a greater predilection for recurrences than atherothrombotic strokes, both early and late in life. The role of a patent foramen ovale in strokes, specifically in "cryptogenic strokes", is a matter of concern that deserves due attention. The use of tissue-engineered heart valves and aspirin for minimizing the risk of stroke is recommended. Transthoracic echocardiography (TTE) is advantageous for assessing heart function in the acute phase of ischemic stroke. Transesophageal echocardiography (TEE) is considered the criterion standard procedure for detecting LAA thrombi. Computed tomography (CT) scans are good imaging modalities for identifying and excluding bleeding. Magnetic resonance imaging (MRI) images are by far the most effective imaging technique available for assessing the brain parenchymal state. We conducted a thorough review of the literature on the use of imaging modalities, highlighting the important contribution of TTE, TEE, CT, and MRI in the evaluation of cardioembolic stroke.
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Affiliation(s)
- Sergiu Florin Arnautu
- Department of Neurology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Neurology, Clinical Emergency County Hospital, Timisoara, Romania.,Centre of the Cognitive Research in Neuropsychiatric Pathology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
| | - Diana Aurora Arnautu
- Department of Cardiology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
| | - Ana Lascu
- Department of Functional Sciences, Discipline Pathophysiology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Centre for Translational Research and Systems Medicine, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Institute of Cardiovascular Diseases, Timisoara, Romania
| | - Andrei A Hajevschi
- Department of Neurology, Clinical Emergency County Hospital, Timisoara, Romania
| | - Ciprian Ilie Ilie Rosca
- Advanced Research Center for Cardiovascular Pathology and Hemostasis, Department of Internal Medicine I - Medical Semiology I, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Internal Medicine, Municipal Emergency University Hospital, Timisoara, Romania.,Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania
| | - Abhinav Sharma
- Department of Cardiology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania.,Department of Occupational Medicine, Municipal Emergency University Hospital, Arad, Romania
| | - Dragos Catalin Jianu
- Department of Neurology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Neurology, Clinical Emergency County Hospital, Timisoara, Romania.,Centre of the Cognitive Research in Neuropsychiatric Pathology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
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16
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From cryptogenic to ESUS: Toward precision medicine? Rev Neurol (Paris) 2022; 178:939-952. [PMID: 35597610 DOI: 10.1016/j.neurol.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/20/2022]
Abstract
Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up. They differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. It is also different from uncommon heritable and non-heritable causes. The term embolic stroke of undetermined source (ESUS) proposed in 2014 is defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. The major advantage of this definition compared to cryptogenic definition is the proposition of a specific work-up. In a general population, frequent potential sources of embolism in patients with ESUS have been suggested since a long time and include: patent foramen ovale (PFO), covert atrial fibrillation (AF), complex aortic arch atheroma, large vessel atheroma with stenosis<50%, carotid web, atrial cardiomyopathy, thrombophilia associated with cancer. It took almost 30 years to show, in patients under 60 with a cryptogenic stroke and a PFO, that PFO occlusion was superior to medical treatment alone for recurrent stroke. PFO under 60 is therefore no longer a cryptogenic cause of infarction. The concept of cryptogenic stroke and its refinement in ESUS have been fruitful for the identification of PFO associated as a cause. Covert AF can be detected by different techniques but its risk significance for recurrent stroke might be different from the simple electrocardiographic detection of AF. With the development of direct oral anticoagulants (DOAs), randomized studies in patients with ESUS, were run for stroke prevention but no difference was observed between patients treated by DOA compared to aspirin. These studies showed however the heterogeneity of ESUS patients. Further ESUS classification should be considered as a tool to identify homogeneous groups. We propose to further split the ESUS group into different subgroups: ESU-PFO>60-year-old, ESUS-ATH with stenosis<50%, ESUS-AF (covert AF & atrial cardiomyopathy), ESUS-cancer and others. Precision medicine is the ability to make targeted healthcare decisions based on the specific risks of individual patients. One preliminary stage is therefore to identify homogeneous groups suitable in the future for new therapeutic trials and, at the end, for new specific treatments.
