Cardioembolic Causes Research Articles

Impact of Systolic Blood Viscosity on Deep White Matter Hyperintensities in Patients With Acute Ischemic Stroke.

Elevated blood viscosity (BV), a critical determinant in blood rheology, is a contributing factor in cerebrovascular diseases. The specific influence of BV on small vessel disease burden remains unexplored. This study aims to examine the relationship between BV and regional white matter hyperintensity (WMH) volume in patients with acute ischemic stroke. We enrolled a cohort of 302 patients with acute ischemic stroke or transient ischemic attack who were admitted to a hospital within 7 days of symptom onset in this study. We measured whole BV using a scanning capillary-tube viscometer and categorized systolic blood viscosity into 3 groups based on established references. We quantified and normalized WMH volumes using automated localization and segmentation software by NEUROPHET Inc. We performed multivariable logistic regression analysis to assess the correlation between systolic BV and WMH. The mean subject age was 66.7±13.4 years, and 38.7% (n=117) of the participants were female. Among a total of 302 patients, patients with higher deep WMH volume (T3) were typically older and had an atrial fibrillation, strokes of cardioembolic or undetermined cause, elevated levels of C-reactive protein, diastolic blood viscosity and systolic BV. A multivariable adjustment revealed a significant association between high systolic BV and increased deep-WMH volume (odds ratio [OR], 2.636 [95% CI, 1.225-5.673]). Elevated systolic BV is more likely to be associated with deep WMH volume in patients with acute ischemic stroke or transient ischemic attack. These findings reveal novel therapeutic strategies focusing on blood rheology to enhance cerebral microcirculation in stroke management.

Ten-year statewide cross-sectional review of pediatric sinogenic intracranial abscess and empyema in Queensland, Australia: microbial profile before and after COVID-19.

Sinogenic intracranial infections in children, such as subdural empyema or intracranial abscess, are a rare disease process with significant associated morbidity. Recent literature has suggested that there may have been an increase in frequency of these infections following the COVID-19 pandemic, but the literature has been conflicting, perhaps related to the heterogenous management of COVID-19 lockdowns in various states and differences in data capture between methods. The collection of statewide Australian data overcomes these limitations by capturing a comprehensive sample though the public healthcare system of patients who were subject to a homogeneous statewide approach to public health policy during the COVID-19 pandemic (population 5.6 million, including 1.3 million children). The objective of this study was to present population-level data to address the question of whether the incidence of intracranial infections changed in pediatric patients before and after the COVID-19 pandemic. The authors present a retrospective 10-year statewide description of sinogenic intracranial infections in Queensland, Australia. A comparison was made between the incidence and microbiological profile before and after the onset of COVID-19 lockdowns on March 22, 2020. Forty-four pediatric intracranial infections undergoing neurosurgical intervention were identified within the review period. After exclusion of postsurgical and cardioembolic causes, 33 sinogenic intracranial infections were included (16 before and 17 after 2020, with a mean annualized incidence of 0.25 vs 0.37 cases per 100,000 children, respectively; p > 0.05). The most frequent organisms identified were Streptococcus milleri (n = 19), polymicrobial (n = 4), and S. aureus (n = 3). No significant differences in antimicrobial profile, susceptibility, parenchymal involvement, or clinical outcome were identified between the pre- and post-COVID-19 groups. No statistically significant differences in the epidemiology of pediatric intracranial infection have occurred in the state of Queensland, Australia, before and after March 22, 2020, and the COVID-19 pandemic.

