1
|
Lee P, Dhillon G, Pourafkari M, DaBreo D, Jaff Z, Appireddy R, Jin A, Boissé Lomax L, Durafourt BA, Boyd JG, Nasirzadeh AR, Tampieri D, Jalini S. Non-ECG-gated cardiac CT angiography in acute stroke is feasible and detects sources of embolism. Int J Stroke 2024; 19:189-198. [PMID: 37515467 PMCID: PMC10811964 DOI: 10.1177/17474930231193335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND A significant portion of cryptogenic stroke is hypothesized to be secondary to cardiac embolism. However, transthoracic echocardiogram is usually delayed after stroke, and more detailed cardiac imaging is not routinely done. AIMS This study aimed to determine whether non-ECG-gated cardiac CT angiography (cCTA) during hyperacute stroke would provide diagnostic quality images and act as an adjunct modality of cardiac imaging to detect sources of emboli. METHODS In this single-center prospective cohort study, modified Code Stroke imaging was implemented with a 64-slice CT scanner, where the longitudinal axis of CT angiography was extended from the carina to the diaphragm. The primary outcomes of image quality, recruitment feasibility, impact on hyperacute time metrics, and additional radiation dose were assessed. Secondary outcomes consisted of detection of high-risk cardiac sources of embolism, mediastinal or lung pathology, and impact on etiologic classification. RESULTS One hundred and twenty eligible patients were enrolled, of which 105 (87.5%) had good/moderate quality images for motion artifact and 119 (99.2%) for contrast opacification. Total CT time, door-to-needle time, and door-to-groin puncture time were unchanged with the addition of cCTA. Eighty-nine patients received a final diagnosis of ischemic stroke, of which 12/89 (13.5%) had high-risk cardioembolic findings on cCTA. Incidental findings, such as pulmonary embolism (PE) (7/89, 7.9%) and malignancy (6/89, 6.7%), were observed. cCTA led to changes in management for 19/120 (15.8%) of all patients, and reclassification of stroke etiology for 8/89 (9%) of patients. CONCLUSIONS Non-ECG-gated cCTA can be feasibly incorporated into Code Stroke and provide diagnostic quality images without delays in hyperacute time metrics. It can detect high-risk cardiac sources, and other findings impacting patient care. This may help reclassify a subset of cryptogenic stroke cases and improve secondary prevention.
Collapse
Affiliation(s)
- Peter Lee
- School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Gurmohan Dhillon
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Marina Pourafkari
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Dominique DaBreo
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Zardasht Jaff
- Division of Cardiology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Albert Jin
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Lysa Boissé Lomax
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Bryce A Durafourt
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - John Gordon Boyd
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Amir Reza Nasirzadeh
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Donatella Tampieri
- Department of Radiology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| |
Collapse
|
2
|
Sposato LA, Albin CSW, Elkind MSV, Kamel H, Saver JL. Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence. Stroke 2024; 55:236-247. [PMID: 38134261 DOI: 10.1161/strokeaha.123.040546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
Collapse
Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry (L.A.S.), Western University, London, ON, Canada
- Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada (L.A.S.)
| | - Catherine S W Albin
- Department of Neurology & Neurosurgery, Emory University School of Medicine, Atlanta, GA (C.S.W.A.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| |
Collapse
|
3
|
Bashir Z, Chen EW, Wang S, Shu L, Goldstein ED, Rana M, Kala N, Dai X, Mandel D, Has P, Xie M, Wang T, Dickey JB, Poppas A, Simmons J, Song C, Yaghi S, Haines P. Left atrial strain, embolic stroke of undetermined source, and atrial fibrillation detection. Echocardiography 2024; 41:e15738. [PMID: 38284672 DOI: 10.1111/echo.15738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Atrial cardiopathy is a proposed mechanism of embolic stroke of undetermined source (ESUS). Left atrial (LA) strain may identify early atrial cardiopathy prior to structural changes. We aim to study the associations between LA strain, ESUS, and atrial fibrillation (AF) detection in ESUS. METHODS The study population included patients with ESUS and noncardioembolic (NCE) stroke presenting to the Rhode Island Hospital Stroke Center between January 2016 and June 2017 who underwent transthoracic echocardiography. Speckle tracking echocardiography (STE) was used to measure the three phases of LA strain (reservoir, conduit, and contractile). Binary logistic regression analysis was performed to determine the associations between LA strain and stroke subtype (ESUS vs. NCE) as well as follow-up detection of AF in ESUS patients. RESULTS We identified 656 patients, 307 with ESUS and 349 with NCE. In binary logistic regression, the lowest tertiles of LA reservoir (adjusted OR 1.944, 95% CI 1.266-2.986, p = .002), contractile (aOR 1.568, 95% CI 1.035-2.374, p = .034), and conduit strain (aOR 2.288, 95% CI 1.448-3.613, p = .001) were more likely to be significantly associated with ESUS compared to NCE stroke. Among all ESUS patients, the lowest tertiles of LA reservoir strain (OR 2.534, 95% CI 1.029-6.236, p = .043), contractile strain (OR 2.828, 95% CI 1.158-6.903, p = .022), and conduit strain (OR 2.614, 95% CI 1.003-6.815, p = .049) were significantly associated with subsequent detection of AF. CONCLUSION Reduced LA strain is associated with ESUS occurrence and AF detection in ESUS patients. Therefore, quantification of LA strain in ESUS patients may improve risk stratification and guide secondary prevention strategies.
Collapse
Affiliation(s)
- Zubair Bashir
- Department of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Edward W Chen
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shuyuan Wang
- Department of Ultrasound, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liqi Shu
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Eric D Goldstein
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Maheen Rana
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Narendra Kala
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Xing Dai
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel Mandel
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Phinnara Has
- Lifespan Biostatistics, Epidemiology and Research Design, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mingxing Xie
- Department of Ultrasound, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Wang
- Stanford Cardiovascular Institute, Stanford University, Palo Alto, California, USA
| | - John B Dickey
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcestor, Massachusetts, USA
| | - Athena Poppas
- Department of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James Simmons
- Department of Pulmonary, Critical Care, and Sleep Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher Song
- Department of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Philip Haines
- Department of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
4
|
Berdalin AB, Namestnikova DD, Cherkashova EA, Golovin DA, Gubskiy IL, Lelyuk VG. Arterial Hypertension and Its Consequences Are the Main Predictors of Embolic Stroke of Undetermined Source. Dis Markers 2023; 2023:3469755. [PMID: 38025665 PMCID: PMC10667056 DOI: 10.1155/2023/3469755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/09/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023]
Abstract
Methods We performed a hospital-based prospective cohort study with 1,317 enrolled participants. We compared patients and healthy volunteers according to the main demographic, anthropometric parameters, stroke risk factors, comorbidities, and data of clinical and instrumental examination. In order to balance the study and the control groups for age and sex, the propensity score matching was performed. In order to generate the overall predictive model, a multivariate analysis was performed using the binary logistic regression method. Results The following predictors of ESUS were identified in current study: arterial hypertension (AH); increased heart rate and pulmonary arterial systolic pressure (PASP); the presence of conduction disturbance; the enlargement of left, right atrium, and left ventricle end-systolic length; increased intima-media thickness (IMT) in right and left common carotid artery (CCA); lowered Montreal Cognitive Assessment (MoСA) cognitive scale score; the presence of subcortical microbleeds; central brain atrophy; the larger size of third ventricle; and the higher medial temporal lobe atrophy (MTA) score. The following risk factors were included in the final predictive model: the presence of AH (p < 0.0005; OR = 12.98 (95% CI: 4.53-37.21)) and PASP (p=0.018; OR = 1.13 (95% CI: 1.02-1.25)) and male sex (p=0.046; OR = 2.771 (95% CI: 1.017-7.555)). The Nagelkerke's pseudo-R-squared value was 0.404 and the significance of the Hosmer-Lemeshow test was 0.733, which indicate the goodness of the final logistic regression model. Conclusions We propose that AH and its consequences are the main predictors of ESUS. The results of this study emphasize the importance of AH control for primary and secondary prevention of ESUS.
Collapse
Affiliation(s)
- Alexander B. Berdalin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Daria D. Namestnikova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Elvira A. Cherkashova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Denis A. Golovin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Ilya L. Gubskiy
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Vladimir G. Lelyuk
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| |
Collapse
|
5
|
Masood S, Ashraf SMK, Malik MA, Wahab S. P-wave indices and left atrial mechanics as predictors of atrial cardiopathy in embolic stroke of undetermined source. Sci Rep 2023; 13:19965. [PMID: 37968274 PMCID: PMC10651911 DOI: 10.1038/s41598-023-44285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023] Open
Abstract
Recent research has shed light on the culpability of LA (left atrial) abnormality, in the form of atrial cardiopathy, as an independent risk factor for the development of atrial fibrillation, LA thrombus and subsequent stroke. The aim of this study was to measure LA electromechanical dissociation (EMD), LA volumes, P-wave dispersion (PWD) and P-wave terminal force in V1 (PTFV1) as markers of atrial cardiopathy in patients with ESUS (embolic stroke of undetermined source), to determine whether atrial cardiopathy is an integral part in the causal pathway of ESUS. 28 patients presenting with ischemic stroke and fulfilling the criteria for ESUS were enrolled into this cross-sectional, observational study along with a control group of 28 age- and gender-matched apparently healthy individuals. On ECG, PWD and PTFV1 were measured. On echocardiography, LA EMD and LA volumes were recorded. Increased PWD (34.14 ± 9.89 ms vs. 27.32 ± 8.95 ms; p = 0.01), atrial EMD (73.32 ± 16.31 ms vs. 63.63 ± 13.59 ms; p = 0.02) and LA volumes were observed in patients with ESUS as compared to controls. A significant correlation was also found between these parameters (p < 0.01). According to the results of our study, PWD, atrial EMD and LA volumes may be novel predictors for ESUS. Our results support the notion that atrial cardiopathy is a distinct mechanism of thrombosis in ESUS patients. Further research is required to clarify its function in the causation of stroke, ESUS in particular.
Collapse
Affiliation(s)
- Samia Masood
- Department of Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India.
| | - Syed Mohammad Kamil Ashraf
- Department of Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India
| | - Mohammad Azharuddin Malik
- Department of Cardiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India
| | - Shagufta Wahab
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India
| |
Collapse
|
6
|
Mattoso AAA, Sena JP, Hotta VT. The Role of Echocardiography in the Assessment of the Interatrial Septum and Patent Foramen Ovale as an Emboligenic Source. Arq Bras Cardiol 2023; 120:e20220903. [PMID: 37909574 PMCID: PMC10586815 DOI: 10.36660/abc.20220903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/07/2023] [Accepted: 07/17/2023] [Indexed: 11/03/2023] Open
Abstract
A comunicação do septo atrial (CIA) representa, aproximadamente, de 6%-10% dos defeitos cardíacos congênitos, com incidência de 1 em 1.500 nascidos vivos.1 Forame oval patente (FOP) é mais comum e está presente em mais de 20%-25% dos adultos.2 Síndromes clínicas associadas a CIA e FOP são variáveis, com implicações abrangendo a medicina pediátrica e adulta, neurologia e cirurgia. O interesse adicional na anatomia do septo interatrial (SIA) aumentou substancialmente nas últimas duas décadas, com evolução simultânea dos procedimentos percutâneos envolvendo cardiopatia estrutural do lado esquerdo e procedimentos eletrofisiológicos. Idealmente, essas intervenções baseadas em cateter requerem rota direta para o átrio esquerdo (AE) através do SIA, necessitando completo entendimento de sua anatomia. Atualmente, tecnologias de imagem sofisticadas e não invasivas como ecocardiografia transesofágica bidimensional (ETE 2D) e tridimensional (ETE 3D), ressonância cardíaca (RMC) e tomografia computadorizada (TC) passaram por um extraordinário desenvolvimento tecnológico, fornecendo detalhes anatômicos das estruturas cardíacas visualizadas em formato 2D e 3D e são essenciais para diagnóstico e tratamento de pacientes com doenças cardíacas. A avaliação da anatomia e anormalidades do SIA, portanto, requer abordagem padronizada e sistemática, integrando modalidades diagnósticas e fornecendo avaliação adequada e uniforme para terapias cirúrgicas e transcateter.
