Potential Cardiac Source Of Embolism Research Articles

Nonsustained atrial tachycardia in 24-hour Holter monitoring: a potential cardiac source of embolism in acute ischemic stroke

BackgroundWhether nonsustained atrial tachycardia (NSAT) has a causative role similar to paroxysmal atrial fibrillation (AF) in ischemic stroke is unclear. We investigated the clinical and imaging features of ischemic stroke patients with NSAT to demonstrate that these patients would have a higher proportion of embolic strokes.MethodsWe retrospectively reviewed ischemic stroke patients who underwent Holter monitoring and selected patients with NSAT. The clinical and imaging characteristics were compared between patients with and without NSAT, and the risk factors for embolic stroke were evaluated. Moreover, the images of the selected patients were analyzed according to the Trials of Org 10172 in Acute Stroke Treatment classification.ResultsFrom a total of 1,051 patients who had 24-hour Holter monitoring, 681 patients were selected for the study. Among the selected patients, NSAT was detected in 243 patients. The patients with NSAT had a significantly higher proportion of imaging findings suggestive of cerebral embolism compared with patients without NSAT (27% vs. 14%, P<0.001). Moreover, the presence of NSAT was a statistically significant factor associated with imaging findings suggestive of cerebral embolism in the univariate (OR, 2.22; 95% CI, 1.51–3.27; P<0.001) and multivariate (OR, 2.26; 95% CI, 1.53–3.34; P<0.001) analyses. The patients with NSAT had a significantly older age at diagnosis, higher proportion of female sex, higher proportion of hypertension, lower proportion of smokers, higher CHA2DS2-VASc score, and higher left atrium index value compared with patients without NSAT.ConclusionsThe embolic pattern of acute ischemic stroke in patients with NSAT was frequently observed and shared clinical characteristics of AF rather than those of atherosclerosis. As NSAT may be a potential source of cardiac embolism, we suggest a more intensive search for modifiable risk factors such as AF in ischemic stroke in patients with NSAT.

Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction

Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015–8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46–57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.

Study of Embolic Cerebral Stroke in Atrial Fibrillation Patients. Severity, Recurrence and Outcome

Background: Patients with AF and concomitant potential cardiac sources of embolism increase the risk of recurrent embolism despite anticoagulation. Objectives: The aim of this study was to study different cardiac sources of embolism in stroke patients with AF and was to study if the presence of concomitant cardiac sources of embolism in AF stroke patients has impact on stroke severity, recurrence, response to treatment & outcome. Patients and methods: The study was a prospective clinical study that was conducted on 60 patients admitted to the Intensive Care Unit (ICU), Menoufia University Hospitals.The patients were divided into 2 groups: Group I: Patients with concomitant cardiac sources of embolism. Group II: Patients without concomitant cardiac sources of embolism. Results: There was significant difference found between the two groups regarding recurrence (P=0.045). We found that Elders, diabetics, patients with dyslipidemia, patients with CVD, severe National Institutes of Health Stroke Scale (NIHSS) score patients and big infarction size were significantly associated with poor stroke outcome. Conclusion: In conclusion, we found that most of the recurrent ischemic strokes were associated with elders, diabetics, patients with dyslipidemia, patients with CVD, severe NIHSS score patients and big infarction size.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography.

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

The Effect of Transoesophageal Echocardiography on Treatment Change in a High-Volume Stroke Unit.

Background and purpose—current guidelines recommend the use of transesophageal echocardiography (TEE) in relation to cardio-embolic sources of stroke. Methods—by using an hospital-based cohort, we retrospectively analyzed consecutive patients with acute ischemic stroke (AIS), acute hemorrhagic stroke (AHS) and transient ischemic attack (TIA) who were admitted in Strasbourg Stroke Center, France between November 2017 to December 2018. TEE reports were screened for detection of potential cardiac sources of embolism and the subsequent change in medical management. We performed univariate and multivariate analyses to identify predictors of relevant TEE findings. Results-out of the 990 patients admitted with confirmed stroke, 432 patients (42.6%) underwent TEE. Patients with TEE were younger (62.8 ± 14.8 vs. 73.8, p < 0.001), presented less comorbidities and lower stroke severity assessed by lower NIHSS (2 IQR (0–4) vs. 3 IQR (0–10), p < 0.01) and Modified Rankin Scale (1 IQR (0–1) vs. 1 (0–3), p < 0.01). A total of 227 examinations (52.5%) demonstrated abnormal findings considered as potential cardiac sources of embolism and 31 examinations (7.1%) were followed by subsequent change in medical management. Age (HR: 0.948, 95% CI 0.923 to 0.974; p < 0.001), previous AIS (HR: 3.542, 95% CI 1.290 to 9.722; p = 0.01), previous TIA (HR: 7.830, CI 95% 2214 to 27,689; p = 0.001) and superficial middle cerebral artery territory infarction (HR: 2.774, CI 95% 1.168–6.589; p = 0.021) were strong independent predictors with change in medical management following TEE. Conclusions—additional TEE changed the medical course of stroke patients in 7.1% in a French high-volume stroke unit.