Increased plasma levels of N-terminal pro-B-type natriuretic peptide as biomarker for the diagnosis of cardioembolic ischaemic stroke

BackgroundDespite comprehensive study, the aetiology of stroke is not identified in 35% of cases. AimsWe conducted a study to assess the diagnostic capacity of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the identification of ischaemic stroke of cardioembolic origin. The secondary purpose of the study was to evaluate the prognostic value of NT-proBNP for predicting 90-day all-cause mortality. MethodsWe designed a prospective observational study including patients hospitalised due to stroke between March 2019 and March 2020. Blood samples were collected on admission to the emergency department and serum NT-proBNP levels were determined. Statistical analysis was performed using a bivariate logistic regression model and receiver operating characteristic (ROC) and Kaplan–Meier curves. Statistical significance was established at p<.05. ResultsThe study included 207 patients with first ischaemic stroke. Plasma NT-proBNP levels were significantly higher (p<.001) in the cardioembolic stroke group (2069pg/mL±488.5). ROC curves showed that NT-proBNP>499pg/mL was the optimum value for diagnosing cardioembolic ischaemic stroke (sensitivity, 82%; specificity, 80%). Moreover, plasma NT-proBNP levels>499pg/mL were independently associated with cardioembolic stroke (OR: 9.881; p=.001). Finally, NT-proBNP>1500pg/mL was useful for predicting 90-day mortality (sensitivity, 70%; specificity, 93%). ConclusionsNT-proBNP was independently associated with cardioembolic stroke and should be quantified in blood tests within 24h of stroke onset. High plasma levels (>499pg/mL) may indicate an underlying cardioembolic cause, which should be further studied, while NT-proBNP >1500pg/mL was associated with increased 90-day mortality.

Incidence of atrial fibrillation in patients with renal infarction: A retrospective cohort analysis of the Korean national health insurance registry

BackgroundRegarding the pathophysiology of renal infarction (RI), cardioembolic causes could have large proportion. However, there are notable variations in prevalence of atrial fibrillation (AF) among patients with RI across different studies, ranging from 17 to 65%. The primary objective of this study is to analyze the incidence of AF in patients with RI. MethodsThis nationwide retrospective cohort study enrolled 5200 patients with RI from the Korean National Institute of Health Services database spanning the years 2013 to 2019. The study accessed the AF incidence rate within 12 months in patients without a prior history of AF. Events occurring within 3 months of RI diagnosis were excluded to mitigate cases diagnosed during the initial screening or those with AF diagnoses that were potentially overlooked in the past. ResultsAF occurred in 19.1% of patients with RI over the entire period (median: 2.5 years, interquartile range 1.04–4.25 years). The majority of AF cases (16.1%) occured within the first year, resulting in an overall incidence rate of 7.0 per 100 person-years. Patients with newly developed AF were, on average, older than those who did not develop AF (64.1 vs. 57.3 years, P < 0.001). The independent predictors of AF were identified as age, male sex, higher body mass index, current smoking, ischemic heart disease, and heart failure. ConclusionsPhysicians should consider the implementation of active rhythm monitoring for patients with RI to identify potential occurrence of subclinical AF, even if not initially diagnosed during the initial screening after RI diagnosis.

Ischemic Stroke in Young Tunisian Adults.

Ischemic Stroke in young adults is a real public health problem; it's a major cause of disability, alters quality of life and has a great socio-economic impact. determine risk factors and specify the etiology of arterial ischemic stroke in young Tunisian adults. In this 5 years retrospective study (2015-2020), we included all young adults (18-50 years) admitted for arterial ischemic stroke (AIS). Risk factors were registered and analyzed. All patients were investigated using a standard protocol: biological tests, brain imaging, carotid ultrasound and cardiac assessment. Additional investigations were carried out at the discretion of the treating physician. The cause of ischemic stroke was classified according to the TOAST criteria. We collected 200 patients with AIS. The mean age was 41.37 years ± 6.99. Traditional vascular risk factors were observed in more than 1⁄4 patients. A definite cause of stroke was identified in 120 patients. Cardio-embolic causes were the most common among our patients (19%) followed by atherosclerosis of the large arteries (11.5%). Other determined etiologies were found in 27.5% of patients. The etiology remained unclear in 40% of cases: undetermined despite complete investigation in 17.5%, undetermined and incompletely investigated 14.5 % and more than one potential pathomechanisms in 8%. Through this study, we demonstrated the diversity of etiology of stroke in young Tunisian adults. Changes of lifestyle are responsible for the occurrence of the traditional risk factors at an early age. Rheumatic heart diseases remain a frequent cause of AIS in our area.