Collapse
Affiliation(s)
| | - Joberto Pinheiro Sena
- Hospital Santa IzabelSalvadorBABrasilHospital Santa Izabel – Hemodinâmica, Salvador, BA – Brasil
| | - Viviane Tiemi Hotta
- Instituto do CoraçãoHCFMUSPSão PauloSPBrasilInstituto do Coração HC-FMUSP – Unidade Clinica de Miocardiopatias e Doenças da Aorta, São Paulo, SP – Brasil
- Fleury Medicina e SaúdeSão PauloSPBrasilFleury Medicina e Saúde, São Paulo, SP – Brasil
| |
Collapse
|
7
|
George J, Sylaja PN, Sreedharan SE. Recurrence of Cryptogenic (ESUS) Strokes in the First Year: Predictors and Outcome-A South Indian Study. Ann Indian Acad Neurol 2023; 26:728-732. [PMID: 38022488 PMCID: PMC10666862 DOI: 10.4103/aian.aian_282_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/09/2023] [Accepted: 06/24/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Around 9-25% of ischemic strokes are embolic stroke of undetermined source (ESUS) with an annual recurrence risk of 4.5-5%. Regarding ESUS, studies from India are limited. Here, we studied the prevalence of cryptogenic ESUS among stroke subtypes, recurrence risk and outcome at 1 year, and their predictors. Materials and Methods We performed a single-center study of ambispective nature. Patients above 18 years of age with a diagnosis of cryptogenic (ESUS) strokes from January 1, 2017, to December 31, 2020 (4 years), with a 1-year follow-up were recruited in our study. All the patients underwent neuroimaging computerised tomography/magnetic resonance tomography (CT/MRI) with angiography, electrocardiogram (ECG), transthoracic echo (TTE), and rhythm monitoring. Functional outcome was measured using the modified Rankin scale with scores 0-2 taken as good outcome. Results We had 234 (11.21% of total ischemic strokes) subjects satisfying the criteria for ESUS over the study period with a mean age of 58.2 ± 12.8 years. 46 patients had a history of stroke/transient ischemic attack (TIA) at admission. 9.4% had a recurrent event at 1 year. The most important neuroimaging predictor of recurrent strokes was multiple embolic followed by superficial watershed pattern. Around 10% had more than one marker of atrial cardiopathy positive. While the risk factors, coronary artery disease (CAD), and neuroimaging pattern showed an association with recurrent events at 1 year on bivariate analysis, only the latter two remained significant on multivariate analysis. Conclusions Our cohort of ESUS had a higher annual recurrence risk than reported before. Though vascular risk factors and ipsilateral vessel abnormalities were more in the recurrent ESUS group, it did not significantly affect the recurrence risk at 1 year. CAD and multiple embolic patterns on imaging showed an association with recurrent strokes, suggesting a possible cardiac substrate in our ESUS population as well.
Collapse
Affiliation(s)
- Jithin George
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - P. N. Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sapna E. Sreedharan
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| |
Collapse
|
8
|
McCabe JJ, Evans NR, Gorey S, Bhakta S, Rudd JHF, Kelly PJ. Imaging Carotid Plaque Inflammation Using Positron Emission Tomography: Emerging Role in Clinical Stroke Care, Research Applications, and Future Directions. Cells 2023; 12:2073. [PMID: 37626883 PMCID: PMC10453446 DOI: 10.3390/cells12162073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023] Open
Abstract
Atherosclerosis is a chronic systemic inflammatory condition of the vasculature and a leading cause of stroke. Luminal stenosis severity is an important factor in determining vascular risk. Conventional imaging modalities, such as angiography or duplex ultrasonography, are used to quantify stenosis severity and inform clinical care but provide limited information on plaque biology. Inflammatory processes are central to atherosclerotic plaque progression and destabilization. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a validated technique for quantifying plaque inflammation. In this review, we discuss the evolution of FDG-PET as an imaging modality to quantify plaque vulnerability, challenges in standardization of image acquisition and analysis, its potential application to routine clinical care after stroke, and the possible role it will play in future drug discovery.
Collapse
Affiliation(s)
- John J. McCabe
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Nicholas R. Evans
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - Sarah Gorey
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Shiv Bhakta
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - James H. F. Rudd
- Division of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK;
| | - Peter J. Kelly
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| |
Collapse
|
9
|
Tan ESJ, de Leon J, Boey E, Chin HK, Ho KH, Aguirre S, Sim MG, Seow SC, Sharma VK, Kojodjojo P. Stroke Recurrence in Embolic Stroke of Undetermined Source Without Atrial Fibrillation on Invasive Cardiac Monitoring. Heart Lung Circ 2023; 32:1000-1009. [PMID: 37291002 DOI: 10.1016/j.hlc.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND More than half of patients with embolic stroke of undetermined source (ESUS) suffer from recurrent ischaemic stroke, despite the absence of atrial fibrillation (AF) on invasive cardiac monitoring (ICM). This study investigated the predictors and prognosis of recurrent stroke in ESUS without AF on ICM. METHOD This prospective study included patients with ESUS at two tertiary hospitals from 2015 to 2021 who underwent comprehensive neurological imaging, transthoracic echocardiography, and inpatient continuous electrographic monitoring for ≥48 hours prior to ICM for definitive exclusion of AF. Recurrent ischaemic stroke, all-cause mortality, and functional outcome by the modified Rankin scale (mRS) at 3 months were evaluated in patients without AF. RESULTS Of 185 consecutive patients with ESUS, AF was not detected in 163 (88%) patients (age 62±12 years, 76% men, 25% prior stroke, median time to ICM insertion 26 [7, 123] days), and stroke recurred in 24 (15%) patients. Stroke recurrences were predominantly ESUS (88%), within the first 2 years (75%), and involved a different vascular territory from qualifying ESUS (58%). Pre-existing cancer was the only independent predictor of recurrent stroke (adjusted hazard ratio [AHR] 5.43, 95% CI 1.43-20.64), recurrent ESUS (AHR 5.67, 95% CI 1.15-21.21), and higher mRS score at 3 months (ß 1.27, 95% CI 0.23-2.42). All-cause mortality occurred in 17 (10%) patients. Adjusting for age, cancer, and mRS category (≥3 vs <3), recurrent ESUS was independently associated with more than four times greater hazard of death (AHR 4.66, 95% CI 1.76-12.34). CONCLUSIONS Patients with recurrent ESUS are a high-risk subgroup. Studies elucidating optimal diagnostic and treatment strategies in non-AF-related ESUS are urgently required.
Collapse
Affiliation(s)
- Eugene S J Tan
- Department of Cardiology, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore.
| | - Jhobeleen de Leon
- Department of Cardiology, National University Heart Centre, Singapore
| | - Elaine Boey
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore
| | - Howe-Keat Chin
- Department of Neurology, National University Health System, Singapore
| | - Kian-Hui Ho
- Department of Cardiology, National University Heart Centre, Singapore
| | - Shana Aguirre
- Department of Cardiology, National University Heart Centre, Singapore
| | - Ming-Gin Sim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Swee-Chong Seow
- Department of Cardiology, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Neurology, National University Health System, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Cardiology, Ng Teng Fong General Hospital, Singapore
| |
Collapse
|
10
|
Pezawas T. ECG Smart Monitoring versus Implantable Loop Recorders for Atrial Fibrillation Detection after Cryptogenic Stroke-An Overview for Decision Making. J Cardiovasc Dev Dis 2023; 10:306. [PMID: 37504563 PMCID: PMC10380665 DOI: 10.3390/jcdd10070306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 07/29/2023] Open
Abstract
Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, most studies had substantial gaps in monitoring time, especially early after the index event. Following this, AF rates would be higher if patients underwent continuous monitoring early after stroke, avoiding any gaps in monitoring. The few existing randomized studies focused on patients with cryptogenic stroke but did not focus otherwise specifically on prevention strategies in patients at high risk for AF (patients at higher age or with high CHA2DS2-VASC scores). Besides invasive implantable loop recorders (ILRs), external loop recorders (ELRs) and mobile cardiac outpatient telemetry (MCOT) are non-invasive tools that are commonly used for long-term ECG monitoring in cryptogenic-stroke patients in the ambulatory setting. The role of MCOT and hand-held devices within ECG smart monitoring in the detection of AF for the prevention of and after cryptogenic stroke is currently unclear. This intense review provides an overview of current evidence, techniques, and gaps in knowledge and aims to advise which patients benefit most from the current available devices.
Collapse
Affiliation(s)
- Thomas Pezawas
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| |
Collapse
|
11
|
Vos A, Rajakariar K, Siriratnam P, Freeman M. Recurrent strokes in the setting of anomalous left coronary artery from the pulmonary artery. BMJ Case Rep 2023; 16:e253772. [PMID: 37348924 PMCID: PMC10314464 DOI: 10.1136/bcr-2022-253772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
A young woman presented with a syncopal episode. As part of the work-up for her presentation, an MRI of the brain was performed which showed a small acute stroke. She subsequently had a further embolic-appearing stroke 9 months later. The initial investigations for the work-up of her strokes did not reveal any major abnormalities, including an unremarkable ECG and transthoracic echocardiogram (TTE). A transoesophageal echocardiogram (TOE) showed aneurysmal apical and mid-anteroseptal akinesis with mildly reduced left ventricular ejection fraction. Anomalous left coronary artery from the pulmonary artery (ALCAPA) was confirmed on coronary angiogram. Although ALCAPA presenting in adulthood is rare, our case highlights the value of TOE over TTE in the work-up of cryptogenic strokes, particularly in young patients with embolic strokes of undetermined source.