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17
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Kim SH, Nam TM, Lee SH, Jang JH, Kim YZ, Kim KH, Kim DH, Lee CH. Association of aortic arch calcification on chest X-ray with procedural thromboembolism after coil embolization of cerebral aneurysm. J Clin Neurosci 2022; 99:373-378. [DOI: 10.1016/j.jocn.2022.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 11/30/2022]
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18
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Mayerhofer E, Kanz D, Guschlbauer B, Anderson CD, Asmussen A, Grundmann S, Strecker C, Harloff A. Bubble Test and Carotid Ultrasound to Guide Indication of Transesophageal Echocardiography in Young Patients With Stroke. Front Neurol 2022; 13:836609. [PMID: 35309558 PMCID: PMC8931264 DOI: 10.3389/fneur.2022.836609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Indication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain. Methods This prospective double-blinded study included patients with cryptogenic acute ischemic stroke or transient ischemic attack (TIA) ≥18 and ≤60 years. After routine diagnostics, all patients underwent patent foramen ovale (PFO) screening by transcranial Doppler (TCD) bubble test, carotid ultrasound for atherosclerosis screening (intima-media-thickness >0.90 mm or plaques), and TEE. We calculated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the combined non-invasive ultrasound to predict therapy-relevant TEE findings. Results We included 240 consecutive patients (median 51 years, 39% women) of which 68 (28.3%) had both a negative bubble test and no carotid atherosclerosis. Of these, 66 (97.1%) had unremarkable TEE findings; in one patient a small PFO was found and closed subsequently, in another patient a 4.9 mm thick aortic atheroma was found, and double platelet inhibition initiated. Of the other 172 (71.7%) patients, 93 (54%) had PFO and 9 (5.2%) complex aortic plaques. No other therapy-relevant findings were present in both groups. Non-invasive ultrasound had a sensitivity of 98.0%, specificity of 47.8%, NPV of 97.1%, and PPV of 58.1% for therapy-relevant TEE findings. Conclusions Bubble test and carotid ultrasound could be used for the individual decision for/against TEE in patients with cryptogenic stroke ≤60 years. If they are unremarkable, TEE can be omitted with high safety regarding secondary prevention. If bubble test is positive and/or carotid ultrasound shows atherosclerosis, TEE should be carried out if PFO or aortic atheroma are potentially relevant for further patient management.
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Affiliation(s)
- Ernst Mayerhofer
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Dirk Kanz
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Brigitte Guschlbauer
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | | | - Alexander Asmussen
- Department of Cardiology and Angiology I Heart Center, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Sebastian Grundmann
- Department of Cardiology and Angiology I Heart Center, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Christoph Strecker
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- *Correspondence: Andreas Harloff
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19
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Retrograde aortic thrombosis with TEVAR for secondary stroke prevention: Case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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20
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Mbonde AA, O'Carroll CB, Dulamea OA, Anghel D, Chong BW, Dumitrascu OM. Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks. Asia Pac J Ophthalmol (Phila) 2022; 11:168-176. [PMID: 35213421 DOI: 10.1097/apo.0000000000000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.
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Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Cumara B O'Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Octaviana A Dulamea
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Daniela Anghel
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Brian W Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US
| | - Oana M Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
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21
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Atherosclerotic Disease of the Proximal Aorta. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Secondary Prevention of Cardioembolic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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23
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24
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Cryptogenic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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26
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Heslin ME, Thon JM, Caruso E, Romiyo P, Rana A, Yu S, Thau L, Rana A, Kamen S, Siegler JE. Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction. J Clin Neurosci 2021; 95:31-37. [PMID: 34929648 DOI: 10.1016/j.jocn.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022]
Abstract
Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015-8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46-57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.
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Affiliation(s)
- Mark E Heslin
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA.
| | - Jesse M Thon
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Evan Caruso
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Prasanth Romiyo
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ankit Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - James E Siegler
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
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Coexisting of aortic arch atheroma and atrial fibrillation for short-term recurrence and poor functional outcome in acute stroke. Neurol Sci 2021; 43:2387-2396. [PMID: 34748067 DOI: 10.1007/s10072-021-05722-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Multiple embolic sources are sometimes observed simultaneously in patients with embolic stroke. The present study investigated the effects of coexisting aortic arch atheroma ≥ 4 mm thick and atrial fibrillation (AF) on short-term stroke recurrence and functional outcome. METHODS Transesophageal echocardiography (TEE) was performed in consecutive embolic stroke patients, and 395 patients were classified into 4 groups according to the presence of aortic arch atheroma ≥ 4 mm thick and AF: AF - /ARCH - group, AF + /ARCH - group, AF - /ARCH + group, and AF + /ARCH + group. In accordance with these 4 groups, we evaluated stroke recurrence and all-cause death for 3 months after stroke onset, and also evaluated the 3-month functional outcome using the modified Rankin scale (mRS). RESULTS Among the 128 AF patients, 39.1% also had aortic arch atheroma ≥ 4 mm thick. Of the 395 enrolled cases, the AF + /ARCH + group showed the highest frequencies of stroke recurrence and all-cause death during 3 months after onset. On multivariate analysis, stroke recurrence or all-cause death during 3 months after onset was relatively more frequent in the AF + /ARCH + group than in the AF + /ARCH - group (OR, 2.34; 95% CI, 0.82-6.69; p = 0.11), but that was not statistically significant, and poor functional outcome (mRS score 3-6) at 3 months was significantly more frequent in the AF + /ARCH + group than in the AF + /ARCH - group (OR, 2.59; 95% CI, 1.08-6.24; p = 0.0339). CONCLUSIONS Aortic arch atheroma concomitant with AF is not rare and appears associated with increased risks of stroke recurrence and poor functional outcome.