Abstract WP128: Using Clinical Data to Reclassify ESUS Patients to Either Large Artery Atherosclerotic or Cardioembolic Stroke Mechanisms

Introduction: Defining the specific underlying pathophysiology of ischemic stroke is critical for minimizing the risk of recurrent events with personalized secondary prevention treatments. A notable portion of ischemic strokes are classified as embolic stroke of undetermined source (ESUS), leaving these patients without optimal treatment tailored to their pathophysiology. Hypothesis: Standard clinically collected data can reliably reclassify a substantial portion of ESUS patients into either a large artery atherosclerotic (LAA) or cardioembolic (CE) cause. Methods: A statistical model was developed to discriminate LAA from CE using a retrospective cohort of ischemic stroke patients treated at the University of Washington. A total of 189 patients were included (79 CE and 61 LAA to train the model, 49 ESUS patients to assess reclassification). Sixteen candidate predictors were collected across several sources: clinical risk factors, blood tests, echocardiography, ECG, and neurovascular imaging (Table 1). The LASSO (least absolute shrinkage and selection operator) was used to select important predictors in a penalized logistic regression model with stroke etiology (LAA vs. CE) as the outcome. ESUS patients were considered reclassified if the model-based probability of CE or LAA was at least 75%. Results: Of 189 patients, the mean (SD) age was 68 (14) years and 40% were women. The LASSO selected 12 predictors to discriminate CE vs. LAA (Table 1), with a corresponding cross-validated C-statistic = 0.87 (95% CI: 0.82-0.94). When the model was applied to the 49 ESUS patients, 23 (47%) were reclassified to LAA and 6 (12%) to CE. Conclusions: A multivariate model based on standard clinical data can separate LAA from CE with a high degree of discrimination. Applying this model led to reclassification to either LAA or CE in 59% of ESUS patients. Such approaches may enable more personalized secondary prevention strategies, but need to be tested in future trials.

Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment.

Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.

Exploring the Chagas Disease-Stroke “Connection”: Findings from a Large Multicenter Study

Introduction: Strokes are traditionally attributed to risk factors like aging, hypertension, diabetes, and atherosclerosis. Chagas disease has emerged as an important risk factor for stroke in Latin American. Our study aims at describing the largest cohort of patients with Chagas disease and ischemic stroke and determining variables associated with stroke recurrence and cardioembolic cause. Methods: This study is the result of a national multicenter cohort study conducted in Brazil. The study spanned from January 2009 to December 2016 and involved a comprehensive retrospective analysis of medical records of patients with both Chagas disease and stroke. This cohort comprised 499 individuals from diverse Brazilian regions, focusing on vascular risk factors and the epidemiological variables associated with Chagas disease and stroke. Results: Our findings underscore the significant prevalence of traditional vascular risk factors among Chagas disease patients who had stroke. 81% of patients had hypertension, 56% dyslipidemia, and 25% diabetes. We observed a 29.7% recurrence rate, especially within the cardioembolic subgroup. 56% of the patients had embolic stroke of undetermined source (ESUS). Specific electrocardiography abnormalities were associated with an increased risk of cardioembolic etiology (with three altered results increasing 81 fold the chance of the stroke being of cardioembolic nature). Age emerged as a protective factor (OR: 0.98, 95% confidence interval [CI]: 0.970–0.997) against cardioembolic etiology. Anticoagulation therapy was associated with reduced risk (OR: 0.221, 95% CI 0.104–0.472), highlighting the importance of accurate etiological classification. Conversely, female gender (OR: 1.83, 95% CI: 1.039–3.249) emerged as a significant risk factor for stroke recurrence. Conclusion: This study significantly advances our epidemiological understanding of the intersection between Chagas disease and stroke. It emphasizes the critical need for extensive epidemiological investigations, a deeper comprehension of stroke recurrence determinants, and accurate etiological classification to reduce the ESUS population. Our findings have substantial clinical implications, suggesting the need of control of vascular risk factors and comorbidities and hold promise for improving patient care and reducing the burden of Chagas disease and stroke worldwide.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review.