Collapse
Affiliation(s)
- Ayesha Vos
- Department of Neurology, Eastern Health, Box Hill, Victoria, Australia
| | - Kevin Rajakariar
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Pakeeran Siriratnam
- Faculty of Medicine, Nursing and Health Sciences, Monash University Eastern Health Clinical School, Box Hill, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University Eastern Health Clinical School, Box Hill, Victoria, Australia
| |
Collapse
|
12
|
Guo J, Wang D, Jia J, Zhang J, Peng F, Lu J, Zhao X, Liu Y. Atrial cardiomyopathy and incident ischemic stroke risk: a systematic review and meta-analysis. J Neurol 2023:10.1007/s00415-023-11693-3. [PMID: 37014420 DOI: 10.1007/s00415-023-11693-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND AND PURPOSE Growing evidence suggests that atrial cardiomyopathy may play an essential role in thrombosis and ischemic stroke. The aim of this systematic review and meta-analysis was to quantify the values of cardiomyopathy markers for predicting ischemic stroke risk. METHODS PubMed, Embase, and the Cochrane Library were searched for longitudinal cohort studies evaluating the association between cardiomyopathy markers and incident ischemic stroke risk. RESULTS We included 25 cohort studies examining electrocardiographic, structural, functional, and serum biomarkers of atrial cardiomyopathy involving 262,504 individuals. P-terminal force in the precordial lead V1 (PTFV1) was found to be an independent predictor of ischemic stroke as both a categorical variable (HR 1.29, CI 1.06-1.57) and a continuous variable (HR 1.14, CI 1.00-1.30). Increased maximum P-wave area (HR 1.14, CI 1.06-1.21) and mean P-wave area (HR 1.12, CI 1.04-1.21) were also associated with an increased risk of ischemic stroke. Left atrial (LA) diameter was independently associated with ischemic stroke as both a categorical variable (HR 1.39, CI 1.06-1.82) and a continuous variable (HR 1.20, CI 1.06-1.35). LA reservoir strain independently predicted the risk of incident ischemic stroke (HR 0.88, CI 0.84-0.93). N-terminal pro-brain natriuretic peptide (NT-proBNP) was also associated with incident ischemic stroke risk, both as a categorical variable (HR 2.37, CI 1.61-3.50) and continuous variable (HR 1.42, CI 1.19-1.70). CONCLUSION Atrial cardiomyopathy markers, including electrocardiographic markers, serum markers, LA structural and functional markers, can be used to stratify the risk of incident ischemic stroke.
Collapse
Affiliation(s)
- Jiahuan Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China
| | - Jiaokun Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China
| | - Fei Peng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China
| | - Jingjing Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fanyang Street 119, Beijing, 100070, China.
| |
Collapse
|
13
|
Johansen MC. The Future of Ischemic Stroke Diagnosis and a Review of Underrecognized Ischemic Stroke Etiologies. Neurotherapeutics 2023; 20:613-623. [PMID: 37157043 PMCID: PMC10275839 DOI: 10.1007/s13311-023-01383-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
Accurate ischemic stroke etiologic determination and diagnosis form the foundation of excellent cerebrovascular care as from it stems initiation of the appropriate secondary prevention strategy as well as appropriate patient education regarding specific risk factors for that subtype. Recurrent stroke rates are highest among those patients who receive an incorrect initial stroke diagnosis. Patient distrust and patient reported depression are also higher. The cause of the ischemic stroke also informs predicted patient outcomes and the anticipated recovery trajectory. Finally, determining the accurate cause of the ischemic stroke provides the patient the opportunity to enroll in appropriate research studies studying mechanism, or targeting treatment approaches for that particular disease process. Advances in ischemic stroke research, imaging techniques, biomarkers, and the ability to rapidly perform genetic sequencing over the past decade have shown that classifying patients into large etiologic buckets may not always be appropriate and may represent one reason why some patients are labeled as cryptogenic, or for whom an underlying etiology is never found. Aside from the more traditional stroke mechanisms, there is new research emerging regarding clinical findings that are not normative, but the contributions to ischemic stroke are unclear. In this article, we first review the essential steps to accurate ischemic stroke etiologic classification and then transition to a discussion of embolic stroke of undetermined source (ESUS) and other new entities that have been postulated as causal in ischemic stroke (i.e., genetics and subclinical atherosclerosis). We also discuss the limitations that are inherent in the current ischemic stroke diagnostic algorithms and finally review the most recent studies regarding more uncommon diagnoses and the future of stroke diagnostics and classification.
Collapse
|
14
|
Field TS, Sposato LA, Hill MD, Healey JS, Andrade JG, Zhou LW. Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management. Can J Cardiol 2023; 39:172-186. [PMID: 36272633 DOI: 10.1016/j.cjca.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/07/2023] Open
Abstract
In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.
Collapse
Affiliation(s)
- Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Luciano A Sposato
- Schulich School of Medicine and Dentistry, Robarts Research Institute, Heart and Brain Laboratory, London, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lily W Zhou
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
15
|
Jing J, Yang X, Wu Y, Meng X, Li Z, Jiang Y, Pan Y, Jin A, Zhao X, Wang Y, Li H, Wang Y. A score to predict the stroke recurrence of patients with embolic stroke of undetermined source. J Neurol 2022. [PMID: 35925397 DOI: 10.1007/s00415-022-11277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 10/16/2022]
Abstract
AIM We aimed to develop a score and validate it in a prospective cohort to identify the patients with ESUS at high risk for stroke recurrence. METHODS We assessed the stroke recurrence in ESUS patients of the Third China National Stroke Registry. We performed multivariable logistic regression analysis to identify predictors of stroke recurrence in the derivation cohort. Based on the coefficient of each covariate of the fitted multivariable model, we generated an integer-based point scoring system. We validated the score in the validation cohort assessing its discrimination and calibration. RESULTS 2415 patients were included: 1611 in the derivation and 804 in the validation sample. We developed a scoring system (0-15 points) by assigning 2 points for hypertension, 3 points for diabetes mellitus, 4 points for multiple stage infarction, 2 points for watershed involved infarction, 1 points for left atrial diameter index (per increasing 2.5 mm/m2) and 3 points for without statin at discharge. The rate of stroke recurrence was 5.9% per year (95% CI 4.2-7.6%) in patients with low risk(a score of 0-5), 9.4% (7.3-11.5%) in patients with intermediate risk (6-10), and 26.8% (16.5-37.1%) in patients with high risk (11-15). The AUC (area under curve of receiver operator characteristic curve) of the score in the derivation cohort and validation cohort was, respectively, 0.60 (0.55-0.65) and 0.63 (0.56-0.70). The score was well calibrated both in the derivation cohort (p = 0.36) and validation cohort (p = 0.26) with the Hosmer-Lemeshow test. CONCLUSION The developed score can improve risk stratification after ESUS in secondary care settings.
Collapse
|
16
|
Arauz A, Arteaga C, Zapata-Gómez C, Ramos-Ventura C, Méndez B, Otiniano-Sifuentes R, Haseeb S, González-Oscoy R, Baranchuk A. Embolic stroke of undetermined source: beyond atrial fibrillation. Neurologia (Engl Ed) 2022; 37:362-370. [PMID: 35672123 DOI: 10.1016/j.nrleng.2019.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/03/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Embolic stroke of undetermined source (ESUS) accounts for 25% of all cerebral infarcts; only 30% are associated with paroxysmal atrial fibrillation (AF). Various biochemical, electrocardiographic, and echocardiographic findings may suggest left atrial damage and increased risk of embolism in the absence of clinically documented AF or atrial flutter. In this review, we analyse the available evidence on atrial cardiopathy or atrial disease, its involvement in ESUS, and its identification through electrocardiographic, echocardiographic, and serum markers and its possible therapeutic implications. DEVELOPMENT A systematic search was conducted on MEDLINE (PubMed) using the following MeSH terms: MeSH [ESUS]+[atrial cardiopathy]+[atrial fibrillation]+[interatrial block]+[treatment]. We selected what we considered to be the most useful original prospective or retrospective studies and systematic reviews. We then read the full texts of the articles and checked the references cited in each article. We analyse epidemiological and demographic variables of patients with ESUS, as well as recent evidence related to presentation and prognosis and factors associated with recurrence and mortality. We review the contribution of atrial cardiopathy diagnosis prior to the detection of AF and the clinical, electrocardiographic, and echocardiographic variables and the biochemical markers associated with its development and its potential contribution to cerebral embolism. CONCLUSIONS The systematic search of biochemical and electrocardiographic, and echocardiographic alterations can be useful to identify ESUS patients at higher risk of recurrence.
Collapse
Affiliation(s)
- A Arauz
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico; Queen's University, Kingston, Ontario, Canada.
| | - C Arteaga
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - C Zapata-Gómez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - C Ramos-Ventura
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - B Méndez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - R Otiniano-Sifuentes
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - S Haseeb
- Queen's University, Kingston, Ontario, Canada
| | - R González-Oscoy
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - A Baranchuk
- Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
17
|
Khan R, Hosseini F, Kohli N. Patent Foramen Ovale Closure for Remote Stroke - Better Late Than Never? Can J Cardiol 2022; 38:1132-1134. [PMID: 35688411 DOI: 10.1016/j.cjca.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/30/2022] [Accepted: 06/03/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Razi Khan
- Royal Columbian Hospital, University of British Columbia, New Westminster, British Columbia, Canada.
| | - Farshad Hosseini
- School of Medicine, University of British Columbia, New Westminster, British Columbia, Canada
| | - Natasha Kohli
- Royal Columbian Hospital, University of British Columbia, New Westminster, British Columbia, Canada
| |
Collapse
|
18
|
Arauz A, Arteaga C, Zapata-Gómez C, Ramos-Ventura C, Méndez B, Otiniano-Sifuentes R, Haseeb S, González-Oscoy R, Baranchuk A. Embolic stroke of undetermined source: Beyond atrial fibrillation. Neurologia 2022; 37:362-370. [PMID: 31060753 DOI: 10.1016/j.nrl.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/31/2019] [Accepted: 03/03/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Embolic stroke of undetermined source (ESUS) accounts for 25% of all cerebral infarcts; only 30% are associated with paroxysmal atrial fibrillation (AF). Various biochemical, electrocardiographic, and echocardiographic findings may suggest left atrial damage and increased risk of embolism in the absence of clinically documented AF or atrial flutter. In this review, we analyse the available evidence on atrial cardiopathy or atrial disease, its involvement in ESUS, and its identification through electrocardiographic, echocardiographic, and serum markers and its possible therapeutic implications. DEVELOPMENT A systematic search was conducted on MEDLINE (PubMed) using the following MeSH terms: MeSH [ESUS]+[atrial cardiopathy]+[atrial fibrillation]+[interatrial block]+[treatment]. We selected what we considered to be the most useful original prospective or retrospective studies and systematic reviews. We then read the full texts of the articles and checked the references cited in each article. We analyse epidemiological and demographic variables of patients with ESUS, as well as recent evidence related to presentation and prognosis and factors associated with recurrence and mortality. We review the contribution of atrial cardiopathy diagnosis prior to the detection of AF and the clinical, electrocardiographic, and echocardiographic variables and the biochemical markers associated with its development and its potential contribution to cerebral embolism. CONCLUSIONS The systematic search of biochemical and electrocardiographic, and echocardiographic alterations can be useful to identify ESUS patients at higher risk of recurrence.