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Abstract
BACKGROUND Stroke is the third leading cause of early death worldwide. Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Patient outcomes might be improved if they are offered anticoagulants that reduce their risk of developing new blood clots and do not increase the risk of bleeding. This is an update of a Cochrane Review first published in 1995, with updates in 2004, 2008, and 2015. OBJECTIVES To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) for people with acute presumed or confirmed ischaemic stroke. Our hypotheses were that, compared with a policy of avoiding their use, early anticoagulation would be associated with: • reduced risk of death or dependence in activities of daily living a few months after stroke onset; • reduced risk of early recurrent ischaemic stroke; • increased risk of symptomatic intracranial and extracranial haemorrhage; and • reduced risk of deep vein thrombosis and pulmonary embolism. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (August 2021); the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), in the Cochrane Library (searched 5 August 2021); MEDLINE (2014 to 5 August 2021); and Embase (2014 to 5 August 2021). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies. SELECTION CRITERIA Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. We assessed the overall certainty of the evidence for each outcome using RoB1 and GRADE methods. MAIN RESULTS We included 28 trials involving 24,025 participants. Quality of the trials varied considerably. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition, or reporting bias. Anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence is related to effects of anticoagulant therapy initiated within the first 48 hours of onset. No evidence suggests that early anticoagulation reduced the odds of death or dependence at the end of follow-up (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.92 to 1.03; 12 RCTs, 22,428 participants; high-certainty evidence). Similarly, we found no evidence suggesting that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (OR 0.99, 95% CI 0.90 to 1.09; 22 RCTs, 22,602 participants; low-certainty evidence) during the treatment period. Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.75, 95% CI 0.65 to 0.88; 12 RCTs, 21,665 participants; moderate-certainty evidence), it was also associated with an increase in symptomatic intracranial haemorrhage (OR 2.47; 95% CI 1.90 to 3.21; 20 RCTs, 23,221 participants; moderate-certainty evidence). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60, 95% CI 0.44 to 0.81; 14 RCTs, 22,544 participants; high-certainty evidence), but this benefit was offset by an increase in extracranial haemorrhage (OR 2.99, 95% CI 2.24 to 3.99; 18 RCTs, 22,255 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Since the last version of this review, four new relevant studies have been published, and conclusions remain consistent. People who have early anticoagulant therapy after acute ischaemic stroke do not demonstrate any net short- or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis, and pulmonary embolism but increased bleeding risk. Data do not support the routine use of any of the currently available anticoagulants for acute ischaemic stroke.
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Min Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
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Ali L, Safan A, Kamran S, Akhtar N, Elalamy O. Acute Thromboembolic Ischemic Stroke From Complex Aortic Arch Plaque. Cureus 2021; 13:e16977. [PMID: 34540387 PMCID: PMC8423320 DOI: 10.7759/cureus.16977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 12/04/2022] Open
Abstract
Atherosclerosis is a systemic pathologic process, may involve aorta and is important cause of systemic embolization. The risk of embolism is increased for mobile and complex aortic plaques that are >4 mm thick. The most common manifestations are stroke, transient ischemic attack (TIA) and peripheral embolization. Imaging modalities used include transesophageal echocardiogram (TEE), CT angiography and magnetic resonance angiography (MRA). The mainstays of medical treatment are antiplatelets and statin. The role of anticoagulation is reserved for plaques with thrombotic component. There were two patients who presented with large acute ischemic stroke with high grade, floating aortic arch thrombus and complex aortic arch plaques. In one of cases, after 10-day follow-up CT aortic angiography showed completely resolved thrombus after being treated with IV tissue plasminogen activator (TPA) followed by low molecular weight heparin (LMWH). The risk of embolism depends on size of aortic plaques and mobility. TEE is modality of choice for thoracic aortic plaques. Aortic plaques >4 mm are independent predictors of recurrent ischemic stroke. There are limited data available for off-label use of intravenous thrombolysis and mechanical thrombectomy (MT) in presence of aortic arch thrombus in acute ischemic strokes. These two case reports help in recognition of aortic arch complex plaques as independent risk factor for recurrent stroke. The right patients may consider about the use of intravenous alteplase and MT performed via trans-brachial access after excluding aortic dissection and aneurysm. In future, multicenter, randomized controlled trials will be required for safety of IV TPA and MT.
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Affiliation(s)
- Liaquat Ali
- Neurology, Hamad General Hospital, Doha, QAT
| | - Abeer Safan
- Neurology, Hamad Medical Corporation, Doha, QAT
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Thomalla G, Upneja M, Camen S, Jensen M, Schröder J, Barow E, Boskamp S, Ostermeier B, Kissling S, Leinisch E, Tiburtius C, Clausen H, Cheng B, Blankenberg S, Nedelmann M, Steinbrecher A, Andres F, Rosenkranz M, Sinning C, Schnabel RB, Gerloff C. Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study. Stroke 2021; 53:177-184. [PMID: 34496617 DOI: 10.1161/strokeaha.121.034868] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause. METHODS In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE. RESULTS Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%], P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001). CONCLUSIONS In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03411642.
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Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Mira Upneja
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Stephan Camen
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Julian Schröder
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Stefan Boskamp
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | | | - Sandra Kissling
- Klinik für Neurologie, Kreiskliniken Reutlingen, Germany. (S.K., F.A.)
| | - Elke Leinisch
- Klinik für Neurologie, Helios Klinikum Erfurt, Germany (E.L., A.S.)
| | - Claudia Tiburtius
- Klinik für Kardiologie, Albertinen Krankenhaus, Hamburg, Germany (C.T.)
| | - Henning Clausen
- Klinik für Neurologie, Regio Kliniken Pinneberg, Germany (H.C., M.N.)