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

Clinical markers of atrial abnormality as predictors of cardioembolic events in patients with embolic stroke of undetermined source

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Unrestrictive grant for fellowship support - Abbot Medical Background Embolic stroke of undetermined source (ESUS) represents 17% of ischemic strokes. The lack of etiology leads to unsuitable treatment, higher stroke recurrence, and death. Several features presume atrial cardiomyopathy (ACM) as a potential etiology of embolism among ESUS population, but its causative role is not steadily grounded. Purpose To assess predictors, focusing on markers of ACM, of diagnosis of a cardioembolic source in ESUS patients during a long-term follow-up. Methods (Figure 1) - This study was an observational, retrospective, monocentric, cohort trial designed to assess predictors of cardioembolic events occurrence in an ESUS population along a 9-year follow-up. 128 ESUS patients who faced an ischemic stroke with a negative extensive etiological assessment from 2009 to 2012 were consecutively included. Upon ESUS diagnosis, clinical, echocardiographic (including transthoracic and transoesophageal echocardiogram), electrocardiographic (ECG), and Holter-ECG features were recorded. The occurrence of atrial fibrillation (AF) and the recurrence of ischemic stroke were registered during follow-up. Diagnosis of a cardioembolic source, a composite outcome, was defined as AF occurrence and/or recurrence of ischemic stroke, for which a cardioembolic cause was diagnosed secondary to the etiologic evaluation. Results (Figure 2) - AF and a cardioembolic source were diagnosed in 13 patients (10.2%) and 17 patients (13.3%) respectively, during the 9-year follow-up. Overall ischemic stroke recurrence was diagnosed in 13 patients (10.2%). Through univariate analyses, age higher than 65 (HR=4.9, p&amp;lt;0.01, 95%CI:1.5-16.1), abnormal P-wave axis (HR=4.3, p=0.01, 95%CI:1.4-13.2), increased PAC burden (HR=6.0, p&amp;lt;0.01, 95%CI:2.0-18.5), left atrial (LA) dilation (HR=6.1, p&amp;lt;0.01, 95%CI:2.0-18.7), and abnormal LA appendage outflow velocity (HR=8.6, p&amp;lt;0.01, 95%CI:1.8-41.7) were associated with AF occurrence. The AF occurrence was independently predicted by LA dilation (HR=6.69, 95%CI:1.17-37.47, p=0.02) and abnormal P-wave axis (HR=5.91, 95%CI:1.37-25.56,p=0.02). High blood pressure(HR=4.7, p=0.04, 95%CI:1.1-20.6), CHA2DS2-VASc score higher than 2 (HR=3.3, p=0.03, 95%CI:1.1-9.3), age higher than 65 (HR=3.5, p=0.02, 95%CI:1.5-16.1), increased of PAC burden (HR=6.2, p&amp;lt;0.01, 95%CI:2.2-17.1), and LA dilation (HR=4.2, p&amp;lt;0.01, 95%CI=1.6-10.9) were found as predictors of the diagnosis of a cardioembolic source during follow-up. The abnormal P-wave axis was an independent predictor of the diagnosis of a cardioembolic source (HR=3.82, 95%CI:1.03-14.09, p=0.04) in ESUS population. No risk marker assessed at baseline was associated to the recurrence of overall ischemic stroke recurrence. Conclusion LA dilation and abnormal P-wave axis are significant and independent predictors of the diagnosis of cardioembolic source and AF occurrence in ESUS population. ACM seems to be involved in the cardioembolic process in a significant portion of ESUS population.

Is cardioembolic stroke more frequent than expected in acute ischemic stroke due to large vessel occlusion?