Collapse
Affiliation(s)
- A Arauz
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México; Queen̿s University, Kingston, Ontario, Canadá.
| | - C Arteaga
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - C Zapata-Gómez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - C Ramos-Ventura
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - B Méndez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - R Otiniano-Sifuentes
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - S Haseeb
- Queen̿s University, Kingston, Ontario, Canadá
| | - R González-Oscoy
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - A Baranchuk
- Queen̿s University, Kingston, Ontario, Canadá
| |
Collapse
|
19
|
Han M, Heo J, Jung JW, Lee IH, Kim JH, Lee H, Kim YD, Nam HS. Association between Low Ankle-Brachial Index and Poor Outcomes in Patients with Embolic Stroke of Undetermined Source. J Clin Med 2022; 11. [PMID: 35683461 DOI: 10.3390/jcm11113073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023] Open
Abstract
We investigated the association of low ankle-brachial index (ABI < 0.9) with major adverse cardiovascular events (MACE) and all-cause mortality in patients with embolic stroke of undetermined source (ESUS) as well as whether the association differed by ESUS subtype. This retrospective single-center study included ESUS patients who underwent transesophageal echocardiography and ABI during hospitalization. ESUS was classified as ESUS with minor cardioembolic source, arteriogenic embolism, two or more causes, or no cause. Arteriogenic embolism was defined and classified as complex aortic or non-stenotic relevant artery plaque. MACE was defined as stroke recurrence, acute coronary syndrome, hospitalization for heart failure, or death. Overall, 829 patients were included, with a median follow-up of 45.8 months. Of these, 42 (5.1%) and 370 (44.6%) had low ABI and arteriogenic embolism, respectively. ABI < 0.9 was independently associated with MACE (hazard ratio [HR]: 2.038, 95% confidence interval [CI]: 1.093−3.801) and all-cause mortality (HR: 3.608, 95% CI: 1.538−8.465) according to the multivariable Cox regression analysis. Between ESUS subtypes, low ABI was independently associated with MACE (HR: 2.513, 95% CI: 1.257−5.023) and all-cause mortality (HR: 5.681, 95% CI: 2.151−15.008) in arteriogenic embolism patients, especially in those with complex aortic plaque. However, in non-arteriogenic embolism patients, low ABI was not related to MACE and mortality. In ESUS patients, low ABI was linked to MACE and all-cause mortality, especially in those with arteriogenic embolisms from complex aortic plaque.
Collapse
|
20
|
Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
Collapse
Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
21
|
Perera KS, de Sa Boasquevisque D, Rao-Melacini P, Taylor A, Cheng A, Hankey GJ, Lee S, Fabregas JM, Ameriso SF, Field TS, Arauz A, Coutts SB, Arnold M, Mikulik R, Toni D, Mandzia J, Veltkamp RC, Meseguer E, Haeusler KG, Hart RG. Evaluating Rates of Recurrent Ischemic Stroke Among Young Adults With Embolic Stroke of Undetermined Source: The Young ESUS Longitudinal Cohort Study. JAMA Neurol 2022; 79:450-458. [PMID: 35285869 PMCID: PMC8922202 DOI: 10.1001/jamaneurol.2022.0048] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Cryptogenic strokes constitute approximately 40% of ischemic strokes in young adults, and most meet criteria for the embolic stroke of undetermined source (ESUS). Two randomized clinical trials, NAVIGATE ESUS and RESPECT ESUS, showed a high rate of stroke recurrence in older adults with ESUS but the prognosis and prognostic factors among younger individuals with ESUS is uncertain. Objective To determine rates of and factors associated with recurrent ischemic stroke and death and new-onset atrial fibrillation (AF) among young adults. Design, Setting, and Participants This multicenter longitudinal cohort study with enrollment from October 2017 to October 2019 and a mean follow-up period of 12 months ending in October 2020 included 41 stroke research centers in 13 countries. Consecutive patients 50 years and younger with a diagnosis of ESUS were included. Of 576 screened, 535 participants were enrolled after 1 withdrew consent, 41 were found to be ineligible, and 2 were excluded for other reasons. The final follow-up visit was completed by 520 patients. Main Outcomes and Measures Recurrent ischemic stroke and/or death, recurrent ischemic stroke, and prevalence of patent foramen ovale (PFO). Results The mean (SD) age of participants was 40.4 (7.3) years, and 297 (56%) participants were male. The most frequent vascular risk factors were tobacco use (240 patients [45%]), hypertension (118 patients [22%]), and dyslipidemia (109 patients [20%]). PFO was detected in 177 participants (50%) who had transthoracic echocardiograms with bubble studies. Following initial ESUS, 468 participants (88%) were receiving antiplatelet therapy, and 52 (10%) received anticoagulation. The recurrent ischemic stroke and death rate was 2.19 per 100 patient-years, and the ischemic stroke recurrence rate was 1.9 per 100 patient-years. Of the recurrent strokes, 9 (64%) were ESUS, 2 (14%) were cardioembolic, and 3 (21%) were of other determined cause. AF was detected in 15 participants (2.8%; 95% CI, 1.6-4.6). In multivariate analysis, the following were associated with recurrent ischemic stroke: history of stroke or transient ischemic attack (hazard ratio, 5.3; 95% CI, 1.8-15), presence of diabetes (hazard ratio, 4.4; 95% CI, 1.5-13), and history of coronary artery disease (hazard ratio, 10; 95% CI, 4.8-22). Conclusions and Relevance In this large cohort of young adult patients with ESUS, there was a relatively low rate of subsequent ischemic stroke and a low frequency of new-onset AF. Most recurrent strokes also met the criteria for ESUS, suggesting the need for future studies to improve our understanding of the underlying stroke mechanism in this population.
Collapse
Affiliation(s)
- Kanjana S Perera
- Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Danielle de Sa Boasquevisque
- Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Purnima Rao-Melacini
- Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.,Department of Statistics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Amanda Taylor
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Anna Cheng
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia.,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sarah Lee
- Department of Neurology & Neurological Sciences, Stanford Stroke Center, Stanford, California.,Stanford Children's Health, Stanford, California
| | - Joan Marti Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Thalia S Field
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Antonio Arauz
- National Institute of Neurology, La Fama, Tlalpan, México
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Calgary, Calgary, Alberta, Canada
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's University Hospital, Brno, Czech Republic.,Masaryk University, Brno, Czech Republic
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Jennifer Mandzia
- Department of Neurosciences, Western University, London, Ontario, Canada
| | - Roland C Veltkamp
- Division of Brain Sciences, Imperial College, The Hammersmith Hospital, London, United Kingdom
| | | | | | - Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | |
Collapse
|
22
|
Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
Collapse
Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | | | | | | |
Collapse
|
23
|
Carrington M, Pereira AR, Mendes IC, Anjos R. Intracardiac versus extracardiac shunt in a young man with ischaemic stroke. BMJ Case Rep 2022; 15:e247877. [PMID: 35260403 PMCID: PMC8905973 DOI: 10.1136/bcr-2021-247877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/03/2022] Open
Abstract
A 24-year-old man with a history of recent ischaemic stroke was diagnosed with patent foramen ovale (PFO) and referred for closure at our hospital. At admission, besides low peripheral oxygen saturation (88%), physical examination was otherwise normal. We performed intraprocedural transoesophageal echocardiogram that revealed no PFO, although agitated saline injection demonstrated bubbles lately on the left atrium. The atrial septum could not be crossed. We suspected an extracardiac shunt, so pulmonary angiograms were performed that revealed the presence of a left pulmonary arteriovenous malformation (PAVM). A Konar-MF Occluder was used to occlude the PAVM, with a satisfactory result. At 6 months follow-up, the patient had normal peripheral oxygen saturation and a new pulmonary angiogram showed no residual shunt. Intrapulmonary shunts are a rare and under-recognised cause of paradoxical emboli in young patients; physicians should be aware of this diagnosis as percutaneous occlusion is indicated and critical to avoid recurrent ischaemic episodes.
Collapse
Affiliation(s)
| | | | - Inês Carmo Mendes
- Pediatric Cardiology Department and Reference Center for Congenital Heart Diseases, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Santa Cruz, Lisboa, Portugal
| | - Rui Anjos
- Pediatric Cardiology Department and Reference Center for Congenital Heart Diseases, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Santa Cruz, Lisboa, Portugal
| |
Collapse
|
24
|
Hu X, Chen J, Fu H, Chen Y, Fan D, Chen Y, Shen C. Association Between Carotid Artery Perivascular Fat Density and Embolic Stroke of Undetermined Source. Front Neurol 2022; 12:765962. [PMID: 35250789 PMCID: PMC8894862 DOI: 10.3389/fneur.2021.765962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022] Open
Abstract
AimThis study aims to retrospectively evaluate the association between pericarotid inflammation and the presence of embolic stroke of undetermined source (ESUS).MethodsIn total, 126 patients with ESUS and 118 patients with ischemic stroke from large artery atherosclerosis (LAA) were enrolled. All the patients underwent brain MRI and a neck CT angiography (CTA) examination. Reviewers were blinded to infarct location and stroke cause. Paired t-tests assessed within-subjects differences in mean Hounsfield units (HUs) in carotid perivascular fat between the cerebral infarction side and contralateral side for ESUS and LAA ischemic stroke cases. The unpaired Student's t-test was used to assess between-subjects differences in mean HUs between ESUS and LAA ischemic stroke cases.ResultsIn both the ESUS cases and LAA ischemic stroke cases, the pericarotid fat density around the carotid artery ipsilateral to the stroke significantly increased compared with contralateral stroke position in both the groups (ESUS cases −56.31 ± 18.70 vs. −67.31 ± 20.01, p = 0.000; LAA ischemic stroke cases −51.62 ± 19.95 vs. −64.58 ± 22.68, p = 0.000). However, there was no significant difference in ipsilateral and contralateral positions to infarct between ESUS cases and LAA ischemic stroke cases (ipsilateral to infarct −56.31 ± 18.70 vs. −51.62 ± 19.95, p = 0.059; contralateral to infarct −67.31 ± 20.01 vs. −64.58 ± 22.68, p = 0.320).ConclusionWe found increased density in the fat surrounding carotid artery ipsilateral to stroke compared with contralateral in ESUS, suggesting the presence of an inflammatory reaction that extends beyond the vessel lumen in patients with ESUS with a risk factor profile similar to LAA strokes.
Collapse
Affiliation(s)
- Xiaohong Hu
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Jianhui Chen
- Emergency Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Huajun Fu
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Yinjuan Chen
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Daofeng Fan
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Yangui Chen
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Chaoxiong Shen
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
- *Correspondence: Chaoxiong Shen
| |
Collapse
|
25
|
|
26
|
Kamran S, Akhtar N, Singh R, Imam Y, Haroon KH, Amir N, Hussain S, Al Jerdi S, Ojha L, Own A, Muhammad A, Perkins JD. Association of Major Adverse Cardiovascular Events in Patients With Stroke and Cardiac Wall Motion Abnormalities. J Am Heart Assoc 2021; 10:e020888. [PMID: 34259032 PMCID: PMC8483461 DOI: 10.1161/jaha.121.020888] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background The association of cardiac wall motion abnormalities (CWMAs) in patients with stroke who have major adverse cardiovascular events (MACE) remains unclear. The purpose of this study was to estimate the 50‐month risk of MACE, including stroke recurrence, acute coronary events, and vascular death in patients with stroke who have CWMAs. Methods and Results We performed a retrospective analysis of prospectively collected acute stroke data (acute stroke and transient ischemic attack) over 50 months by electronic medical records. Data included demographic and clinical information, vascular imaging, and echocardiography data including CWMAs and MACE. Of a total of 2653 patients with acute stroke/transient ischemic attack, CWMA was observed in 355 (13.4%). In patients with CWMAs, the embolic stroke of undetermined source (50.7%) was the most frequent index stroke subtype and stroke recurrences (P=0.001). In multivariate Cox regression after adjustment for demographics, traditional risk, and confounding factors, CWMA was independently associated with a higher risk of MACE (adjusted hazard ratio [HR], 1.74; 95% CI, 1.37–2.21 [P=0.001]). Similarly, CWMA independently conferred an increased risk for ischemic stroke recurrence (adjusted HR, 1.50; 95% CI, 1.01–2.17 [P=0.04]), risk of acute coronary events (aHR, 2.50; 95% CI, 1.83–3.40 [P=0.001]) and vascular death (adjusted HR, 1.57; 95% CI, 1.04–2.40 [P=0.03]), in comparison to the patients with stroke without CWMA. Conclusions In a multiethnic cohort of ischemic stroke with CWMA, CWMA was associated with 1.7‐fold higher risks of MACE independent of established risk factors. Embolic stroke of undetermined source was the most common stroke association with CWMA. Patients with stroke should be screened for CWMA to identify those at higher risk of MACE.