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Stefan Blankenberg
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.).,Klinik für Neurologie und Neurologische Frührehabilitation, Albertinen Krankenhaus, Hamburg, Germany (S.B., M.R.)
| | - Max Nedelmann
- Klinik für Neurologie, Regio Kliniken Pinneberg, Germany (H.C., M.N.)
| | | | - Frank Andres
- Klinik für Neurologie, Kreiskliniken Reutlingen, Germany. (S.K., F.A.)
| | - Michael Rosenkranz
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.).,Klinik für Neurologie und Neurologische Frührehabilitation, Albertinen Krankenhaus, Hamburg, Germany (S.B., M.R.)
| | - Christoph Sinning
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Renate B Schnabel
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
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Duloquin G, Graber M, Baptiste L, Mohr S, Garnier L, Ndiaye M, Blanc-Labarre C, Hervieu-Bègue M, Osseby GV, Giroud M, Béjot Y. [Management of ischemic stroke in the acute phase]. Rev Med Interne 2021; 43:286-292. [PMID: 34481684 DOI: 10.1016/j.revmed.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.
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Affiliation(s)
- G Duloquin
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Graber
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Baptiste
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - S Mohr
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Garnier
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Ndiaye
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - C Blanc-Labarre
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Hervieu-Bègue
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - G-V Osseby
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Giroud
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - Y Béjot
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France.
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Ronsoni RM, Saffi MAL, Gonçalves MVM, Nakayama IH, Luz Leiria TL. A New Vision at the Interface of Atrial Fibrillation and Stroke. Front Cardiovasc Med 2021; 8:689313. [PMID: 34434974 PMCID: PMC8380765 DOI: 10.3389/fcvm.2021.689313] [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: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Current evidence questions the linear sequence traditionally described in atrial fibrillation, blood stasis, intracavitary thrombus, and embolization to the central nervous system. Currently, new perspectives have been described based on questions from the linearly traditional chronology of events; it is within this scope that the article has its objective. Evidences: The association of the two entities is biologically plausible and supported by different cohorts with a higher risk of developing atrial fibrillation, especially in the cardioembolic form. Concepts (temporal dissociation, biological gradient, etc.) determine the existence of other factors associated with cardioembolism, not exclusively by atrial fibrillation. The entire cascade of events associated with myopathy and atrial remodeling can generate damage to the myocyte and amplify the prothrombotic status. It is important to clarify that atrial myopathy can present itself as atrial fibrillation initially or not, but should always be considered thrombogenic in all the contexts of their clinical presentation. Considering atrial heart disease as a cause of embolic stroke, it could explain that one-third of strokes are considered cryptogenic. Conclusions: The traditional model exclusively associating the presence of atrial fibrillation in the genesis of thromboembolism is incomplete. The concept of atrial cardiopathy where cardioembolism occurs in a non-atrial fibrillation dependent manner fits better with current data. The future challenge is to effectively detect the various manifestations of atrial heart disease, generating direct implications for the identification of patients at risk of stroke and also for better management after a cardioembolic event.
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Affiliation(s)
- Rafael M Ronsoni
- Electrophysiology Department, Instituto de Ritmologia Cardíaca, Joinville, Brazil.,Department of Medicine, Universidade da Região de Joinville, Joinville, Brazil
| | | | | | | | - Tiago Luiz Luz Leiria
- Programa de Pós-Graduação em Ciências da Saúde - Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
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33
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Association of Aortic Arch Calcification on Chest X-ray with Procedural Thromboembolism after Mechanical Thrombectomy for Acute Ischemic Stroke. MEDICINA-LITHUANIA 2021; 57:medicina57090859. [PMID: 34577782 PMCID: PMC8467333 DOI: 10.3390/medicina57090859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
Background and Objective: Procedural thromboembolism after a mechanical thrombectomy (MT) for an acute ischemic stroke (AIS) has rarely been studied. It may occur from the artery-to-artery embolization of atherosclerotic plaque in the aortic arch. We investigated the relationship between aortic arch calcification (AoAC) on a chest X-ray and procedural thromboembolism on diffusion-weighted imaging (DWI) after an MT. Materials and Methods: From January 2017 to December 2020, 131 patients underwent DWI within two days following an MT for an AIS. Procedural thromboembolism was defined as new DWI-positive lesions in other territories from the occluded artery on DWI within two days after MT. Results: Procedural thromboembolism was observed in 30 (22.9%) patients. Procedural thromboembolism was associated with old age (72.3 ± 9.44 vs. 65.7 ± 12.8 years, p = 0.003), a longer procedural time (77.6 ± 37.6 vs. 60.1 ± 29.7 min, p = 0.024), and AoAC (calcification (73.3%) vs. no calcification (29.7%), p < 0.001). Multivariable logistic regression analysis showed that procedural thromboembolism was independently associated with AoAC (adjusted odds ratio (OR): 6.107, adjusted 95% confidence interval (CI): 2.374–15.705, p < 0.001) and a longer procedural time (adjusted OR: 1.015, adjusted 95% CI: 1.001–1.030, p = 0.031). Conclusions: Procedural thromboembolism after an MT for an AIS was related to AoAC on a chest X-ray and a longer procedural time. Our results suggest that although rapid recanalization is the most crucial goal of an MT for an AIS, the importance of the careful advance of the guiding catheter through the aortic arch should not be underestimated to reduce the risk of procedural thromboembolism, especially in patients with AoAC on a chest X-ray.