Cardioembolic and atherosclerotic occlusions are two leading causes of acute ischemic stroke with large artery occlusion. Cardioembolic cause is more frequent in strokes due to large vessel occlusion among strokes of all types. In this study, we aimed to analyze and determine the rate of cardioembolic cause in patients with LVO treated with mechanical thrombectomy. This study is a retrospective analysis of 1,169 patients with LVO that were treated with mechanical thrombectomy in 2019. Both anterior and posterior circulation occlusions eligible for thrombectomy were included. Among the 1,169 patients who performed mechanical thrombectomy, there were 52.6 % males with a mean age of 63.2 ± 12.9 years and 47.4% females with a mean age of 67.4 ± 13.3 years. The average NIHSS score was 15.3 ± 4.8. The successful revascularization (mTICI 2b-3) rate was 85.2%, the 90-day good functional outcome rate (mRS 0-2) was 39.8% and mortality (mRS 6) rate was 22.9%. Most common causes of ischemic stroke were cardioembolism in 532/1,169 (45.5%), followed by 461/1,169 (39.5%) undetermined etiologies and others, 175/1,169 (15%) large vessel disease. Atrial fibrillation is found to be the most common cause of cardioembolic stroke with 76.3% incidence. We identified 11 (0.9%) acute stroke patients treated with MT who had recurrent LVO and received repeated MT. A cardioembolic cause was found to cause the recurrent LVO in 7 (63.6%) patients. In this retrospective study, cardioembolic source seems to constitute majority of causes in acute ischemic strokes due to large vessel occlusions. Further exploration is needed especially in cryptogenic strokes to reveal possible cardioembolic source of emboli.

Incidence of atrial fibrillation in patients with cryptogenic stroke

Background: Stroke can cause serious disability and mortality among the worldwide population. Atrial fibrillation (AF) is one of the major risk factors for ischemic stroke and a common cause of cardioembolism in old age. Aims and Objectives: The aim of the study was to study the incidence of AF in patients with cryptogenic stroke (CS). Materials and Methods: A prospective and observational study on AF and stroke was carried out in the Department of Cardiology/Neurology, in a tertiary care hospital. Data were collected in the form of chief complaints, medical history, clinical examination, and treatment given in the enclosed proforma for 1 year. On follow-up, specified goals including hypertension (HTN) management, lipid management, and diabetes management were done as per current guidelines. Results: Out of 100 CS patients, 69 were male and the mean age of the patients in this study was 59±13.37 years. The incidence of AF was 11% at the end of 1 year with male predominance (64%) and a mean age of 62±12.94 years. The mean CHADS2 Score in this study group was 1.40 with a standard deviation of 1.31. Stroke reoccurred in 12% of patients at the end of 1-year follow-up. Patients with recurrent stroke were mostly elderly with a mean age of 70 years (SD=9.78, P=0.03). Conclusion: It is found that a longer duration of electrocardiographic monitoring after CS increases the proportion diagnosed with AF and should be done in selected high-risk cases, especially in patients with HTN, dyslipidemia, diabetes mellitus, chronic kidney disease, and high CHADS2 score.

Left Atrial Appendage Thrombosis and Oral Anticoagulants: A Meta-Analysis of Risk and Treatment Response.