Collapse
Affiliation(s)
- Saadat Kamran
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medical School Doha Qatar
| | - Naveed Akhtar
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medical School Doha Qatar
| | - Rajvir Singh
- Heart Hospital Hamad Medical Corporation Doha Qatar
| | - Yahya Imam
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | | | - Noman Amir
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Suhail Hussain
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | | | - Laxmi Ojha
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Ahmed Own
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Ahmad Muhammad
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medical School Doha Qatar
| | - Jonathan D Perkins
- Perception Movement Action Research Consortium University of Edinburgh United Kingdom
| |
Collapse
|
27
|
Yang X, Jing J, Meng X, Li Z, Pan Y, Jiang Y, Xiang X, Liu H, Chen Y, Liu L, Zhao X, Wang Y, Li H, Wang Y. Characteristics and prognosis of patients with embolic stroke of undetermined source in China. Int J Stroke 2021; 17:526-535. [PMID: 34125633 DOI: 10.1177/17474930211028040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to explore the frequencies, risk factors, and natural history of embolic stroke of undetermined source (ESUS) through a national prospective registry in China. METHODS Between August 2015 and March 2018, the Third China National Stroke Registry recruited consecutive patients with ischemic stroke or transient ischemic attack in China. The baseline characteristics, risks of stroke, and prognosis in patients with embolic stroke of undetermined source were described and compared with that in patients with other causative subtypes. RESULTS A total of 15,166 transient ischemic attack and ischemic stroke patients were enrolled in the Third China National Stroke Registry. Among 8528 ischemic stroke with standard diagnostic work-up, 2415 (28.3%) patients were diagnosed with embolic stroke of undetermined source. The mean age was 61 years and 70% of them were male. Compared to patients with cardioembolic strokes and small vessel disease, patients with embolic stroke of undetermined source had higher prevalence of nonstenosing large artery atherosclerosis (37.93% vs. 31.26%, P = 0.008 and 37.93% vs. 34.40%, P = 0.044 respectively). The cumulative probability of stroke recurrence in patients with embolic stroke of undetermined source at three months and one year was 5.59% and 8.74%. Compared with embolic stroke of undetermined source patients (0.70% and 1.99%), patients with the large artery atherosclerosis and cardioembolic strokes had higher cumulative probability of death at three months (1.94% and 3.22%) and one year (4.17% and 7.39%). CONCLUSIONS Embolic stroke of undetermined source is a common cause of ischemic stroke in Chinese population with a higher stroke recurrence than previously reported. It was more likely to have nonstenosing large artery atherosclerosis in patients with embolic stroke of undetermined source than with cardioembolic strokes and small vessel disease.
Collapse
Affiliation(s)
- Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Project Management, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xianglong Xiang
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huan Liu
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Research Methodology and Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
28
|
Veltkamp R, Pearce LA, Korompoki E, Sharma M, Kasner SE, Toni D, Ameriso SF, Mundl H, Tatlisumak T, Hankey GJ, Lindgren A, Berkowitz SD, Arauz A, Ozturk S, Muir KW, Chamorro Á, Perera K, Shuaib A, Rudilosso S, Shoamanesh A, Connolly SJ, Hart RG. Characteristics of Recurrent Ischemic Stroke After Embolic Stroke of Undetermined Source: Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol 2021; 77:1233-1240. [PMID: 32628266 DOI: 10.1001/jamaneurol.2020.1995] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance The concept of embolic stroke of undetermined source (ESUS) unifies a subgroup of cryptogenic strokes based on neuroimaging, a defined minimum set of diagnostic tests, and exclusion of certain causes. Despite an annual stroke recurrence rate of 5%, little is known about the etiology underlying recurrent stroke after ESUS. Objective To identify the stroke subtype of recurrent ischemic strokes after ESUS, to explore the interaction with treatment assignment in each category, and to examine the consistency of cerebral location of qualifying ESUS and recurrent ischemic stroke. Design, Setting, and Participants The NAVIGATE-ESUS trial was a randomized clinical trial conducted from December 23, 2014, to October 5, 2017. The trial compared the efficacy and safety of rivaroxaban and aspirin in patients with recent ESUS (n = 7213). Ischemic stroke was validated in 309 of the 7213 patients by adjudicators blinded to treatment assignment and classified by local investigators into the categories ESUS or non-ESUS (ie, cardioembolic, atherosclerotic, lacunar, other determined cause, or insufficient testing). Five patients with recurrent strokes that could not be defined as ischemic or hemorrhagic in absence of neuroimaging or autopsy were excluded. Data for this secondary post hoc analysis were analyzed from March to June 2019. Interventions Patients were randomly assigned to receive rivaroxaban, 15 mg/d, or aspirin, 100 mg/d. Main Outcomes and Measures Association of recurrent ESUS with stroke characteristics. Results A total of 309 patients (205 men [66%]; mean [SD] age, 68 [10] years) had ischemic stroke identified during the median follow-up of 11 (interquartile range [IQR], 12) months (annualized rate, 4.6%). Diagnostic testing was insufficient for etiological classification in 39 patients (13%). Of 270 classifiable ischemic strokes, 156 (58%) were ESUS and 114 (42%) were non-ESUS (37 [32%] cardioembolic, 26 [23%] atherosclerotic, 35 [31%] lacunar, and 16 [14%] other determined cause). Atrial fibrillation was found in 27 patients (9%) with recurrent ischemic stroke and was associated with higher morbidity (median change in modified Rankin scale score 2 [IQR, 3] vs 0 (IQR, 1]) and mortality (15% vs 1%) than other causes. Risk of recurrence did not differ significantly by subtype between treatment groups. For both the qualifying and recurrent strokes, location of infarct was more often in the left (46% and 54%, respectively) than right hemisphere (40% and 37%, respectively) or brainstem or cerebellum (14% and 9%, respectively). Conclusions and Relevance In this secondary analysis of randomized clinical trial data, most recurrent strokes after ESUS were embolic and of undetermined source. Recurrences associated with atrial fibrillation were a minority but were more often disabling and fatal. More extensive investigation to identify the embolic source is important toward an effective antithrombotic strategy. Trial Registration ClinicalTrials.gov Identifier: NCT02313909.
Collapse
Affiliation(s)
- Roland Veltkamp
- Division of Brain Sciences, Imperial College London, London, United Kingdom.,Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Lesly A Pearce
- currently a biostatistics consultant, St Catharines, Ontario, Canada
| | - Eleni Korompoki
- Division of Brain Sciences, Imperial College London, London, United Kingdom.,Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Mukul Sharma
- Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | | | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Graeme J Hankey
- Faculty of Health and Medical Sciences, Medical School, University of Western Australia, Perth, Australia
| | - Arne Lindgren
- Department of Clinical Sciences and Neurology, Lund University, Lund, Sweden.,Department of Neurology, Skåne University Hospital, Lund, Sweden
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manual Velasco Suarez, Mexico City, Mexico
| | - Serefnur Ozturk
- Department of Neurology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Ángel Chamorro
- Department of Neuroscience, Hospital Clinic of Barcelona, Institute Reçerca Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Kanjana Perera
- Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Salvatore Rudilosso
- Department of Neuroscience, Hospital Clinic of Barcelona, Institute Reçerca Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Ashkan Shoamanesh
- Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert G Hart
- Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
29
|
Karelis G, Micule M, Klavina E, Haritoncenko I, Kikule I, Tilgale B, Polaka I. The Riga East University Hospital Stroke Registry-An Analysis of 4915 Consecutive Patients with Acute Stroke. ACTA ACUST UNITED AC 2021; 57:632. [PMID: 34207100 DOI: 10.3390/medicina57060632] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: A hospital-based stroke registry is a useful tool for systematic analyses of the epidemiology, clinical characteristics, and natural course of stroke. Analyses of stroke registry data can provide information that can be used by health services to improve the quality of care for patients with this disease. Materials and Methods: Data were collected from the Riga East University Hospital (REUH) Stroke Registry in order to evaluate the etiology, risk factors, clinical manifestations, treatment, functional outcomes, and other relevant data for acute stroke during the period 2016–2020. Results: During a five-year period, 4915 patients (3039 females and 1876 males) with acute stroke were registered in the REUH Stroke Registry. The causative factors of stroke were cardioembolism (45.7%), atherosclerosis (29.9%), lacunar stroke (5.3%), stroke of undetermined etiology (1.2%), and stroke of other determined causes (1.2%). The most frequent localizations of intracerebral hemorrhage were subcortical (40.0%), lobar (18.9%), and brainstem (9.3%). The most prevalent risk factors for stroke were hypertension (88.8%), congestive heart failure (71.2%), dyslipidemia (46.7%), and atrial fibrillation (44.2%). In addition, 1018 (20.7%) patients were receiving antiplatelet drugs, 574 (11.7%) were taking statins, and 382 (7.7%) were taking anticoagulants. At discharge, 35.5% of the patients were completely independent (mRS (modified Rankin Scale) score: 0–2), while 49.5% required some form of assistance (mRS score: 3–5). The intrahospital mortality rate was 13.7%, although it was higher in the hemorrhage group (30.9%). Conclusions: Our stroke registry data are comparable to those of other major registries. Analysis of stroke registry data is important for improving stroke care and obtaining additional information for stroke studies.
Collapse
|
30
|
Taniguchi H, Takata T, Takechi M, Furukawa A, Iwasawa J, Kawamura A, Taniguchi T, Tamura Y. Explainable Artificial Intelligence Model for Diagnosis of Atrial Fibrillation Using Holter Electrocardiogram Waveforms. Int Heart J 2021; 62:534-539. [PMID: 34053998 DOI: 10.1536/ihj.21-094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation is a clinically important arrhythmia. There are some reports on machine learning models for AF diagnosis using electrocardiogram data. However, few reports have proposed an eXplainable Artificial Intelligence (XAI) model to enable physicians to easily understand the machine learning model's diagnosis results.We developed and validated an XAI-enabled atrial fibrillation diagnosis model based on a convolutional neural network (CNN) algorithm. We used Holter electrocardiogram monitoring data and the gradient-weighted class activation mapping (Grad-CAM) method.Electrocardiogram data recorded from patients between January 4, 2016, and October 31, 2019, totaling 57,273 electrocardiogram waveform slots of 30 seconds each with diagnostic information annotated by cardiologists, were used for training our proposed model. Performance metrics of our AI model for AF diagnosis are as follows: sensitivity, 97.1% (95% CI: 0.969-0.972); specificity, 94.5% (95% CI: 0.943-0.946); accuracy, 95.3% (95% CI: 0.952-0.955); positive predictive value, 89.3% (95% CI: 0.892-0.897); and F-value, 93.1% (95% CI: 0.929-0.933). The area under the receiver operating characteristic curve for AF detection using our model was 0.988 (95% CI: 0.987-0.988). Furthermore, using the XAI method, 94.5 ± 3.5% of the areas identified as regions of interest using our machine learning model were identified as characteristic sites for AF diagnosis by cardiologists.AF was accurately diagnosed and favorably explained with Holter ECG waveforms using our proposed CNN-based XAI model. Our study presents another step toward realizing a viable XAI-based detection model for AF diagnoses for use by physicians.
Collapse
Affiliation(s)
- Hirohisa Taniguchi
- Department of Cardiology, International University of Health and Welfare School of Medicine
| | | | - Mineki Takechi
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital
| | - Asuka Furukawa
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital
| | - Jin Iwasawa
- Department of Cardiology, International University of Health and Welfare School of Medicine
| | - Akio Kawamura
- Department of Cardiology, International University of Health and Welfare School of Medicine
| | - Tadahiro Taniguchi
- Department of Information Science and Engineering, Ritsumeikan University
| | - Yuichi Tamura
- Department of Cardiology, International University of Health and Welfare School of Medicine.,CardioIntelligence Inc.,Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital
| |
Collapse
|
31
|
Abstract
Background Embolic stroke of undetermined source (ESUS) accounts for up to 25% of strokes. Understanding risk factors associated with ESUS is important in reducing stroke burden worldwide. However, ESUS patients are younger and present with fewer traditional risk factors. Significant global variation in ESUS populations also exists making the clinical picture of this type of stroke unclear. Methods and results ESUS patients were pair matched for age, sex, and ethnicity with a group of all other strokes (both n = 331). Exploratory factor analysis was applied in both groups to 14 risk and clinical factors to identify latent factors. In ESUS patients, two latent factors emerged consisting primarily of heart-related variables such as left ventricular wall motion abnormalities, reduced ejection fraction, and increased left atrial volume index, as well as aortic arch atherosclerosis. This is in comparison to the all other strokes group, which was dominated by traditional stroke risk factors. Conclusions Our findings support the existence of a unique pattern of risk factors specific to ESUS. We show that LVWMA and corresponding changes in left heart function are a potential source of emboli in these patients. In addition, the clustering of aortic arch atherosclerosis with left heart factors suggests a causal link. Through the application of exploratory factor analysis, this work contributes to a further understanding of stroke mechanisms in ESUS.
Collapse
Affiliation(s)
- Jon D Perkins
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,PMARC, University of Edinburgh, Edinburgh, UK
| | - Naveed Akhtar
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
| | - Rajvir Singh
- Heart Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Asad Kamran
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Saadat Ilyas
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
| |
Collapse
|
32
|
Roessler FC, Kalms N, Jann F, Kemmling A, Ribbat-Idel J, Stellmacher F, König IR, Ohlrich M, Royl G. First approach to distinguish between cardiac and arteriosclerotic emboli of individual stroke patients applying the histological THROMBEX-classification rule. Sci Rep 2021; 11:8433. [PMID: 33875717 DOI: 10.1038/s41598-021-87584-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 03/30/2021] [Indexed: 12/16/2022] Open
Abstract
Endovascular treatment of strokes caused by large vessel occlusion enables the histopathological investigation of the retrieved embolus, possibly providing a novel opportunity to contribute to the diagnostic workup of etiology and to define secondary prevention measures in strokes with uncertain genesis. We aimed to develop a classification rule based on pathophysiological considerations and adjustment to reference thrombi for distinction between cardiac and arteriosclerotic emboli and to validate this classification rule on a patient cohort. From 125 patients with stroke due to large vessel occlusion and thrombectomy, 82 patients with known etiology (55 cardioembolic and 27 arterioembolic strokes) were included. The corresponding emboli were histologically evaluated by two raters blinded to the etiology of stroke by means of a novel classification rule. Presumed etiology and classification results were compared. Agreement concerning cardiac emboli was 72.2% (95% CI: 58.4–83.5) for rater I and 78.2% (95% CI: 65.0–88.2) for rater II. Agreement concerning arteriosclerotic emboli was 70.4% (95% CI: 49.8–86.3) for rater I and 74.1% (95% CI: 53.7–88.9) for rater II. Overall agreement reached 71.6% (95% CI: 60.5–81.1) for rater I and 76.8% (95% CI: 66.2–85.4) for rater II. Within the limits of generally restricted accuracy of histological evaluations, the classification rule differentiates between cardiac and arteriosclerotic emboli of acute ischemic stroke patients. Further improvement is needed to provide valuable complementary data for stroke etiology workup.
Collapse
|
33
|
Rodriguez-Granillo GA, Cirio JJ, Ciardi C, Caballero ML, Diluca P, Castrillon R, Ceron M, Scrivano E, Lylyk P. Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19. Minerva Cardiol Angiol 2021; 69:606-618. [PMID: 33703860 DOI: 10.23736/s2724-5683.21.05547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.
Collapse
Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina - .,National Council of Scientific and Technical Investigations - Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina -
| | - Juan J Cirio
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Celina Ciardi
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Maria L Caballero
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pablo Diluca
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Ricardo Castrillon
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Marcos Ceron
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Esteban Scrivano
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| |
Collapse
|
34
|
Elzanaty AM, Patel N, Sabbagh E, Eltahawy EA. Patent foramen ovale closure in the management of cryptogenic stroke: a review of current literature and guideline statements. Curr Med Res Opin 2021; 37:377-384. [PMID: 33460329 DOI: 10.1080/03007995.2021.1876648] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of percutaneous device closure over medical management in preventing cryptogenic stroke recurrence. This paper aims to review the current literature for referring physicians who may encounter patients with patent foramen ovale before referring these patients to stroke specialists and/or interventional cardiologists. METHOD For this Narrative review, we conducted a broad literature search with expert selection of relevant data. Our search included a review of the currently available trials, guideline statements, position papers, cost-effectiveness of device closure data, as well as the impact of device closure on quality of life. RESULTS Most European societies are now in favor of evaluating all patients aged 60 years or younger with recent cryptogenic stroke in the setting of a PFO after careful consideration of the patient's echocardiographic and clinical risk factors. On the other hand, American societies, except for the American Academy of Neurology, have not yet passed official updated recommendations. CONCLUSION PFO closure can be considered for the prevention of recurrent cryptogenic stroke in patients aged ≤60 years after a thorough evaluation and discussion about benefits and potential risks (including but not limited to atrial fibrillation) of the procedure. Accumulating evidence supports prognostic, quality of life, and economic benefit from percutaneous PFO closure with newer generation closure devices in the right subset of patients. HIGHLIGHTS Data from 4 major trials (RESPECT, CLOSE, DEFENSE-PFO, REDUCE) demonstrates the superiority of PFO closure over medical management alone in preventing cryptogenic stroke recurrence. Trials investigated mostly patients ≤60 years old, and therefore results may not be generalizable to the entire population. Further randomized trials evaluating the safety and efficacy of PFO closure in patients older than 60 years are warranted.Atrial fibrillation is one of the most common "occult" causes of cryptogenic stroke and should be excluded by ambulatory electrocardiographic monitoring. It is important to also rule out other causes of stroke, including hypercoagulable states, atherosclerotic lesions, other cardioembolic sources, and arterial dissection.Complications of PFO procedure include new-onset AF, development of scar tissue, risk of aortic root dilation and subsequent erosions, and potential thrombi formation on the device.PFO closure with medical therapy is more cost-effective than medical therapy alone.Patients who underwent PFO closure had lower rates of depression, anxiety, and stress compared to those who did undergo closure.Development of the RoPE score has helped clinicians identify patients with cryptogenic stroke and PFO who might be a candidate for PFO closure. A score of 7, 8, and 9-10 corresponds to a causal risk of 72%, 84%, and 88%, respectively, and defines a subset of patients who may benefit from PFO closure.Current guidelines recommend determining the need for PFO closure on a case-by-case basis, depending on risk factors, in patients age 60 or less with recent cryptogenic stroke in the setting of PFO.
Collapse
Affiliation(s)
- Ahmed M Elzanaty
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Neha Patel
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Ebrahim Sabbagh
- Department of Cardiology, University of Toledo, Toledo, OH, USA
| | - Ehab A Eltahawy
- Department of Cardiology, University of Toledo, Toledo, OH, USA
| |
Collapse
|
35
|
Yan L, Huangfu C, Yang N, Li R, Yang X, Feng Y, Xuan L, Wang Q, Meng Y, Hou X, Li X. Sex- related differences in the factors associated with outcomes among patients with strokes of undetermined source: a hospital-based follow-up study. Postgrad Med 2021; 133:428-435. [PMID: 33554703 DOI: 10.1080/00325481.2021.1886770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: Sex-related differences are well established among stroke patients, including the incidence and prevalence of stroke being higher among men than among women. However, the sex-related factors for differences in the outcomes of strokes of undetermined source (SUSs) have not been well described, especially in the Chinese population. We assessed the sex-related differences in the factors associated with outcomes among patients with SUSs in China.Method: Between January 2011 and December 2018, we recruited 205 patients diagnosed with SUSs from Kailuan General Hospital (China). The clinical features, risk factors, and outcome data were collected for the patients at 3 and 12 months after their strokes.Results: There were higher frequencies of hyperlipidemia (27.8% vs. 26.4%), smoking (41.4% vs. 5.6%), and alcohol consumption (21.8% vs. 0%) for male patients than for female patients. However, women were more likely than men to have hypertension (63.9% vs. 46.6%), diabetes (27.8% vs. 20.3%), and atrial fibrillation (9.7% vs. 5.3%); they were also more likely to be obese (16.7% vs. 12.0%). There were no significant differences in outcome between the sexes. Among men, severe strokes were associated with higher case fatality and disability risks at 12 months after stroke onset; hyperlipidemia was a risk factor for recurrence within 3 months of the initial stroke. Among women, severe strokes also increased the risk of disability; in women, high total cholesterol (TC) and age were associated with poor outcomes.Conclusion: The factors associated with outcomes in SUS differed by sex. For male patients, more severe stroke and hyperlipidemia were associated with poor outcomes in SUS. Risk factors for poor outcomes in female patients were stroke severity, age, and TC level. These findings suggest that taking measures to manage blood lipid levels and severe stroke among patients with SUS is important for both male and female patients and is crucial for reducing the burden of stroke in China.
Collapse
Affiliation(s)
- Lili Yan
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Chunmei Huangfu
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Na Yang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Renzi Li
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xiuping Yang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Yujing Feng
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Lihui Xuan
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Qian Wang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Yanhong Meng
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xiaoqiang Hou
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xuemei Li
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| |
Collapse
|
36
|
Guglielmi V, Rinkel LA, Groeneveld NS, Lobé NH, Boekholdt SM, Bouma BJ, Beenen LF, Marquering HA, Majoie CB, Roos YB, van Randen A, Planken RN, Coutinho JM. Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design. Eur Stroke J 2021; 5:441-448. [PMID: 33598563 PMCID: PMC7856589 DOI: 10.1177/2396987320962911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
Rationale About one-third of ischaemic strokes are caused by cardioembolism, and a substantial proportion of cryptogenic strokes likely also originate from the heart or aortic arch. Early determination of aetiology is important to optimise management. Computed Tomography-angiography of the heart is emerging as an alternative to echocardiography to detect cardio-aortic sources of embolism in stroke patients, but its diagnostic yield in acute ischaemic stroke has not been thoroughly assessed.Hypothesis: We hypothesise that electrocardiography-gated computed tomography-angiography of the heart and aortic arch, acquired in the acute phase in patients with ischaemic stroke, has a higher diagnostic yield than transthoracic echocardiography as a first-line screening method for detection of cardio-aortic sources of embolism. Methods and design Mind the Heart is a single-centre prospective observational cohort study. We will include consecutive adult patients with acute ischaemic stroke who are potentially eligible for reperfusion therapy. Patients undergo non-electrocardiography-gated computed tomography-angiography of the aortic arch, cervical and intracranial arteries, directly followed by prospective sequential electrocardiography-gated cardiac computed tomography-angiography. Routine work-up for cardioembolism including 12-leads electrocardiography, Holter electrocardiography and transthoracic echocardiography is performed as soon as possible. The primary endpoint is the proportion of patients with a predefined high-risk cardio-aortic source of embolism on computed tomography-angiography versus transthoracic echocardiography in patients who underwent both investigations. Based on an expected 5% additional yield of computed tomography-angiography, a sample size of 450 patients is required. Conclusions The Mind the Heart study will generate a reliable estimate of the diagnostic yield of echocardiography-gated cardio-aortic computed tomography-angiography performed in the acute phase of ischaemic stroke.
Collapse
Affiliation(s)
- Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick Hj Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo Fm Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
37
|
Hart RG, Perera KS. Intracranial Atherosclerotic Plaque and Embolic Stroke of Undetermined Source: Another Piece of the Puzzle. J Am Coll Cardiol 2021; 77:692-694. [PMID: 33573738 DOI: 10.1016/j.jacc.2020.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Kanjana S Perera
- Department of Medicine (Neurology), McMaster University, Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
38
|
Ekizoglu E, Atmaca M, Çinar-Balcıoglu Ç, Yesilot N, Çoban O. CHADS 2 and CHA 2DS 2-VASc Scores Can Guide the Evaluation of Cryptogenic Ischemic Stroke. Neurol India 2021; 69:1716-1721. [DOI: 10.4103/0028-3886.333477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
39
|
Sueda K, Horiuchi M, Funakoshi H, Hiraoka E. Embolic Stroke Caused by Hereditary Hemorrhagic Telangiectasia with Pulmonary Arteriovenous Malformation. J Gen Intern Med 2020; 35:3707-10. [PMID: 32815056 DOI: 10.1007/s11606-020-06126-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/10/2020] [Indexed: 02/03/2023]
|
40
|
Ma H, Liu J, Lv S, Zhang P, Guo WT, Qu Y, Guo ZN, Yang Y. Dynamic Cerebral Autoregulation in Embolic Stroke of Undetermined Source. Front Physiol 2020; 11:557408. [PMID: 33192551 PMCID: PMC7607044 DOI: 10.3389/fphys.2020.557408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/28/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Dynamic cerebral autoregulation (dCA) in acute ischemic stroke is probably compromised. Although the characteristics of dCA in different types of stroke have been largely investigated, dCA in embolic stroke of undetermined source (ESUS) remains poorly understood. In this group, we aimed to elucidate the characteristics of dCA and their relevance to clinical outcomes. METHODS The study enrolled 77 ESUS patients and 50 controls. Bilateral cerebral blood flow velocities (CBFV) of middle cerebral arteries and arterial blood pressure were simultaneously recorded using a transcranial Doppler combined with a servo-controlled finger plethysmograph. Transfer function analysis was used to obtain dCA parameters including phase, gain, coherence at very low frequency (VLF) and low frequency (LF), and the rate of recovery (RoRc) of CBFV. A multivariable logistic regression model was established to explore the relationship between dCA and clinical outcomes. RESULTS Gain at VLF and LF, phase at LF, and RoRc of CBFV in bilateral hemispheres of the ESUS group were consistently worse than those of the control group (all P < 0.001). Bilateral RoRc of CBFV was significantly higher in patients with favorable outcomes than in those with unfavorable outcomes (stroke hemisphere: P < 0.001; non-stroke hemisphere, P = 0.029). Rate of recovery of CBFV in stroke hemisphere >13.3%/s was an independent predictor of favorable clinical outcomes (adjusted odds ratio = 30.95, 95% CI: 5.33-179.81, P < 0.001). CONCLUSIONS Dynamic cerebral autoregulation was relatively impaired in both stroke and non-stroke hemispheres in ESUS patients, and functioning dCA after ESUS may indicate favorable clinical outcomes.
Collapse
Affiliation(s)
- Hongyin Ma
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Shan Lv
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Peng Zhang
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Wei-Tong Guo
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yang Qu
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Zhen-Ni Guo
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
41
|
Lévy S, Santini L, Cappato R, Steinbeck G, Capucci A, Saksena S. Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol 2020; 59:495-507. [PMID: 33048302 DOI: 10.1007/s10840-020-00859-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
Symptomatic atrial fibrillation (AF) or clinical AF is associated with impaired quality of life, higher risk of stroke, heart failure, and increased mortality. Current clinical classification of AF is based on the duration of AF episodes and the recurrence over time. Appropriate management strategy should follow guidelines of Scientific Societies. The last decades have been marked by the advances in mechanism comprehension, better management of symptomatic AF, particularly regarding stroke prevention with the use of direct oral anticoagulants and a wider use of AF catheter or surgical ablations. The advent of new tools for detection of asymptomatic AF including continuous monitoring with implanted electronic devices and the use of implantable cardiac monitors and recently wearable devices or garments have identified what is called "subclinical AF" encompassing atrial high-rate episodes (AHREs). New concepts such as "AF burden" have resulted in new management challenges. Oral anticoagulation has proven to reduce substantially stroke risk in patients with symptomatic clinical AF but carries the risk of bleeding. Management of detected asymptomatic atrial arrhythmias and their relation to clinical AF and stroke risk is currently under evaluation. Based on a review of recent literature, the validity of current clinical classification has been reassessed and appropriate updates are proposed. Current evidence supporting the inclusion of subclinical AF within current clinical classification is discussed as well as the need for controlled trials which may provide responses to current therapeutic challenges particularly regarding the subsets of asymptomatic AF patients that might benefit from oral anticoagulation.
Collapse
Affiliation(s)
- Samuel Lévy
- Marseille School of Medicine, Aix-Marseille University, Marseille, France.
| | - Luca Santini
- Cardiology Division, G. B. Grassi Hospital, Via G. Passeroni 28, Ostia Lido, RM, Italy
| | - Riccardo Cappato
- Arrhythmia and Elecrtrophysiology Center, IRCCS-MultiMedica Group, Via Milanese 300, 20099, Milan, Sesto San Giovanni, Italy
| | | | - Alessandro Capucci
- Department of Cardiology, Università Politecnica delle Marche, Ancona, Italy
| | - Sanjeev Saksena
- Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ, USA
| |
Collapse
|
42
|
Grifoni E, Giglio D, Guazzini G, Cosentino E, Latini E, Dei A, Del Rosso A, Guarnaccia V, Baldini M, Bartolozzi ML, Martinucci P, Sani F, Giordano A, Dainelli F, Maggi F, Giulietti C, Romagnoli M, Cinotti S, Schipani E, Murgida GS, Di Martino S, Cozzi A, Carli Ballola A, Dacomo D, Valori D, Masotti L. Age-related burden and characteristics of embolic stroke of undetermined source in the real world clinical practice. J Thromb Thrombolysis 2020; 49:75-85. [PMID: 31494844 DOI: 10.1007/s11239-019-01951-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Few data are available on age-related burden and characteristics of embolic stroke of undetermined source (ESUS) in the real world clinical practice. The aim of our study was to provide information about it. We retrospectively analyzed data of patients consecutively admitted to our Stroke Unit along 1 year (2017, November 1st-2018, October 31st). The etiology of ischemic stroke was defined at hospital discharge; ESUS was considered as a subset of cryptogenic stroke, and defined according to the 2014 international criteria. In the analyzed period, 306 patients, 52.3% females, mean age ± SD 77.9 ± 11.9 years, were discharged with diagnosis of ischemic stroke. Ischemic strokes of cardioembolic and lacunar origin were the most frequent subtypes: 30.1% and 29.4%, respectively. Cardioembolic strokes were particularly frequent in patients ≥ 75 years, and almost always associated with atrial fibrillation. Overall, in 80 patients (26.1%) the etiology of stroke was undetermined; in 25 (8.2%) it remained undefined because of death or severe comorbidity, making further diagnostic work-up not worthy. Cryptogenic stroke occurred in 55 patients (18%), and ESUS criteria were satisfied in 39 of them (12.7%). According to age, cryptogenic stroke was diagnosed in 21.1% (21.1% ESUS) of patients < 65 years, 24.2% (19.4% ESUS) of patients aged 65-74 years, 15.5% (9.2% ESUS) of patients ≥ 75 years. After diagnostic work-up, patent foramen ovale was most commonly associated with ESUS (17.9%), especially in patients < 65 years (62.5%); covert paroxysmal atrial fibrillation was detected in 10.5% of ESUS patients ≥ 75 years. In the real world clinical practice, the frequency of ischemic strokes of undetermined etiology, and of those satisfying ESUS criteria, is not negligible, especially in younger patients. A thorough diagnostic work-up, with an age-specific approach, is therefore necessary and of the utmost importance for the identification of stroke etiology, in order to optimize secondary stroke prevention strategies.
Collapse
Affiliation(s)
- Elisa Grifoni
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Davide Giglio
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Giulia Guazzini
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Eleonora Cosentino
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Ester Latini
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Alessandro Dei
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | | | | | | | | | | | - Francesca Sani
- Cardiology, San Giovanni di Dio Hospital, Florence, Italy
| | - Antonio Giordano
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Francesca Dainelli
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Francesca Maggi
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Chiara Giulietti
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Mario Romagnoli
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Stefano Cinotti
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Elena Schipani
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | | | - Stefania Di Martino
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Andrea Cozzi
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Adele Carli Ballola
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Debora Dacomo
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Debora Valori
- Cardiology, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Luca Masotti
- Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Florence, Italy.
| |
Collapse
|
43
|
Yan B, Tu H, Lam C, Swift C, Ho MS, Mok VCT, Sui Y, Sharpe D, Ghia D, Jannes J, Davis S, Liu X, Freedman B. Nurse Led Smartphone Electrographic Monitoring for Atrial Fibrillation after Ischemic Stroke: SPOT-AF. J Stroke 2020; 22:387-395. [PMID: 33053954 PMCID: PMC7568969 DOI: 10.5853/jos.2020.00689] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/17/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Paroxysmal atrial fibrillation (PAF) underlying acute stroke frequently evades detection by standard practice, considered to be a combination of routine electrocardiogram (ECG) monitoring, and 24-hour Holter recordings. We hypothesized that nurse-led in-hospital intermittent monitoring approach would increase PAF detection rate. METHODS We recruited patients hospitalised for stroke/transient ischemic attack, without history of atrial fibrillation (AF), in a prospective multi-centre observational study. Patients were monitored using a smartphone-enabled handheld ECG (iECG) during routine nursing observations, and underwent 24-hour Holter monitoring according to local practice. The primary outcome was comparison of AF detection by nurse-led iECG versus Holter monitoring in patients who received both tests: secondary outcome was oral anticoagulant commencement at 3-month following PAF detection. RESULTS One thousand and seventy-nine patients underwent iECG monitoring: 294 had iECG and Holter monitoring. AF was detected in 25/294 (8.5%) by iECG, and 8/294 (2.8%) by 24-hour Holter recordings (P<0.001). Median duration from stroke onset to AF detection for iECG was 3 days (interquartile range [IQR], 2 to 6) compared with 7 days (IQR, 6 to 10) for Holter recordings (P=0.02). Of 25 patients with AF detected by iECG, 11 were commenced on oral anticoagulant, compared to 5/8 for Holter. AF was detected in 8.8% (69/785 patients) who underwent iECG recordings only (P=0.8 vs. those who had both iECG and 24-hour Holter). CONCLUSIONS Nurse-led in-hospital iECG surveillance after stroke is feasible and effective and detects more PAF earlier and more frequently than routine 24-hour Holter recordings. Screening with iECG could be incorporated into routine post-stroke nursing observations to increase diagnosis of PAF, and facilitate institution of guideline-recommended anticoagulation.