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Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1020] [Impact Index Per Article: 340.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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van der Maten G, Dijkstra S, Meijs MFL, von Birgelen C, van der Palen J, den Hertog HM. Cardiac imaging in ischemic stroke or transient ischemic attack of undetermined cause: Systematic review & meta-analysis. Int J Cardiol 2021; 339:211-218. [PMID: 34197841 DOI: 10.1016/j.ijcard.2021.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with "cryptogenic stroke or TIA" the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT). METHODS AND RESULTS We performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3-71.2 years, 49.2-59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies. CONCLUSIONS TTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands; Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands.
| | - Saskia Dijkstra
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands
| | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands; Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands; Department of Research Methodology, Measurement and Data Analysis, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, the Netherlands
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Schnabel RB, Häusler KG. [Cardiac diagnostics after ischemic stroke or transitory ischemic attack]. Dtsch Med Wochenschr 2021; 146:801-808. [PMID: 34130322 DOI: 10.1055/a-1221-7095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Stroke is the most common cause of permanent disability and one of the most common causes of death. Cardio-embolic strokes are associated with a poor prognosis and a high risk of recurrence compared to other stroke etiologies. The most common source of cardiac embolism is atrial fibrillation which must be quickly identified to optimize secondary stroke prevention. A structured evaluation after ischemic stroke includes taking the medical history, a physical examination, 12-lead ECG recording, rhythm monitoring for 72 h, transthoracic echocardiography and transesophageal echocardiography, if an atrial embolic source of stroke is suspected. Extended cardiac work-up (e. g., MRI/CT, prolonged rhythm monitoring) should be performed in selected patients based on diagnostic findings.
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Gusdon AM, Farrokh S, Grotta JC. Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease. Semin Neurol 2021; 41:365-387. [PMID: 33851394 DOI: 10.1055/s-0041-1726331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.
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Affiliation(s)
- Aaron M Gusdon
- Department of Neurosurgery, UTHealth Neurosciences, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas
| | - Salia Farrokh
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Texas Medical Center, Houston
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39
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Poli S, Siebert E, Mbroh J, Poli K, Krumbholz M, Mengel A, Greulich S, Härtig F, Müller KAL, Bocksch W, Gawaz M, Ziemann U, Zuern CS. Closure or medical therapy of patent foramen ovale in cryptogenic stroke: prospective case series. Neurol Res Pract 2021; 3:16. [PMID: 33789756 PMCID: PMC8015114 DOI: 10.1186/s42466-021-00114-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Results of randomized controlled trials (RCT) do not provide definite guidance for secondary prevention after ischemic stroke (IS)/transient ischemic attack (TIA) attributed to patent foramen ovale (PFO). No recommendations can be made for patients > 60 years. We aimed to compare interventional and medical PFO-management in cryptogenic IS/TIA patients, including patients > 60 years. Methods Prospective case series including consecutive cryptogenic IS/TIA patients with PFO at Tuebingen university stroke unit, Germany. ‘PFO-closure’ was recommended in patients ≤70 years when featuring high-risk PFO (i.e., with atrial septal aneurysm, spontaneous, or high-grade right-to-left shunt during Valsalva). Primary (recurrent IS/intracranial hemorrhage) and secondary endpoints (e.g., disability) were assessed during ≥1-year follow-up; planned subgroup analyses of patients ≤60/> 60 years. Results Among 236 patients with median age of 58 (range 18–88) years, 38.6% were females and median presenting National Institutes of Health Stroke Scale score was 1 (IQR 0–4). Mean follow-up was 2.8 ± 1.3 years. No intracranial hemorrhage was observed. Recurrent IS rate after ‘PFO-closure’ was 2.9% (95%CI 0–6.8%) and 7% (4–16.4) in high-risk PFO patients ≤60 (n = 103) and > 60 years (n = 43), respectively, versus 4% (0–11.5) during ‘medical therapy alone’ MTA (n = 28). 42 low-risk PFO patients treated with MTA experienced no recurrent IS/TIA. Conclusions In our real-world study, IS recurrence rate in ‘PFO-closure’ high-risk PFO patients ≤60 years was comparable to that observed in recent RCT. High-risk PFO patients > 60 years who underwent PFO-closure had similar IS recurrence rates than those who received MTA. MTA seems the appropriate treatment for low-risk PFO. Trial registration ClinicalTrials.gov, registration number: NCT04352790, registered on: April 20, 2020 – retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00114-3.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.
| | - Elisabeth Siebert
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Markus Krumbholz
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Simon Greulich
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Florian Härtig
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Karin A L Müller
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Wolfgang Bocksch
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Christine S Zuern
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
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40
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Witte KK, Tsivgoulis G, Reynolds MR, Tsintzos SI, Eggington S, Ismyrloglou E, Lyon J, Huynh M, Egea M, de Brouwer B, Ziegler PD, Franco N, Joglekar R, Rosemas SC, Liu S, Thijs V. Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation. BMC Cardiovasc Disord 2021; 21:160. [PMID: 33789592 PMCID: PMC8015049 DOI: 10.1186/s12872-021-01967-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/23/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. Methods CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. Results Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953–£7018 per patient (UK), €6683–€7368 (Netherlands), €4933–€9378 (Spain), AUD$5353–6539 (Australia) and $26,768–$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468–$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). Conclusions Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-01967-x.