: BackgroundLeft atrial appendage thrombus (LAAT) is the main cause of cardioembolism in patients with nonvalvular atrial fibrillation (AF). Emerging evidence indicates that direct oral anticoagulants (DOACs) may be a preferred, safer choice for patients with LAAT. However, current guidelines indicate vitamin K antagonist (VKA) as the preferred treatment for LAAT. We conducted a meta-analysis to compare the efficacy of VKA and DOAC for the treatment of LAAT. Methods: The search was conducted in the PubMed, Embase, Google Scholar, and Cochrane Library databases from inception to July 2022, with the language restricted to English. A first analysis was conducted to evaluate the risk of LAAT under VKA or DOAC treatment. A second analysis was conducted to compare the resolution of LAAT under VKA and DOAC treatment. Results: In 13 studies comparing LAAT incidence rates under VKA and DOAC treatment, significant superiority of DOAC was detected (pooled RR = 0.65, 95% CI = 0.47–0.90, p = 0.009) with moderate heterogeneity being identified in the pooled studies. In 13 studies comparing LAAT resolution under VKA and DOAC use, treatment with DOAC exhibited a significantly increased probability of LAAT resolution compared with VKA (pooled odds ratio = 1.52, 95% CI = 1.02–2.26, p = 0.040). Conclusions: This meta-analysis suggests a superiority of DOAC over VKA with respect to LAAT incidence in people with AF and the likelihood of LAAT resolution. Due to their established safety profile, DOAC is a preferable choice for anticoagulation, although further randomized controlled studies are warranted to provide further evidence of their suitability as a new recommended treatment.

LA strain helps identifying the cardioembolic etiology of transient ischemic attacks

Abstract Background Patients who have transient ischemic attacks (TIA) often suffer from asymptomatic and paroxysmal atrial fibrillation (AF). Due to the fact that AF is located in the atria, we sought to determine whether abnormalities in left atrial (LA) structure and function could help identify the cardioembolic cause of TIA in patients with sinus rhythm but with documented episodes of paroxysmal AF. Methods The research included 190 individuals with TIA and classified them into two groups based on the presence (group I) or absence (group II) of confirmed paroxysmal AF. The diagnosis of paroxysmal AF was established by an assessment of medical records. To prevent assessing atrial stunning, cardiac ultrasonography was conducted in sinus rhythm at least 14 days following the initiation the TIA. Results The results indicated that patients in group I were older, more often female, had a history of stroke or TIA, and had a higher CHA2DS2-VASc score. Additionally, they exhibited increased LA volumes, a decreased LA emptying fraction, and markedly altered LA deformation patterns. Three factors were found as being independently associated with paroxysmal AF using multivariate logistic regression: age, LA reservoir strain, and LA emptying fraction (P&amp;lt;0.0001). The variables had as cut-off values: age &amp;gt;55 years, LA reservoir strain&amp;lt;−17%, and LA emptying fraction &amp;lt;51%. Conclusion The current research establishes that LA strains are independently associated with paroxysmal AF in patients with TIA and may aid in determining the cardioembolic origin of these events. Our findings have considerable clinical implications because, until now, LA 2D-STE was not included in the usual evaluation of TIA patients, but it may be the ideal next step in this regard. Funding Acknowledgement Type of funding sources: None.

Risk of New-Diagnosed Atrial Fibrillation After Transient Ischemic Attack.

BackgroundTransient ischemic attack (TIA) provides a unique opportunity to optimize secondary preventive treatments to avoid subsequent ischemic stroke (SIS). Although atrial fibrillation (AF) is the leading cause of cardioembolism in IS and anticoagulation prevents stroke recurrence (SR), limited data exists about the risk of new-diagnosed AF (NDAF) after TIA and the consequences of the diagnostic delay. The aim of our study was to determine this risk in a cohort of TIA patients with long-term follow-up.MethodsWe carried out a prospective cohort study of 723 consecutive TIA patients from January 2006 to June 2010. Median follow-up was 6.5 (5.0–9.6) years. In a subgroup of 204 (28.2%) consecutive patients, a panel of biomarkers was assessed during the first 24 h of the onset of symptoms. Multivariate analyses were performed to find out the associated factors of NDAF. Kaplan-Meier analysis was also performed to analyzed risk of SIS.ResultsNDAF was indentified in 116 (16.0%) patients: 42 (36.2%) during admission, 18 (15.5%) within first year, 29 (25%) between one and five years and 27 (23.3%) beyond 5 years. NDAF was associated with sex (female) [hazard ratio (HR) 1.61 (95% CI, 1.07- 2.41)], age [[HR 1.05 (95% CI, 1.03–1.07)], previous ischemic heart disease (IHD) [HR 1.84, (95% CI 1.15–2.97)] and cortical DWI pattern [HR 2.81 (95% CI, 1.87–4.21)]. In the Kaplan-Meier analysis, NT-proBNP ≥ 218.2 pg/ml (log-rank test P < 0.001) was associated with significant risk of NDAF during the first 5 years of follow-up. Patients with NDAF after admission and before 5 years of follow-up had the highest risk of SIS (P = 0.002).ConclusionThe risk of NDAF after TIA is clinically relevant. We identified clinical and neuroimaging factors of NDAF. In addition, NT-proBNP was related to NDAF. Our results can be used to evaluate the benefit of long-term cardiac monitoring in selected patients.

A patient with recurrent strokes: multimodal imaging reveals two possible causes

Abstract An underlying cardio-embolic cause can be identified in a fifth of stroke patients. Cardiac tumors occur rarely in routine clinical practice but can cause severe complications such as heart failure, valve dysfunction, embolic events, or sudden cardiac death. Herein we present the case of a 67-year-old patient with a history of recurrent stroke in whom a patent foramen ovale (PFO) and a hypermobile structure attached to the aortic valve were diagnosed during a transesophageal examination. The structure was interpreted to be a papillary fibroelastoma. Coronary computed tomography angiography completed the diagnosis, helping to exclude a relevant coronary artery disease. The patient underwent an uneventful cardiac surgery with removal of the hypermobile structure and closure of the PFO. The histopathological analysis, however, was negative for elastin in the elastin stain, and thus the diagnosis of a cardiac fibroma was made. The case emphasizes the role of cardiovascular imaging in stroke patients as well as that of histopathological analysis.

Contribution of Orbital Ultrasound to the Diagnosis of Central Retinal Artery Occlusion.

We aimed to evaluate the diagnostic value of orbital ultrasound in the etiologic diagnosis of central retinal artery occlusion (CRAO). For this purpose, patients with CRAO evaluated at our center between 2011 and 2021 were reviewed. Demographic variables, vascular risk factors and ultrasound findings were collected. An orbital duplex was performed in all cases and complemented with other diagnostic explorations. We attended 36 cases of CRAO. In all patients, orbital ultrasound confirmed the diagnosis of CRAO: in 75% emboli material (spot sign) was observed in CRA and in 25% flow alteration in CRA without visible embolus. The positive spot sign (PSS) group differed from patients with negative spot sign (NSS) in terms of etiology: 8 PSS cases (29.6%) had a major cardioembolic cause, 4 (14.8%) a large vessel atheromatous disease, 15 (55.6%) an undetermined cause. Some 21 (77.8%) PSS patients had some minor cardioembolic cause, mainly calcifications of the left valves. In the NSS group, 2 (22%) were diagnosed with giant cell arteritis (GCA). In CRAO, the ultrasound spot sign could be a guide for the detection of embolic sources. Its absence makes it necessary to consider more strongly the possibility of arteritis. Furthermore, our findings suggest a key role of calcium embolism in PSS patients.

Transthoracic echocardiography indices as a biomarker in patients with embolic stroke of undetermined source

BackgroundEmbolic stroke of undetermined source (ESUS) refers to a nonlacunar, nonatherosclerotic infarct in the absence of cardioembolic source or other specific causes of stroke. The presence of ESUS strokes indicates that the conventional risk factors cannot fully account for the pathogenesis of stroke. It is very important to detect useful biomarkers of the risk of ESUS for appropriate 2ry prevention.ResultsThe present study showed significant increase in left ventricular hypertrophy (LVH) measured by left ventricular mass index and increased left atrial volume index, measuring left atrial dilatation, among ESUS patients.ConclusionsPatients with ESUS tended to have Echocardiographic features of heart failure with a preserved ejection fraction (HFpEF) as LVH and left atrial dilatation. Therefore, they should be considered as biomarkers for cardioembolic cerebrovascular accidents with the consideration of anticoagulation with new oral anticoagulants as a primary preventive measure.

Anticoagulation Therapy in Endovascular Thrombectomy Patients With Large‐Vessel Occlusion Caused by Cardioembolism

Background In patients with ischemic stroke, cardioembolism, predominantly caused by atrial fibrillation (AF), is a leading preventable cause of large‐vessel occlusion (LVO). Despite proven efficacy, inadequate oral anticoagulant (OAC) therapy continues to be a major problem in patients with AF, mechanical heart valves, and other potential sources of emboli. We aimed to determine rates of cardioembolic LVO, the adequacy of OAC, and the association of OACs with clinical outcomes in patients with LVO treated with endovascular thrombectomy (EVT). Methods Consecutive patients with cardioembolism treated with EVT were included and had pre‐stroke indication for OACs and the adequacy of anticoagulation determined. The primary outcome was 3‐month functional independence (modified Rankin Scale score 0–2). Secondary outcomes included early neurological recovery (reduction in National Institutes of Health Stroke Scale score ≥8 points, or score of 0–1 at 24 hours), symptomatic intracranial hemorrhage, and 3‐month mortality and modified Rankin Scale score. Results There were 784 patients treated with EVT, of whom 416 (53.1%; 231 men; mean±SD age, 67.1±15.9) had cardioembolic LVO. Of those with cardioembolism, 221 (53.1%) had prevalent AF, 99 (23.8%) incident AF, 48 (11.5%) mechanical heart valves, 10 (2.4%) left ventricular thrombus, and 38 (9.1%) other cardioembolic causes. A total of 242 patients were identified as having a pre‐stroke indication for OACs, and 67 (27.7%) of these patients were considered adequately anticoagulated at time of LVO. In all 242 patients with cardioembolism with a pre‐stroke indication for OACs, adequate anticoagulation was not associated with EVT outcomes. However, adequate anticoagulation in patients with prevalent AF was associated with lower rates of internal carotid artery occlusion (6.8% versus 18.9%; P =0.03) and higher rates of functional independence (odds ratio=1.94; 95% CI, 1.02–3.78]; P =0.04). Conclusions Over half of patients treated with EVT were assessed as having a cardioembolic cause. Just over a quarter of patients with an indication for OACs at the time of LVO were adequately anticoagulated. These figures suggest that a substantial number of EVT procedures may have been avoided if more patients had been adequately anticoagulated.

Selective Serotonin Reuptake Inhibitors and Risk of Noncardioembolic Ischemic Stroke: A Nested Case-Control Study.

Multiple studies have reported that the use of selective serotonin reuptake inhibitors (SSRIs) is associated with an increased risk of ischemic stroke; however, this finding may be the result of a confounding by indication. We examined the association using different approaches to minimize such potential bias. A nested case-control study was carried out in a Spanish primary health-care database over the study period 2001 to 2015. Cases were patients sustaining an ischemic stroke with no sign of cardioembolic or unusual cause. For each case, up to 5 matched controls (for exact age, sex, and index date) were randomly selected. Antidepressants were divided in 6 pharmacological subgroups according to their mechanism of action. The current use of SSRIs (use within a 30-day window before index date) was compared with nonuse, past use (beyond 365 days) and current use of other antidepressants through a conditional logistic regression model to obtain adjusted odds ratios and 95% CI. Only initiators of SSRIs and other antidepressants were considered. A total of 8296 cases and 37 272 matched controls were included. Of them, 255 (3.07%) were current users of SSRIs among cases and 834 (2.24%) among controls, yielding an adjusted odds ratio of 1.14 (95% CI, 0.97-1.34) as compared with nonusers, 0.94 (95% CI, 0.77-1.13) as compared with past-users and 0.74 (95% CI, 0.58-0.93) as compared with current users of other antidepressants. No relevant differences were found by duration (≤1, >1 year), sex, age (<70, ≥70 years old) and background vascular risk. The use of SSRIs was not associated with an increased risk of noncardioembolic ischemic stroke. On the contrary, as compared with other antidepressants, SSRIs appeared to be protective.