Collapse
Affiliation(s)
- Bernard Yan
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne, Parkville, Australia
| | - Hans Tu
- Department of Neurology and Medicine, Western Health, The University of Melbourne, Footscray, Australia
| | - Christina Lam
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne, Parkville, Australia
| | - Corey Swift
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne, Parkville, Australia
| | - Ma Sze Ho
- Lui Che Woo Institute of Innovative Medicine, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Prince of Wales Hospital, and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Vincent C T Mok
- Lui Che Woo Institute of Innovative Medicine, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Prince of Wales Hospital, and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang, China
| | - David Sharpe
- Neurology Department, Concord General Hospital, Sydney, Australia
| | - Darshan Ghia
- Neurology Department, Concord General Hospital, Sydney, Australia
| | - Jim Jannes
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Stephen Davis
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne, Parkville, Australia
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ben Freedman
- Heart Research Institute Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Sydney, Australia
| |
Collapse
|
44
|
Šaňák D, Divišová P, Hutyra M, Král M, Bártková A, Zapletalová J, Látal J, Dorňák T, Hudec Š, Franc D, Polidar P, Veverka T, Kaňovský P. Risk of recurrent ischemic stroke in young cryptogenic patients with embolic stroke of undetermined source. J Neurol Sci 2020; 416:116985. [PMID: 32563078 DOI: 10.1016/j.jns.2020.116985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/20/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Elderly cryptogenic ischemic stroke (IS) patients with embolic stroke of undetermined source (ESUS) have a high risk of recurrent IS (RIS) compared to other stroke subtypes. In young ESUS patients, different sources of embolism may be a cause and the risk of RIS remains not enough established. The aim was to assess and compare risk of RIS between ESUS and non ESUS patients <50 years. METHODS The study set consisted of young acute IS patients <50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). In all analyzed patients, the brain ischemia was confirmed on CT or MRI. All patients underwent identical diagnostic protocol including TEE and long-term ECG-Holter. Cause of IS was assessed according to the ASCOD classification. RESULTS Of 320 enrolled patients <50 years, 219 (68.4%) were identified as cryptogenic (119 males, mean age 41.4 ± 7.2 years) and 122 (38.1%) patients fulfilled the ESUS criteria. During the follow-up with a median of 34 months, three (2.5%) ESUS and 5 (5.2%) non-ESUS patients suffered from RIS (p = .471). One-year risk of RIS was 0.008 (95% CI: 0-0.025) for ESUS and 0.036 (95% CI: 0-0.076) for non-ESUS patients (p = .262). CONCLUSION The risk of RIS was very low in ESUS patients and did not differ from those with non-ESUS. Our finding may indicate that antiplatelet therapy can be effective in the secondary prevention in young ESUS patients if high-risk sources of embolization are excluded extensively.
Collapse
Affiliation(s)
- Daniel Šaňák
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic.
| | - Petra Divišová
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Cardiology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Michal Král
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Andrea Bártková
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Jana Zapletalová
- Department of Biophysics and statistics, Palacký University Medical School, Olomouc, Czech Republic
| | - Jan Látal
- Department of Cardiology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Tomáš Dorňák
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Štěpán Hudec
- Department of Cardiology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - David Franc
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Petr Polidar
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Tomáš Veverka
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Petr Kaňovský
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| |
Collapse
|
45
|
Lattanzi S, Rinaldi C, Pulcini A, Corradetti T, Angelocola S, Zedde ML, Ciliberti G, Silvestrini M. Clinical phenotypes of embolic strokes of undetermined source. Neurol Sci 2020; 42:297-300. [DOI: 10.1007/s10072-020-04700-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/28/2020] [Indexed: 11/28/2022]
|
46
|
Acampa M, Lazzerini PE, Manfredi C, Guideri F, Tassi R, Domenichelli C, Cartocci A, Martini G. Non-stenosing Carotid Atherosclerosis and Arterial Stiffness in Embolic Stroke of Undetermined Source. Front Neurol 2020; 11:725. [PMID: 32849200 PMCID: PMC7396517 DOI: 10.3389/fneur.2020.00725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/15/2020] [Indexed: 02/04/2023] Open
Abstract
Background and Purpose: Recent findings suggested that non-stenosing atherosclerosis (NSA) may play an important pathogenic role, especially in cryptogenic strokes. Furthermore, arterial stiffness has been suggested to be a useful tool in identifying patients with embolic stroke of undetermined source (ESUS) with poor neurological prognosis. In this view, the aim of our study was to assess the association between carotid NSA and arterial stiffness in ESUS patients, in order to better define the cardiovascular risk profile of this subgroup of patients. Methods: We enrolled 100 patients with ESUS (52 males, 48 females) and 48 patients with ischemic stroke from atherosclerosis. All patients underwent clinical and neuroimaging examination. A 24-h heart rate and blood pressure monitoring was performed in order to evaluate systolic, diastolic and mean blood pressure, pulse pressure, and arterial stiffness index (ASI). Results: NSA was present in 48 patients. In comparison with non-NSA-ESUS, in NSA-ESUS the mean age was higher, neurological deficit was more severe, hypertension, and diabetes were more common; systolic blood pressure, pulse pressure, and ASI were higher. In particular NSA-ESUS had ASI levels similar to strokes due to atherosclerosis. Conclusions: Our findings shed light on specific cardiovascular risk profiles underlying different subtypes of ESUS, suggesting the presence of increased arterial stiffness in NSA-ESUS patients with a risk factors profile similar to strokes due to atherosclerosis.
Collapse
Affiliation(s)
- Maurizio Acampa
- Stroke Unit, Department of Emergency-Urgency and Transplants, "Santa Maria Alle Scotte" General Hospital, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Chiara Manfredi
- Stroke Unit, Department of Emergency-Urgency and Transplants, "Santa Maria Alle Scotte" General Hospital, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesca Guideri
- Stroke Unit, Department of Emergency-Urgency and Transplants, "Santa Maria Alle Scotte" General Hospital, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Emergency-Urgency and Transplants, "Santa Maria Alle Scotte" General Hospital, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Carlo Domenichelli
- Stroke Unit, Department of Emergency-Urgency and Transplants, "Santa Maria Alle Scotte" General Hospital, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Giuseppe Martini
- Stroke Unit, Department of Emergency-Urgency and Transplants, "Santa Maria Alle Scotte" General Hospital, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| |
Collapse
|
47
|
Affiliation(s)
- Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital Universitario La Paz, Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Raquel Gutiérrez-Zúñiga
- Department of Neurology and Stroke Center, Hospital Universitario La Paz, Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Exuperio Díez-Tejedor
- Department of Neurology and Stroke Center, Hospital Universitario La Paz, Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| |
Collapse
|
48
|
Kamran S, Singh R, Akhtar N, George P, Salam A, Babu B, Own A, Hamid T, Perkins JD. Left Heart Factors in Embolic Stroke of Undetermined Source in a Multiethnic Asian and North African Cohort. J Am Heart Assoc 2020; 9:e016534. [PMID: 32750304 PMCID: PMC7792276 DOI: 10.1161/jaha.120.016534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Cardiac features diverge in Asians; however, it is not known how these differences relate to embolic stroke of unknown source (ESUS) in Southeast Asian and Eastern Mediterranean regions. Methods and Results A retrospective analysis of prospectively collected acute ischemic stroke data from 2014 to 2018 was performed. Stroke subtypes were noncardioembolic stroke (large‐vessel and small‐vessel disease; n=1348), cardioembolic stroke (n=532), and ESUS (n=656). Subtypes were compared by demographic, clinical, and echocardiographic factors. In multivariate logistic regression, patients with ESUS in comparison with noncardioembolic stroke were twice as likely to have left ventricular diastolic dysfunction (P=0.001), 3 times the odds of global hypokinesia (P=0.001), and >7 times the odds of left ventricular wall motion abnormalities (P=0.001). In the second model comparing ESUS with cardioembolic stroke, patients with ESUS were 3 times more likely to have left ventricular wall motion abnormalities (P=0.001) and 1.5 times more likely to have left ventricular diastolic dysfunction grade I (P=0.009), and 3 times more likely to have left ventricular diastolic dysfunction grades II and III (P=0.009), whereas age (P=0.001) and left atrial volume index (P=0.004) showed an inverse relation with ESUS. ESUS in patients ≥61 years old had higher levels of traditional risk factors such as coronary artery disease, but the coronary artery disease was not significantly different in ESUS age groups (P=0.80) despite higher left ventricular wall motion abnormalities (P=0.001). Conclusions Patients with ESUS and noncardioembolic stroke were younger than patients with cardioembolic stroke. While a third of the patients with ESUS >45 years old had coronary artery disease, it was unrecognized or underreported in the older ESUS age group (≥61 years old). In patients with ESUS from Southeast Asia and Eastern Mediterranean regions, left ventricular wall motion abnormalities and left ventricular diastolic dysfunction were related to ESUS.
Collapse
Affiliation(s)
- Saadat Kamran
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medicine Doha Qatar
| | - Rajvir Singh
- Acute Care Surgery Department Hamad General Hospital Doha Qatar
| | - Naveed Akhtar
- Neuroscience Institute Hamad General Hospital Doha Qatar.,Weill Cornell Medicine Doha Qatar
| | - Pooja George
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Abdul Salam
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Blessy Babu
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Ahmed Own
- Neuroscience Institute Hamad General Hospital Doha Qatar
| | - Tahir Hamid
- Heart Hospital Hamad Medical Corporation Doha Qatar
| | | |
Collapse
|
49
|
Tsai LK, Lee IH, Chen YL, Chao TF, Chen YW, Po HL, Lien LM, Chu PH, Huang WC, Lin TH, Lin MT, Jeng JS, Hwang JJ. Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology. J Formos Med Assoc 2020; 120:93-106. [PMID: 32534996 DOI: 10.1016/j.jfma.2020.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 01/10/2023] Open
Abstract
Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA2D2-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.
Collapse
Affiliation(s)
- Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan
| | - Helen L Po
- Stroke Center and Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Tai Lin
- Division of Pediatric Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Juey-Jen Hwang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| |
Collapse
|
50
|
Abstract
Stroke has traditionally been classified according to the trial of ORG 10172 in acute stroke treatment (TOAST) criteria; however, the concept of cryptogenic stroke did not meet the operational criteria necessary to define patient populations eligible for randomized studies. Therefore, the concept of embolic stroke of undetermined etiology (ESUS) was developed. An underlying hypothesis was that most strokes in patients with ESUS are caused by embolic events, hence, anticoagulation may prevent secondary events. Therefore, two large randomized trials were conducted comparing dabigatran or rivaroxaban with acetylsalicylic acid. Both studies could not show superiority of the new oral anticoagulants (NOAC) compared to aspirin; however, subgroup analyses showed that there is a patient population that may benefit from oral anticoagulation.
Collapse
Affiliation(s)
- Hans-Christoph Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät der Universität Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Deutschland.
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charite - Universitätsmedizin Berlin, Berlin, Deutschland
| |
Collapse
|