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Affiliation(s)
- Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, LIGHT Building, Clarendon Way, Leeds, LS2 9JT, UK.
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, National & Kapodistrian University of Athens Medical School, Athens, Greece
| | | | | | - Simon Eggington
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | | | | | | | | | - Paul D Ziegler
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
| | - Noreli Franco
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
| | - Rashmi Joglekar
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | - Shufeng Liu
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
| | - Vincent Thijs
- Florey Institute of Neuroscience, Melbourne, Australia
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41
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Nicot F, Charbonnel C, Jego C, Jourda F, Vinsonneau U, Garçon P, Turlotte G, Rivière JF, Maurin M, Lubret R, Meimoun P, Akret C, Cournot M, Sokic C, Michel L, Lescure M, Kenizou D, Melay M, Fayard M, Chauvat A, Fouché R, Cartigny G, Dijoux N, Martin AC, Tho-Agostini A, Mann H, Magnin D, Goralski M, Pico F, Georges JL, Belle L. Use of ADAM-C and CHA2DS2-VASc scores to predict complex aortic atheroma after brain ischemia: A prospective observational study. Echocardiography 2021; 38:612-622. [PMID: 33764608 DOI: 10.1111/echo.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/03/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Complex aortic atheroma (CAA) is a common cause of acute brain ischemia (BI), including ischemic stroke (IS) and transient ischemic attack (TIA), and is associated with recurrence. The CHA2DS2-VASc score is a useful tool for predicting stroke in patients with atrial fibrillation (AF), and can also predict cardiovascular events in other populations, including non-AF populations. The ADAM-C score is a new risk score for predicting the diagnostic yield of transesophageal echocardiography (TEE) after BI. We aimed to evaluate the ability of CHA2DS2-VASc and ADAM-C scores to predict CAA after BI. METHODS This prospective, multicenter, observational study included 1479 patients aged over 18 years who were hospitalized for BI. CAA was defined as the presence of one or more of the following criteria: thrombus, ulcerated plaque, or plaque thickening ≥ 4 mm. RESULTS CAA was diagnosed in 216 patients (14.6%). CHA2DS2-VASc and ADAM-C scores were significantly higher in the CAA group versus the non-CAA group (P < .0001 for both). The CHA2DS2-VASc and ADAM-C scores appear to be good predictors of CAA (AUC 0.699 [0.635, 0.761] and 0.759 [0.702, 0.814], respectively). The sensitivity, specificity, predictive positive value (PPV), and negative predictive value (NPV) of the scores for detecting CAA were 94%, 22%, 17%, and 96%, respectively, for a CHA2DS2-VASc score < 2, and 90%, 46%, 22%, and 96%, respectively, for an ADAM-C score < 3 CONCLUSIONS: CHA2DS2-VASc and ADAM-C scores are able to predict CAA after BI. CHA2DS2-VASc < 2 and ADAM-C < 3 both have an interesting NPV of 96%.
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Affiliation(s)
- Florence Nicot
- Department of Cardiology, Versailles Hospital, Le Chesnay, France
| | | | - Christophe Jego
- Department of Cardiology, Toulon inter-armée Hospital, Toulon, France
| | | | - Ulric Vinsonneau
- Department of Cardiology, Brest inter-armée Hospital, Brest, France
| | - Philippe Garçon
- Department of Cardiology, Saint Joseph Hospital, Paris, France
| | - Guillaume Turlotte
- Department of Cardiology, La Roche sur Yon Hospital, La Roche sur Yon, France
| | | | - Marion Maurin
- Department of Cardiology, CHU Grenoble-Alpes, Grenoble, France
| | - Rémy Lubret
- Department of Cardiology, Boulogne sur mer Hospital, Boulogne sur mer, France
| | - Patrick Meimoun
- Department of Cardiology, Compiègne Hospital, Compiègne, France
| | - Chrystelle Akret
- Department of Cardiology, Annecy-Genevois Hospital, Annecy, France
| | - Maxime Cournot
- Department of Cardiology, Saint Paul Hospital, Saint Paul, France
| | - Charles Sokic
- Department of Cardiology, Haguenau Hospital, Haguenau, France
| | - Laurent Michel
- Department of Cardiology, Saint Lo Hospital, Saint Lo, France
| | | | - David Kenizou
- Department of Cardiology, Mulhouse Hospital, Mulhouse, France
| | - Marie Melay
- Department of Cardiology, Vichy Hospital, Vichy, France
| | - Maxime Fayard
- Department of Cardiology, Chalon sur Saone Hospital, Chalon sur Saone, France
| | - Anthony Chauvat
- Department of Cardiology, Argenteuil Hospital, Argenteuil, France
| | - Renaud Fouché
- Department of Cardiology, Montbéliard Hospital, Montbéliard, France
| | | | - Nicolas Dijoux
- Department of Cardiology, Saint Pierre Hospital, Saint Pierre, France
| | - Anne Céline Martin
- Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Hubert Mann
- Department of Cardiology, Voiron Hospital, Voiron, France
| | | | - Marc Goralski
- Department of Cardiology, Orléans Hospital, Orléans, France
| | - Fernando Pico
- Department of Cardiology, Versailles Hospital, Le Chesnay, France.,Department of Neurology, Université Versailles Saint-Quentin en Yvelines et Paris Saclay, Le Chesnay, France
| | | | - Loïc Belle
