Diagnosis Of Embolic Stroke Research Articles

Abstract WP169: The Utility Of Transesophageal Echocardiogram In Embolic Strokes Of Undetermined Source Not Associated With Patent Foramen Ovale

Introduction: Transesophageal echocardiography (TEE) is frequently utilized in the diagnosis of embolic stroke of undetermined significance (ESUS), with a patent foramen ovale (PFO) being the most common finding. Transcranial doppler (TCD) is comparable to TEE in diagnosing a right-to-left shunt, while being less invasive. Our aim is to evaluate the diagnostic yield of TEE excluding the diagnosis of PFO, in patients with ischemic stroke satisfying ESUS criteria. Methods: We retrospectively evaluated patients at our institution with acute ischemic stroke fulfilling ESUS criteria who underwent TEE examination during a 50-month period (May 2017 to July 2021). In these patients, we also evaluated whether TCD bubble study was done. We assessed whether non-PFO TEE findings altered management course. Results: We identified 113 patients with ESUS who underwent investigation with TEE (mean age 65 ± 13.5 years, 62% men, 38% women, median NIH Stroke Scale = 4 points [interquartile range: 2-9]). TEE revealed a PFO in 23.4% (95% CI: 19%-28.8%). TCD was performed in 55.6% of the patients with a PFO found on TEE, and revealed a right-to-left shunt in 80% of them. Excluding the finding of PFO, TEE revealed additional findings in 27 (23.9% [95% CI: 15.9%-31.2%]) patients. This changed management (anticoagulation therapy or surgical evaluation) in 3 (2.7% [95% CI: 0%-5.6%]) patients. The surgical evaluation was due to marantic valve endocarditis. No patients required IV antibiotic therapy due to TEE findings. Conclusions: Abnormal TEE findings only rarely affect the management in ESUS. TCD may be sufficient to screen for PFO in ESUS patients.

Should the Management of Embolic Stroke in the Elderly Be Changed if They Also Have COVID-19?

IntroductionA strong association between stroke and atrial fibrillation (AF) has been demonstrated. Anticoagulation for the prevention of stroke in high-risk patients has the benefit of improving the life expectancy, quality of life, autonomy and social functioning of the patient. The COVID-19 pandemic poses challenges for stroke patients because of the association between SARS-CoV-2 infection and thromboembolic risk.Case descriptionWe describe the case of an 84-year-old female patient admitted due to an embolic stroke and non-anticoagulated AF. Her admission symptoms were sensory-motor aphasia and severe right limb paresis with an NIHSS score of 24. The diagnosis of embolic stroke (namely, total anterior circulation infarct; TACI) was made. Her stroke was extensive so she was not started on anticoagulation. During hospitalization, new embolic events occurred and a concomitant diagnosis of COVID-19 was made with progressive respiratory dysfunction followed by multiorgan failure. The patient died despite appropriate treatment.DiscussionThe prognosis of elderly patients with cardioembolic stroke depends on anticoagulation administration. The NIHSS score on admission of our patient meant anticoagulation therapy was not appropriate. The diagnosis of COVID-19 contributed to the patient’s death.LEARNING POINTSAnticoagulation should be considered in stroke patients with total infarction and atrial fibrillation.There is an association between COVID-19 and thromboembolic stroke.Elderly patients with stroke and COVID-19 are at higher risk of death.

Abstract WP234: Metabolite Profiling Identifies a Specific Profile for Cardioembolic Stroke

Introduction: Accurate determination of stroke etiology is important in order to implement appropriate secondary stroke prevention. Approximately 25% are embolic strokes of undetermined source, a subset of which are eventually attributed to cardioembolism after prolonged outpatient electrocardiogram monitoring. We applied metabolite profiling to determine whether a metabolomic profile could identify a cardioembolic signature that could inform stroke of undetermined source. Hypothesis: We hypothesized that a specific metabolomic profile reflected by circulating metabolites could be derived from patients with stroke due to cardioembolism. Methods: Using liquid chromatography-tandem mass spectrometry, we analyzed 153 metabolites measured in plasma samples collected within 9 hours of stroke onset. Three hundred twenty six patients from an acute stroke cohort collected at two institutions were analyzed. Stroke subtypes were assigned using the Causative Classification System. Association with cardioembolic subtype was assessed and metabolites exceeding the Bonferroni corrected p value threshold were identified. Logistic regression was used to identify independent metabolite predictors of cardioembolic stroke. Results and Conclusion: The following metabolites were significant in univariate analysis: 2-hydroxyglutaric acid, glutathione, glyceric acid, hippuric acid, threonine, ornithine, histidine, cotinine, pseudouridine, C18:2-carnitine, tricarboxylic acid metabolites, and tryptophan pathway metabolites (all p<6.5x10-3). Regression analysis identified the following multivariate predictors of cardioembolic stroke: hippuric acid (p=0.045), ornithine (p=6x10-5), histidine (p=4x10-6), and a composite sum of tricarboxylic acid metabolites (p=0.004). Metabolite profiling may augment traditional approaches to diagnosing cardioembolic stroke and may have implications for the diagnosis of embolic stroke of undetermined source.

Myxomas in All Cardiac Chambers

(Echocardiography 2012;0:1-4)Key words: myxoma, cardiac tumor, embolic strokeCase history:A 24-year-old man presented to the emergencydepartment with inability to speak and weaknesson the right side of his body, which had begunduring a workout session 2 hours earlier. He didnot report any such symptom prior to the currentevent. Family history was negative for cardiac dis-eases or stroke. On physical examination, thevital signs were stable. Right hemiplegia andaphasia were present. A II/VI systolic murmur wasnoted at the left sternal border. The lungs wereclear to auscultation. There were no skin lesions,clubbing, or pedal edema. Electrocardiogramshowed a normal sinus rhythm. A chest x-rayshowed slight cardiomegaly. A noncontrast CT(Somatom Sensation 64, Siemens Medical Solu-tions, Erlangen, Germany) scan of the head wasunrevealing. With a presumptive diagnosis ofembolic stroke, the patient was admitted to aneurological ward unit and a cardiology consul-tation was requested for identification of thepotential cardioembolic source of stroke. A trans-thoracic echocardiography (TTE) (Vivid 7, GEUltrasound, Horten, Norway) was performed thatshowed multiple large intracardiac masses; anapical four-chamber view showed masses in allcardiac chambers (Fig. 1). The largest mass(5 9 4.1 cm) was located in the left atriumattached to the interatrial septum and protrudedinto the left ventricle during diastole (movie clipS1). Also noted were a small hypermobile mass inthe apex of the left ventricle, a right atrial massattached to the interatrial septum, and a hyper-mobile ovoid mass attached to the right ventricu-lar free wall (movie clips S2 and S3), as well as alarge hypermobile 3.8 9 3.4 cm mass at the leftventricular outflow tract (Figs. 2 and 3, movieclip S4). Transesophageal echocardiography(TEE) (Vivid 7, GE Ultrasound) showed anothermass at the entrance of the superior vena cava(movie clip S5). The patient underwent surgicalresection of the masses and six tumors wereresected (Fig. 4). Histopathological examinationof the masses was consistent with myxoma.Urinary free cortisol level, abdominal CT scan,testicular ultrasonography, and thyroid ultraso-nography were normal. Postoperative course wasuneventful and the patient was discharged onday 10 of admission. In a follow-up 10 monthslater, the patient still had some neurologicalsequelae. Repeat TTE and TEE did not showrecurrent masses. The patient’s first-degree familymembers were also subjected to a screeningechocardiography, which revealed no tumor inany of them.Myxomas are the most common type of hearttumors. About 75% of the myxomas are locatedin the left atrium and 20% in the right atrium.Only 3–4% of myxomas are detected in the leftventricle. Right ventricular myxomas are as fre-quent as the left ventricular myxomas. Multilocu-lar myxomas are very rare and only few reports ofcombined atrial and ventricular tumors areextant in the literature.

Stroke in Chagas Disease Patients in Ecudaor

Chagas disease is caused by the flagellated par- asite Trypanosoma cruzi. In Ecuador, this disease has been recognized since 1936, with a prevalence of 1.38% in the general population. Between 15 and 30% of infected persons can develop chronic disease with predominance of chronic cardiac and digestive symptoms. Among its major neuro- logical complications is stroke. Here, we report 3 cases of patients between 53 and 63 years with embolic stroke. In all cases two serological tests for Chagas disease were positive. Comprehensive studies were performed utilizing transtho- racic and transesophageal echocardiography, CT and MRI of the brain and followed up for three years. Case 1 had a left temporal-parietal stroke, Case 2 had an infarct of right middle cerebral artery with hemorrhagic transformation, and Case 3 had left striatal infarction adjacent to the old and new stroke. Chronic of Chagas disease should be included in the differential diagnosis of embolic stroke in individuals from Chagas-endemic areas.

Magnetic Resonance Imaging of Individual Cerebral Perfusion Territories Improves the Diagnosis of Embolic Stroke

This case study demonstrates the feasibility and diagnostic value of the oblique-plane arterial spin labeling method to visualize individual perfusion territories in a patient with embolic stroke. The perfusion territories obtained with this technique differed significantly from the standard anatomical situation. Imaging findings suggested that all acute embolic lesions in both hemispheres had arisen from one symptomatic internal carotid artery stenosis.

Can embolic stroke be diagnosed on the basis of neurologic clinical criteria?

Diagnosis of embolic stroke is based on identification of a source of embolus (SOE) and on neurologic symptoms acknowledged as "clinical criteria." To test the validity of these criteria, we analyzed the symptoms at onset in 193 patients hospitalized after acute cerebral infarction. Patients were grouped according to identification of a cardiac SOE (106 patients), an arterial SOE (38 patients), or no SOE (49 patients). Cross-tabulations demonstrated that only rapidity and loss of consciousness at onset were associated with the presence of a cardiac SOE to a significant degree. Although these symptoms were highly specific for cardiac SOE, they were not sensitive. A distinct clinical neurologic profile from the symptoms and mode of onset was not identified.