Transesophageal echocardiogram in the evaluation of acute ischemic stroke of young adults

INTRODUCTION:Acute ischemic stroke (AIS) in the young age (≤50 years) is a major cause of disability. The underlying mechanism of AIS in this age group is usually different from elderly. Transthoracic echocardiography (TTE) is used to detect the potential cardiac sources of embolism in AIS patients. Transthoracic echocardiogram (TEE) is superior to detect specific underlying cardio-aortic source of embolism when compared to TTE. We aim to evaluate the diagnostic yield and therapeutic impact of TEE in AIS of young adults.METHODS:We retrospectively reviewed the consecutive patients with AIS in our comprehensive center in a 5-year period from our prospectively collected registry. We selected patients with age ≤50 years who had acute infarcts on brain magnetic resonance imaging or head computed tomography and underwent TEE as part of their diagnostic workup. Demographic details including, age, gender, body mass index, cardiovascular risk factors profile, and TEE findings were collected.RESULTS:Among a total 7,930 patients, 876 (11.04%) were found to be ≤50 years old. Among those, TEE was done in 113 patients (12.8%) in addition to TTE. Those who underwent TEE had a mean age of 40.4 ± 7.9 years, 60 were male (53%), 7 (6.2%) had a history of coronary artery disease, 38 (33%) had a history of diabetes, and 45 (40%) had a history of smoking. TEE showed new abnormal findings in a total of 15 patients (13.2%) that were not reported in their TTEs. Out of these, left atrial appendage thrombus was found in 5, infective endocarditis in 4, atrial septal aneurysms associated with patent foramen ovale (PFO) in 3, and spontaneous mobile echo density in three patients. Overall, new findings from TEE resulted in change in the secondary stroke prevention strategy in 14 patients of those who underwent TEE (12.3%). TEE also confirmed the presence of PFO, which was present on TTE with bubble study in 20 (17.6%) patients.CONCLUSION:TEE may provide additional information in the evaluation of the AIS in young adults, which could lead to change of the secondary stroke prevention strategy.

Established and potential echocardiographic markers of embolism and their therapeutic implications in patients with ischemic stroke.

Cardiogenic strokes comprised 11% of all strokes and 25% of ischemic strokes. An accurate identification of the cause of stroke is necessary in order to prepare an adequate preventive strategy. In this review the confirmed and potential causes of embolic strokes are presented, which can be detected in echocardiography in the context of present treatment guidelines and gaps in evidence. There remains a need for further studies assessing the meaning of potential cardiac sources of embolism and establishment of rules for optimal medical prevention (antiplatelet therapy [APT] vs. oral anticoagulation [OAC]) and interventional procedures to reduce the incidence of ischemic strokes. Currently available data does not provide definitive evidence on the comparative benefits of OAC vs. APT in patients with cryptogenic stroke or embolic stroke of undetermined source. There is a lack of antithrombotic treatment scheme in the time between stroke and the completed diagnosis of potential sources of thromboembolism.

The Evolving Role and Use of Echocardiography in the Evaluation of Cardiac Source of Embolism.

This report will review the role of echocardiography in the diagnosis of cardiac sources of embolism. Embolism of cardiac origin accounts for around 15%–30% of ischemic strokes. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthonous cerebrovascular occlusive disease. Transthoracic and/or transesophageal echocardiography serves as a cornerstone in the evaluation, diagnosis, and management of these patients. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism.

Diagnostic Yield of Echocardiography in Transient Ischemic Attack

Echocardiography is often performed to identify a cardiac source of embolism (CSE) causing transient ischemic attack (TIA). However, the diagnostic yield of echocardiography in TIA remains uncertain, and its role in routine evaluation of TIA is controversial. Patients with acute TIA were prospectively enrolled at 4 stroke centers. A CSE was defined using the Causative Classification of Stroke system; patent foramen ovale was considered a relevant CSE only if the patient underwent closure or was placed on anticoagulation. Patients with a known CSE at time of admission were excluded from analysis of the yield of echocardiography. A total of 869 patients were enrolled at stroke centers, and 129 had a known CSE at presentation. Of the 740 remaining patients, 603 (81%) underwent echocardiography. A potential CSE was identified in 60 (10%) of these patients. The most common CSEs noted on echocardiography were complex aortic arch atherosclerosis and patent foramen ovale. History of coronary artery disease (P < .001), lack of prior stroke or TIA (P = .007), and presence of acute infarction on magnetic resonance imaging (MRI) (P < .001) were predictors of CSE on echocardiography. The yield of echocardiography was 29% in patients with both history of coronary artery disease and acute infarction on MRI, 14% with one of these features, and 5% with neither of these features (P < .0001). A CSE identified by echocardiography prompted initiation of anticoagulation in 15 of the 603 (2.5%) subjects. Echocardiography demonstrates a relevant CSE in a significant portion of patients with TIA. However, changes in antithrombotic therapy resulting from echocardiography are infrequent.

Abstract 208: Non-gated Cardiac Ct Angiograms for Detection of Embolic Sources in Acute Ischemic Stroke

Background and Purpose: We assessed the diagnostic feasibility of using a 2-phase 64-slice non-gated cardiac computed tomographic angiography (CTA) in acute stroke patients, done in the same sitting as the brain CTA and using the same contrast dose, for the detection of a cardiac source of embolism. We expected to identify additional causes of stroke related to other unexpected pathology of heart or ascending aorta, which might be useful in therapeutic decision making and prognostication. Methods: We recruited 20 consecutive patients with acute ischemic stroke within the 4.5hours of symptom-onset, activated for intravenous thrombolysis. In addition to our usual CTA protocol that spanned from the arch of aorta to the circle of Willis, we enlarged the field of scanning to include the heart. Radio-contrast load (Omipaque 350) remained unchanged (injected at 3-4ml/sec; total 60-80mls, triggered by bolus tracking). All scans were 0.5cm thick slices and were reviewed by a radiologist and cardiologist and the abnormal findings were conveyed to the treating neurologist. In patients with potential cardiac source of embolism, an urgent trans-thoracic or trans-esophageal echocardiogram was arranged. Results: Of 20 patients, there were 3 abnormal findings, 1patient had a ventricular thrombus , 1 had a localized dissection in the ascending aorta and the third patient had a thrombus at the atrial appendage. Both were confirmed by trans-esophageal echocardiography and anticoagulation was started urgently the next day. None of our patients developed contrast nephropathy on follow up. Conclusions: expanding the field of scanning to include the heart and ascending aorta ( a non-gated cardiac CTA) to the routinely performed CTA of cervico-cranial arterial tree is a noninvasive and useful modality for detecting high-risk cardiac and aortic sources of embolism in acute stroke patients.

Role of atrial fibrillation burden in assessing thromboembolic risk.

Stroke represents the most devastating complication of atrial fibrillation (AF). Our understanding of the pathophysiology of thromboembolism in patients with AF remains incomplete, and as such, our assessment and management of this risk is imperfect. Current guidelines regard the risk of thromboembolism as independent of the frequency or duration of AF.1 Paradoxically, standard practice in the pericardioversion period considers thromboembolic risk to accrue after 48 hours of AF.1 This recommendation, however, is based on limited data, including an observational study of 357 patients which demonstrated that the risk of thromboembolic events was <1% in patients with AF lasting <48 hours who cardioverted without prolonged anticoagulation therapy or a transesophageal echocardiogram.2 No strong randomized control trial data exist to specifically support a 48-hour safety cut-off, and recent data suggest that the duration of AF associated with a significantly increased risk of stroke may in fact be less.3–8 The emergence of technology to allow absolute quantification of the frequency and duration, or burden, of AF offers the opportunity to refine our assessment and management of thromboembolic risk associated with AF. It has been 200 years since William Wood described a ball thrombus in the left atrium of a patient with mitral stenosis9 and 170 years since Virchow identified the critical components required for thrombus formation.10 It took until 1930 for Harvey and Levine to first declare that “auricular fibrillation definitely increases the incidence of auricular thrombosis” in an autopsy series of patients with mural thrombi.11 Uncertainty as to whether nonrheumatic AF resulted in stroke continued for the next 40 plus years until Wolfe and colleagues, in their landmark analysis using the Framingham population data, identified a 5.6-fold increased risk of stroke in patients with chronic nonvalvular AF.12 With time it would become …

Diagnostic and Therapeutic Value of Echocardiography during the Acute Phase of Ischemic Stroke

Echocardiography is routinely used to identify potential cardiac sources of embolism (CSE) in the acute phase of ischemic stroke (IS). We know that transoesophageal echography (TEE) is superior to detect CSE than transthoracic echography (TTE). However, the indications of each technique remain controversial. We aimed to evaluate the diagnostic yield (DY) and the therapeutic impact (TI) of echocardiography (both techniques combined) in IS and to analyze impact of clinical factors on these values. We included consecutive IS patients over a period of 22 months. All patients underwent TTE, and selected patients (young or with a high suspicion of cardioembolic origin) then underwent TEE. DY (detection of CSE) and TI (introduction of oral anticoagulant, closure of patent foramen ovale and targeted cardiologic consultation) were systematically evaluated. We analyzed 300 patients (mean age 61 years). All patients underwent TTE and 127 patients underwent TTE and TEE. Echocardiography overall detected CSE in 22% of patients with a TI in 11% of all cases. The TI was higher in patients less than or equal to 55 years of age. In contrast to other studies, the DY and TI of echocardiography were not associated with vascular risk factors. Echocardiography, as currently practiced in our stroke unit, allows detection of CSE in one patient in five, and leads to change in therapy in half of these cases. Our results suggest that TTE should be used for all patients admitted for IS, and to limit the use of TEE to younger patients.

TRANSESOPHAGEAL ECHO STUDY IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Background: Stroke is one of the major causes of death and disability and due to the high mortality and morbidity rates associated with stroke ,it is becoming a major community health problem worldwide. It has been estimated that cardiogenic emboli are a source of transient ischemic attack (TIA) or stroke in 20% to 40% of all cases. Transesophageal echocardiography (TEE) has been proven superior to transthoracic echocardiography (TTE) for the detection of potential sources of cardiac embolism in patients with previous stroke. In particular, the additional value of TEE in the patients above 45 years of age, in whom TEE is still far from routine procedure, was evaluated. In addition, emphasis was placed on therapeutic consequences, ie, the indication for anticoagulation, based on the results of TEE. Aim of the work : The aim of our study is to evaluate the role of TEE (transesophagealecho) to find indications of anticoagulation despite false absence of its benefit by clinical and transthoracicecho (TTE) examination. Patient and methods: The study was conducted in Zagazig university hospitals and included 100 patients diagnosed with ischemic stroke The diagnosis of stroke was made based on clinical data and brain CT. A full TEE was done and the presence of the following potential sources of embolism was specifically examined (a)left atrial spontaneous echo contrast and thrombus , (b)Impaired Left atrial appendage velocity and the presence of LAA (Left atrial appendage )thrombi , (c)Atheroma in the thoracic aorta, (d)Patent foramen ovale and atrial septal aneurysm (e) others, including valvular vegetations and intracardiac masses . Results:Among the different age groups studied , the prevalence of PFO and MVP (mitral valve prolapse) were highest in patients ˂ 45 years old while the prevalence of complex aortic atheroma was highest in patients ˃45 years old .Risk of stroke recurrence was highest in patients with complex aortic atheroma .Among patients with dyslipidemia,prevalance of ischemic stroke was highest in those older than 45 years old and was significantly higher in low HDL (high density lipoprotein ) (˂40 mg/dl ) and high cholesterol (˃200 mg/dl) group.Furthermore, the risk of stroke recurrence was significantly higher in patients with hypercholesterolemia. