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Komatsu T, Okumura M, Kida H, Takahashi J, Maku T, Kitagawa T, Sato T, Takatsu H, Sakuta K, Sakai K, Umehara T, Mitsumura H, Oseto H, Iguchi Y. Thin aortic arch plaque is associated with the development of atrial fibrillation for embolic stroke of undetermined source in patients with an insertable cardiac monitor. Int J Cardiol 2024; 399:131769. [PMID: 38211671 DOI: 10.1016/j.ijcard.2024.131769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/11/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND AND OBJECTIVE This study's objective is to investigate whether mild aortic arch plaque is associated with the development of atrial fibrillation (AF) in stroke patients with embolic stroke of undetermined source (ESUS) during the first year following the implantation of an insertable cardiac monitor (ICM). METHODS The participants in this cross-sectional observational study were consecutive patients with ESUS, even after transesophageal echocardiography. We assessed the relationship between the thickness of the participants' aortic arch plaque and AF detected after ICM implantation. RESULTS Of the 50 consecutive patients with ESUS enrolled in this study, 12 (24%) developed AF. We observed that thicker aortic arch plaque was associated with undetected AF (2.3 mm vs. 1.2 mm, p < 0.001). Aortic arch plaque thickness was independent associated with undetected AF (OR 54.00, 95% CI 2.706-1077.544, p = 0.009). When the cut-off value for aortic arch plaque thickness was 1.8 mm, the sensitivity and specificity were 71.1% and 91.7%, respectively (95% CI = 0.75-0.98, p < 0.001). Also, patients having both aortic arch plaque with a thickness < 1.8 mm and a CHADS2 score ≥ 4 were more likely to have detectable AF than no AF (88% vs. 12%, p < 0.001). CONCLUSION A thinner aortic arch plaque was associated with the development of AF. Patients with mild aortic plaques below 4 mm but ≥1.8 mm in thickness and without other high-risk features are less likely to have paroxysmal AF on ICM, and these plaques may be a possible source of embolism for their strokes.
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Affiliation(s)
- Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan.
| | - Motohiro Okumura
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Hiroyuki Kida
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Junichiro Takahashi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Takahiro Maku
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Tomomichi Kitagawa
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Hiroki Takatsu
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Kenichi Sakuta
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Kenichiro Sakai
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Tadashi Umehara
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Hidetaka Mitsumura
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
| | - Hirotsuna Oseto
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, Japan
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Kneihsl M, Horner S, Hatab I, Schöngrundner N, Kramer D, Toth-Gayor G, Grangl G, Wünsch G, Fandler-Höfler S, Haidegger M, Berger N, Veeranki S, Fischer U, Enzinger C, Gattringer T. Long-term risk of recurrent cerebrovascular events after patent foramen ovale closure: Results from a real-world stroke cohort. Eur Stroke J 2023; 8:1021-1029. [PMID: 37658692 PMCID: PMC10683717 DOI: 10.1177/23969873231197564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO)-closure is recommended for stroke prevention in selected patients with suspected PFO-associated stroke. However, studies on cerebrovascular event recurrence after PFO-closure are limited by relatively short follow-up periods and information on the underlying aetiology of recurrent events is scarce. PATIENTS AND METHODS All consecutive patients with a cerebral ischaemic event and PFO-closure at the University Hospital Graz were prospectively identified from 2004 to 2021. Indication for PFO-closure was based on a neurological-cardiological PFO board decision. Patients underwent standardized clinical and echocardiographic follow-up 6 months after PFO-closure. Recurrent cerebrovascular events were assessed via electronical health records. RESULTS PFO-closure was performed in 515 patients (median age: 49 years; Amplatzer PFO occluder: 42%). Over a median follow-up of 11 years (range: 2-18 years, 5141 total patient-years), recurrent ischaemic cerebrovascular events were observed in 34 patients (ischaemic stroke: n = 22, TIA: n = 12) and associated with age, hyperlipidaemia and smoking in multivariable analysis (p < 0.05 each). Large artery atherosclerosis and small vessel disease were the most frequent aetiologies of recurrent stroke/TIA (27% and 24% respectively), and only two events were related to atrial fibrillation (AF). Recurrent ischaemic cerebrovascular event rates and incident AF were comparable in patients treated with different PFO occluders (p > 0.1). DISCUSSION AND CONCLUSION In this long-term follow-up-study of patients with a cerebral ischaemic event who had received PFO-closure with different devices, rates of recurrent stroke/TIA were low and largely related to large artery atherosclerosis and small vessel disease. Thorough vascular risk factor control seems crucial for secondary stroke prevention in patients treated for PFO-related stroke.
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Affiliation(s)
- Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Susanna Horner
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Isra Hatab
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Diether Kramer
- Department of Information and Process Management, Steiermärkische Krankenanstaltengesellschaft m.b.H. (KAGes), Graz, Austria
| | - Gabor Toth-Gayor
- Division of Cardiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Gernot Grangl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Gerit Wünsch
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | | | | | - Natalie Berger
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Sai Veeranki
- Department of Information and Process Management, Steiermärkische Krankenanstaltengesellschaft m.b.H. (KAGes), Graz, Austria
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
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Mayfield JJ, Otto CM. Stroke and Noninfective Native Valvular Disease. Curr Cardiol Rep 2023; 25:333-348. [PMID: 36971961 DOI: 10.1007/s11886-023-01855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE OF REVIEW Embolic stroke of undetermined source is a challenging clinical entity. While less common than atrial fibrillation and endocarditis, many noninfective heart valve lesions have been associated with stroke and may be considered as culprits for cerebral infarcts when other more common causes are excluded. This review discusses the epidemiology, pathophysiology, and management of noninfective valvular diseases that are commonly associated with stroke. RECENT FINDINGS Calcific debris from degenerating aortic and mitral valves may embolize to the cerebral vasculature causing small- or large-vessel ischemia. Thrombus which may be adherent to calcified valvular structures or left-sided cardiac tumors may also embolize resulting in stroke. Tumors themselves, most commonly myxomas and papillary fibroelastomas, may fragment and travel to the cerebral vasculature. Despite this broad differential, many types of valve diseases are highly comorbid with atrial fibrillation and vascular atheromatous disease. Thus, a high index of suspicion for more common causes of stroke is needed, especially given that treatment for valvular lesions typically involves cardiac surgery whereas secondary prevention of stroke due to occult atrial fibrillation is readily accomplished with anticoagulation.
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Affiliation(s)
- Jacob J Mayfield
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA.
| | - Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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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] [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.
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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
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Vera A, Cecconi A, Ximénez-Carrillo Á, Ramos C, Martínez-Vives P, Lopez-Melgar B, Sanz-García A, Ortega G, Aguirre C, Montes Á, Vivancos J, Jiménez-Borreguero LJ, Alfonso F. Risk of recurrent stroke and mortality after cryptogenic stroke in diabetic patients. Heart Vessels 2023; 38:817-824. [PMID: 36695856 DOI: 10.1007/s00380-023-02235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Diabetes mellitus is a highly prevalent and growing chronic disease that is associated with increased risk of recurrence among several stroke subtypes. However, evidence on the prognostic role of diabetes in the setting of cryptogenic stroke (CS) remains scarce. METHODS From April 2019 to November 2021, we recruited prospectively 78 consecutive patients with CS. Patients were classified according to the presence of diabetes. Main outcome was the composite of stroke recurrence and death. Secondary outcome was stroke recurrence. RESULTS Mean age of the cohort was 78 ± 7.7 years and 18 patients (23%) had diabetes. After a median clinical follow-up of 23 months the incidence of stroke recurrence and mortality [HR 5.8 (95% CI 1.9-19), p = 0.002] and the incidence of stroke recurrence [HR 16.6 (95% CI 1.8-149), p = 0.012], were higher in patients with diabetes. After adjusting for potential confounders diabetes was identified as an independent predictor of stroke recurrence and death in patients with CS [HR 33.8 (95% CI 2.1-551), p = 0.013]. Other independent predictors of stroke recurrence and mortality were hypertension [HR 31.4 (95% CI 1.8-550), p = 0.018], NTproBNP [HR 1.002 (95% CI 1.001-1.004), p = 0.013] and chronic kidney disease (CKD) [HR 27.4 (95% CI 1.4-549) p = 0.03]. Furthermore, diabetes was an independent predictor of stroke recurrence [HR 103 (95% CI 1.3-8261), p = 0.038]. CONCLUSION Diabetic patients with CS are at higher risk of stroke recurrence and death. Hypertension CKD and NTproBNP are also independent predictors of stroke recurrence and death after CS.
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Affiliation(s)
- Alberto Vera
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Alberto Cecconi
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain.
| | - Álvaro Ximénez-Carrillo
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carmen Ramos
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Pablo Martínez-Vives
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Beatriz Lopez-Melgar
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain
| | - Guillermo Ortega
- Data Analysis Unit, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain
| | - Clara Aguirre
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Álvaro Montes
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - José Vivancos
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Luis Jesús Jiménez-Borreguero
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain.
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
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Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis. Int J Cardiovasc Imaging 2022; 39:737-746. [PMID: 36542217 PMCID: PMC10104947 DOI: 10.1007/s10554-022-02779-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Atrial cardiopathy (AC) has emerged as a potential pathological thrombogenic atrial substract of embolic stroke of undetermined source (ESUS), even in the absence of atrial fibrillation. Left atrium (LA) myocardial deformation analysis may be of value as a subclinical marker of AC and a predictor of ESUS.
Aims
To compare LA mechanical function between ESUS cases and age and sex-matched controls.
Methods
A single-center analytical study with case-control design was performed. Case group was composed by young patients admitted in the Neurology department from January 2017 to June 2021. Control group was composed by age and sex matched controls recruited from the community. All participants performed echocardiogram and a smaller sample underwent cardiac magnetic resonance.
Results
We recruited 31 ESUS patients aged between 18 and 65 years and 31 age and sex matched controls. ESUS patients had a significantly higher prevalence of cardiovascular risk factors and patent foramen ovale (PFO). The prevalence of AC was not different between groups. Echocardiogram parameters, including strain analysis, were similar between groups, except for LA appendage (LAA) ostium variation which was significantly lower in ESUS patients (absolute: 6.5vs8.7mm, p<0.001; relative: 44.5%vs53.4%, p=0.002). After exclusion of patients with PFO, all the results were statistically similar. Regarding cardiac magnetic resonance analysis, there were no statistically significant differences between groups.
Conclusion
This study shows that in our population atria cardiopathy and atrial function was not associated with ESUS.LAA structural and functional abnormalities may play a major role. The role of LAA in ESUS warrants further studies.
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Zedde M, Portaro G, Ferri L, Cavallieri F, Napoli M, Moratti C, Piazza F, Valzania F, Pascarella R. Neurovascular Manifestations of Iron-Deficient Anemia: Narrative Review and Practical Reflections through a Teaching Case. J Clin Med 2022; 11:jcm11206088. [PMID: 36294407 PMCID: PMC9605151 DOI: 10.3390/jcm11206088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
Anemia is one of the most frequent diseases worldwide, affecting one-third of the general population. Anemia in general and in particular, iron-deficient anemia (IDA), has been associated to a higher risk of thrombotic manifestations, including ischemic stroke and cerebral venous thrombosis (CVT), as well as systemic extra-cerebral arterial and venous thrombosis. Despite these data, anemia is seldom considered as an etiological factor of stroke. An individual case encompassing all known neurovascular and systemic arterial and venous thrombotic manifestations related to IDA is presented with the focus on clinical reasoning issues in the diagnostic pathways, starting from the neuroradiological signs. The main questions have been identified and addressed in a narrative review of the most relevant data in the literature from a pragmatic and clinical viewpoint. The presented case concerns a 46-year-old man admitted to the Stroke Unit because of acute ischemic stroke with multiple thrombi in large intracranial and extracranial vessels, multifocal ischemic lesions in several arterial territories and the concurrent finding of asymptomatic CVT, pulmonary embolism with lung infarction and aortic thrombosis. An extended diagnostic work-up excluded the main etiologies (arterial dissection, cardiac embolism, genetic and acquired prothrombotic disorders, such as cancer and antiphospholipid syndrome), except for a severe IDA, such as to require blood transfusions followed by anticoagulant therapy for the several thrombotic manifestations. Neuroimaging and systemic vascular findings have been analyzed, and the main issues proposed by the case in the diagnostic pathway have been identified and discussed in a pragmatic clinical road map reviewing the data provided by the literature. Conclusions: IDA is a common but treatable condition that, independently or synergically, may increase the risk of thrombotic events. The diagnostic and therapeutic approach has not yet been defined, and each case should be individually addressed in a pragmatic clinical road map.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Correspondence: or
| | - Giacomo Portaro
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d’Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Radiology Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Claudio Moratti
- Neuroradiology Unit, Radiology Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Fabrizio Piazza
- CAA and AD Translational Research and Biomarkers Laboratory, School of Medicine and Surgery, University of Milano—Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Franco Valzania
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Radiology Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
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Advanced Echocardiography With Left Atrial Strain and Indexed Left Atrial Three-Dimensional Volume for Predicting Underlying Atrial Fibrillation After Cryptogenic Stroke. Am J Cardiol 2022; 185:87-93. [DOI: 10.1016/j.amjcard.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022]
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Clinical and radiographic phenotypes of patients with multifocal subcortical versus cortical cerebral infarcts. J Stroke Cerebrovasc Dis 2022; 31:106750. [PMID: 36084434 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/22/2022] [Accepted: 08/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Infarct topology is a key determinant in classification of a stroke as potentially embolic, with cortical and multifocal lesions being presumed embolic. Whether isolated subcortical multifocal infarcts are likely embolic has not been well studied. METHODS A prospective, single-center cohort study of consecutive patients with acute multifocal strokes confirmed on diffusion-weighting imaging (DWI) was queried, and patients compared according to the presence of isolated subcortical infarct topology versus cortical ± subcortical topology. Descriptive statistics and multivariable logistic regression were used to determine independent predictors of cryptogenic, subcortical infarcts. RESULTS Of 1739 patients screened, 743 had complete diagnostic testing with DWI evidence of acute infarction, 183 (24.6%) of whom had a multifocal stroke pattern. Isolated subcortical involvement was disproportionate among patients with ESUS (64.9%) when compared to patients with cardioembolic (24.3%) or large vessel disease (10.8%, p<0.01). Following multivariable adjustment, independent predictors of isolated subcortical multifocal infarction were milder strokes (OR 0.94, 95%CI 0.89-0.98) and higher grade Fazekas score (OR 2.32, 95%CI 1.02-5.29), while cardioembolism (OR 0.30, 95%CI 0.08-1.13) and large vessel disease (OR 0.27, 95%CI 0.08-0.91) remained inversely associated (as compared to ESUS). CONCLUSIONS These data suggest that multifocal subcortical infarctions are less likely to have an associated proximal embolic source than multifocal infarctions with cortical involvement. The strong association with chronic microvascular disease suggests this topology is more consistent with acute-on-chronic microvascular injury rather than an occult embolic source.
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Gogia B, Hasan S, Fisher M. A Review of the Current Literature and Updates on Embolic Stroke of Undetermined Source (ESUS). Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kim JG, Boo K, Kang CH, Kim HJ, Choi JC. Impact of Neuroimaging Patterns for the Detection of a Trial Fibrillation by Implantable Loop Recorders in Patients With Embolic Stroke of Undetermined Source. Front Neurol 2022; 13:905998. [PMID: 35769362 PMCID: PMC9234145 DOI: 10.3389/fneur.2022.905998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Atrial fibrillation (AF) is a well-known etiology of embolic stroke of undetermined source (ESUS), although the optimal detection strategy of AF was not been fully evaluated yet. We assessed AF detection rate by implantable loop recorder (ILR) in patients with ESUS and compared the clinical characteristics and neuroimaging patterns between the patients with AF and AF-free patients. Methods We reviewed clinical characteristics and neuroimaging patterns of consecutive patients with who were admitted to our comprehensive stroke center for ESUS and underwent ILR insertion between August 1, 2019, and January 31, 202. The inclusion criteria were (1) 18 years of age or older; (2) classified as having cryptogenic stroke extracted from the group with undetermined stroke according to ESUS International Working Group; and (3) underwent ILR insertion during or after admission due to index ischemic events. Ischemic stroke pattern was classified as (1) tiny-scattered infarction, (2) whole-territorial infarction, (3) lobar infarction and (4) multiple-territorial infarction. Interrogations of data retrieved from the ILR were performed by cardiologists in every month after the implantation. Results In this study, 41 ESUS patients who received an ILR implantation were enrolled (mean age, 64 years; male sex, 65.9%). The rate of AF detection at 6 months was 34% (14 patients), and the mean time from ILR insertion to AF detection was 52.5 days [interquartile range (IQR), 45.0–69.5]. The median initial NIH stroke scale scores were significantly greater in patients with AF than those without AF (6.5 vs. 3.0, p = 0.019). Whole-territorial infarction pattern was significantly more frequent in patients with AF than in those without AF (64.3% vs.11.1%, p = 0.002). Conclusions Higher covert AF detection rates within the ESUS patients were most often associated with higher NIHSS and whole-territorial infarction patterns on brain imaging.
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Affiliation(s)
- Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Kiyung Boo
- Department of Internal Medicine, Jeju National University Hospital, Jeju, South Korea
| | - Chul-Hoo Kang
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Hong Jun Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
- *Correspondence: Jay Chol Choi
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12
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Spence JD. Management of Patients with Embolic Stroke of Unknown Source: Interpreting the Evidence in the Light of Clinical Judgement. Curr Neurol Neurosci Rep 2022; 22:389-393. [PMID: 35524921 DOI: 10.1007/s11910-022-01202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To assess the validity of the belief that anticoagulation is not beneficial in patients with embolic stroke of unknown source (ESUS), and to asssess the benefits and safety of direct-acting oral anticoagulants (DOACs). RECENT FINDINGS The failure of randomized trials to show benefit of anticoagulation in ESUS is probably due to misclassification of large artery atherosclerosis (LAA) as ESUS, as defined by a stenosis ≥ 50%. There are important differences among DOACs. There are a number of problems with dabigatran, and rivaroxaban and edoxaban are not suitable for once-daily dosing. Recent evidence from real-world practice indicates that apixaban is more effective and safer than rivaroxaban. Plaque burden should be included in the definition of LAA. Patients in whom a cardioembolic source is strongly suspected should be anticoagulated; antiplatelet agents are not significantly safer than DOACs, and are not effective in cardioembolic stroke.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON, N6G 2V4, Canada.
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13
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Lin TY, Fu YC, Jan SL, Lin MC. Detecting Patent Foramen Ovale after Cryptogenic Stroke - A Single Center Experience in Taiwan. ACTA CARDIOLOGICA SINICA 2022; 38:373-380. [PMID: 35673343 PMCID: PMC9121751 DOI: 10.6515/acs.202205_38(3).20211228a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/28/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cryptogenic strokes related to a patent foramen ovale (PFO) in young patients have been reported. Percutaneous transcatheter occlusion is considered a safe and effective method for achieving PFO closure. Here, we present our experience of PFO closure in a series of young patients diagnosed with cryptogenic stroke. METHODS This was a retrospective study of 62 patients who were younger than 60 years of age and previously diagnosed with cryptogenic stroke. They underwent cardiac catheterization for the diagnosis of PFO and/or device closure. Bubble and echocardiography studies, the patients' characteristics, complications, and recurrence of stroke were recorded. The Risk of Paradoxical Embolism (RoPE) score index was also calculated. RESULTS Patients with a bubble study grade greater than grade I were likely to have PFO (odds ratio: 22.2 [95% confidence interval: 1.2-412.3]). The mean RoPE score in the PFO closure group was 7.18. Two patients (3.9%) developed atrial fibrillation during the procedure. Ischemic stroke recurred in two patients (3.3%). CONCLUSIONS Combining a bubble study with transcranial Doppler ultrasound or transthoracic echocardiography may increase the validity of PFO diagnosis. Because of the low recurrence rate of stroke and low complication rate, it is important to identify PFO patients with a bubble study grade greater than grade I. Closure of PFO may be a good strategy for preventing recurrent stroke among such patients.