- Department of Cardiology, Annecy-Genevois Hospital, Annecy, France
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42
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Diener HC, Wachter R. [Diagnosis and treatment of acute ischemic insults]. Herz 2021; 46:195-204. [PMID: 33598821 DOI: 10.1007/s00059-021-05021-6] [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] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
In cases of stroke a distinction is made between a transient ischemic attack (TIA), a manifest ischemic infarction and cerebral hemorrhage. Cerebral ischemia can be caused by large vessel disease, small vessel disease, embolic causes, rare causes or stroke of unknown etiology. Acute diagnostic tests include a neurological examination, computed tomography (CT) and/or magnetic resonance imaging (MRI) with angiography, electrocardiography (ECG), and laboratory tests. The basic treatment of patients with TIA or acute ischemic infarction is performed in the stroke unit and includes monitoring of respiratory function, cardiac function, treatment of potential heart failure, detection of swallowing disorders, prophylaxis of thromboembolism, control of blood pressure and elevated blood sugar levels, and lowering of elevated body temperature. In patients with cardioembolic infarction, oral anticoagulation is initiated depending on the severity of the stroke and the size of the stroke on imaging.
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Affiliation(s)
- H C Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - R Wachter
- Klinik und Poliklinik für Kardiologie, Universität Leipzig, Leipzig, Deutschland
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43
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van der Maten G, Reimer JMB, Meijs MFL, von Birgelen C, Brusse-Keizer MGJ, den Hertog HM. Detection of Major Cardioembolic Sources in Real-World Patients with Ischemic Stroke or Transient Ischemic Attack of Undetermined Cause. Cerebrovasc Dis Extra 2021; 11:22-28. [PMID: 33524986 PMCID: PMC7989814 DOI: 10.1159/000512743] [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: 09/17/2020] [Accepted: 11/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background/Aim Current guidelines recommend transthoracic echocardiography (TTE) and ambulatory rhythm monitoring following ischemic stroke or transient ischemic attack (TIA) of undetermined cause for identifying cardioembolic sources (CES). Due to ongoing controversies about this routine strategy, we evaluated its yield in a real-world setting. Methods In a tertiary medical center, we retrospectively evaluated consecutive patients with ischemic stroke or TIA of undetermined cause, who (after standard work-up) underwent TTE, ambulatory rhythm monitoring, or both. CES were classified as major if probably related to ischemic events and warranting a change of therapy. Results Between January 2014 and December 2017, 674 patients had ischemic stroke or TIA of undetermined cause. Of all 484 patients (71.8%) who underwent TTE, 9 (1.9%) had a major CES. However, 7 of them had already been identified for cardiac evaluation due to new major electrocardiographic abnormalities or cardiac symptoms. Thus, only 2 patients (0.4%) truly benefitted from unselected TTE screening. Ambulatory rhythm monitoring was performed in 411 patients (61.0%) and revealed AF in 10 patients (2.4%). Conclusion Detecting a major CES is essential because appropriate treatment lowers the risk of recurrent stroke. Nonetheless, in this real-world study that aimed at routine use of TTE and ambulatory rhythm monitoring in patients with ischemic stroke or TIA of undetermined cause, the prevalence of major CES was low. Most patients with major CES on TTE already had an indication for referral to a cardiologist, suggesting that major CES might also have been identified with a much more selective use of TTE.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands, .,Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands,
| | - Jorieke M B Reimer
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marjolein G J Brusse-Keizer
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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44
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Viedma-Guiard E, Guidoux C, Amarenco P, Meseguer E. Aortic Sources of Embolism. Front Neurol 2021; 11:606663. [PMID: 33519684 PMCID: PMC7843443 DOI: 10.3389/fneur.2020.606663] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022] Open
Abstract
Aortic arch atheroma is a frequent finding in ischemic stroke patients. Its role as a source of cerebral emboli or a marker of atherosclerosis is unclear. Transesophageal echography is considered the gold standard for its detection, whereas computed tomography angiography is a good alternative; magnetic resonance and positron emission tomography could be proposed to better analyze plaque vulnerability. Despite the interest in this condition, the optimal antithrombotic treatment remains uncertain, while intensive lipid-lowering therapy should be recommended. This review aims to offer guidance on patients with aortic arch atheroma, about its causal role in stroke, diagnosis, and treatment based on current available evidence.
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Affiliation(s)
- Elena Viedma-Guiard
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Celine Guidoux
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Elena Meseguer
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
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45
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Strecker C, Günther F, Harloff A. Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients? Front Neurol 2021; 11:588151. [PMID: 33391153 PMCID: PMC7775476 DOI: 10.3389/fneur.2020.588151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke. Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology. Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020. Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.
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Affiliation(s)
- Christoph Strecker
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Felix Günther
- Department of Internal Medicine, Staufenburg Klinik, Durbach, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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46
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Dimancea A, Ene A, Badea R, Ribigan A. Anticoagulation-refractory strokes and selective infarction pattern: What's the link? Clin Case Rep 2021; 9:220-223. [PMID: 33489163 PMCID: PMC7813005 DOI: 10.1002/ccr3.3502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/10/2020] [Accepted: 10/21/2020] [Indexed: 11/10/2022] Open
Abstract
Stroke etiology in the form of a CAP should be actively explored, especially in the context of previous negative work-up and anticoagulant-refractory strokes. Dual antiplatelet therapy proved superior to anticoagulation for secondary prevention.
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Affiliation(s)
- Alexandru Dimancea
- Neurology DepartmentBucharest University Emergency HospitalBucharestRomania
| | - Amalia Ene
- Neurology DepartmentBucharest University Emergency HospitalBucharestRomania
| | - Raluca Badea
- Neurology DepartmentBucharest University Emergency HospitalBucharestRomania
| | - Athena Ribigan
- Neurology DepartmentBucharest University Emergency HospitalBucharestRomania
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Abstract
PURPOSE OF REVIEW Cryptogenic stroke represents a heterogenous but clinically important collection of stroke etiologies for which our understanding continues to grow. Here, we review our current knowledge and most recent recommendations on secondary prevention for common causes of cryptogenic stroke including paroxysmal atrial fibrillation, atrial cardiopathy, patent foramen ovale, and substenotic atherosclerotic disease as well as the under-recognized mechanisms of occult malignancy, heart failure, and, most recently, infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). RECENT FINDINGS The results from recent observational studies and randomized clinical trials have provided greater insight into the causal relationship and attributable risk of these suspected etiologies and have identified potential strategies to reduce the rates of recurrence. However, further clinical trials are needed to confirm the benefits of specific stroke prevention strategies, including the patient populations most likely to benefit from anticoagulation. There is ongoing research aimed at both reducing the proportion of ischemic strokes classified as cryptogenic and resolving much of the clinical equipoise that still exists. The results of these studies have the potential to provide us with a better understanding of these occult mechanisms and allow for more targeted interventions.
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Affiliation(s)
- Chinwe Ibeh
- grid.413734.60000 0000 8499 1112Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University and New York-Presbyterian Hospital, 710 W 168th St, New York, NY USA
| | - Mitchell S. V. Elkind
- grid.413734.60000 0000 8499 1112Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University and New York-Presbyterian Hospital, 710 W 168th St, New York, NY USA ,grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
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48
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Neurologic complications of diseases of the aorta. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:221-239. [PMID: 33632441 DOI: 10.1016/b978-0-12-819814-8.00028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.
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49
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Specktor P, Yalonetsky S, Agmon Y, Sprecher E, Ali FH, Telman G. The effect of TEE on treatment change in patients with acute ischemic stroke. PLoS One 2020; 15:e0243142. [PMID: 33270736 PMCID: PMC7714247 DOI: 10.1371/journal.pone.0243142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Ischemic stroke is a widespread disease carrying high morbidity and mortality. Transesophageal echocardiography (TEE) is considered an important tool in the work-up of patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients; its utility is limited by a semi-invasive nature. The purpose of this study was to evaluate the probability of treatment change due to TEE findings (yield) in the work-up of AIS and TIA patients. Methods Retrospective data on patients with AIS or TIA who underwent TEE examination between 2000–2013 were collected from the institutional registry. Results The average age of 1284 patients who were included in the study was 57±10.4, 66% of patients were male. The most frequent TEE findings included aortic plaques in 54% and patent foramen ovale (PFO) in 15%. TEE findings led to treatment change in 135 (10.5%) patients; anticoagulant treatment was initiated in 110 of them (81%). Most common etiology for switch to anticoagulation was aortic plaques (71 patients); PFO was second most common reason (26 patients). Significant TEE findings (thrombus, endocarditis, tumor) were found in 1.9% of patients, they were more common in young patients (<55; 56% of the patients). Conclusions The beginning of anticoagulation treatment in patients with thick and complicated plaques was found frequently in our study. Significant TEE findings, were infrequent, constituted an absolute indication for treatment change and were more common in younger patients.
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Affiliation(s)
- Polina Specktor
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Department of Neurology, Carmel Hospital, Haifa, Israel
| | | | - Yoram Agmon
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Elliot Sprecher
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Faten Haj Ali
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Gregory Telman
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Technion, Israel Institute of Technology, Haifa, Israel
- * E-mail:
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Secondary Stroke Prevention and Management for the Neuro-Ophthalmologist. J Neuroophthalmol 2020; 40:463-471. [DOI: 10.1097/wno.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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