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Affiliation(s)
- Ting-Yu Lin
- Children’s Medical Center, Taichung Veterans General Hospital
| | - Yun-Ching Fu
- Children’s Medical Center, Taichung Veterans General Hospital
| | - Sheng-Ling Jan
- Children’s Medical Center, Taichung Veterans General Hospital;
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Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University
| | - Ming-Chih Lin
- Children’s Medical Center, Taichung Veterans General Hospital;
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Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University;
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Department of Food and Nutrition, Providence University;
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School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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14
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Topiwala KK, Patel SD, Saver JL, Streib CD, Shovlin CL. Ischemic Stroke and Pulmonary Arteriovenous Malformations: A Review. Neurology 2022; 98:188-198. [PMID: 34880092 PMCID: PMC8826462 DOI: 10.1212/wnl.0000000000013169] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/12/2021] [Indexed: 02/03/2023] Open
Abstract
The potential of covert pulmonary arteriovenous malformations (PAVMs) to cause early onset, preventable ischemic strokes is not well known to neurologists. This is evident by their lack of mention in serial American Heart Association/American Stroke Association (AHA/ASA) Guidelines and the single case report biased literature of recent years. We performed PubMed and Cochrane database searches for major studies on ischemic stroke and PAVMs published from January 1, 1974, through April 3, 2021. This identified 24 major observational studies, 3 societal guidelines, 1 nationwide analysis, 3 systematic reviews, 21 other review/opinion articles, and 18 recent (2017-2021) case reports/series that were synthesized. Key points are that patients with PAVMs have ischemic stroke a decade earlier than routine stroke, losing 9 extra healthy life-years per patient in the recent US nationwide analysis (2005-2014). Large-scale thoracic CT screens of the general population in Japan estimate PAVM prevalence to be 38/100,000 (95% confidence interval 18-76), with ischemic stroke rates exceeding 10% across PAVM series dating back to the 1950s, with most PAVMs remaining undiagnosed until the time of clinical stroke. Notably, the rate of PAVM diagnoses doubled in US ischemic stroke hospitalizations between 2005 and 2014. The burden of silent cerebral infarction approximates to twice that of clinical stroke. More than 80% of patients have underlying hereditary hemorrhagic telangiectasia. The predominant stroke mechanism is paradoxical embolization of platelet-rich emboli, with iron deficiency emerging as a modifiable risk factor. PAVM-related ischemic strokes may be cortical or subcortical, but very rarely cause proximal large vessel occlusions. Single antiplatelet therapy may be effective for secondary stroke prophylaxis, with dual antiplatelet or anticoagulation therapy requiring nuanced risk-benefit analysis given their risk of aggravating iron deficiency. This review summarizes the ischemic stroke burden from PAVMs, the implicative pathophysiology, and relevant diagnostic and treatment overviews to facilitate future incorporation into AHA/ASA guidelines.
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Affiliation(s)
- Karan K Topiwala
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK.
| | - Smit D Patel
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Jeffrey L Saver
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Christopher D Streib
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Claire L Shovlin
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
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15
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Sharobeam A, Churilov L, Parsons M, Donnan GA, Davis SM, Yan B. Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:606521. [PMID: 33363511 PMCID: PMC7753023 DOI: 10.3389/fneur.2020.606521] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Cardioembolic strokes are common however atrial fibrillation, the most common cause, is often asymptomatic and difficult to detect. There is evidence that infarct topography and volume on magnetic resonance imaging may be associated with specific stroke etiologies. Aim: A systematic review and meta-analysis were undertaken to summarize the available evidence on the association between stroke etiology, infarct topography, and volume. Methods: A systematic review was conducted using Medline (OVID), Embase (OVID), and PubMed databases. Hand searches of the gray literature and of reference lists in relevant articles were also performed. A quality assessment was undertaken, based on the STROBE checklist. For each study, the number of patients with and without a CE source of stroke and infarct topography was collected and outcomes presented as odds ratios (OR) with 95% CI and p-values. Results: Four thousand eight hundred and seventy-three patients with ischemic stroke were included, of whom 1,559 were determined to have a CE source. Bilateral infarcts (OR 3.41; 95% CI 2.20–5.29; p < 0.0001) and multiple territory infarcts (OR 1.57; 95% CI 1.12–2.21; p = 0.009) were more common in patients with a CE source of stroke, than patients without a CE source. Lacunar infarcts (OR 0.49; 95% CI 0.31–0.80; p = 0.004) were more likely to occur in patients without a CE source. No significant difference between the frequency of multiple infarcts (OR 0.96; 95% CI 0.57–1.61; p = 0.87) anterior circulation (OR 1.45; 95% CI 0.83–2.53; p = 0.19) or posterior circulation infarcts (OR 1.06; 95% CI 0.72–1.57; p = 0.75), between the two groups were identified. Three out of four studies examining volume, found a significant association between increased infarct volume and CE source of stroke. A sensitivity analysis with cryptogenic and undetermined stroke sources assumed to be cardioembolic, did not alter the associations observed. Conclusion: The findings of this systematic review and meta-analysis are broadly consistent with previous literature and provide more robust evidence on the association between infarct topography, volume and stroke etiology. Our findings may assist with refining cardiac investigations for patients with cryptogenic stroke, based on infarct topography.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Leonid Churilov
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Mark Parsons
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,South Western Sydney Clinical School, The University of New South Wales, Liverpool, NSW, Australia.,Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia.,The Ingham Institute, Liverpool, NSW, Australia
| | - Geoffrey A Donnan
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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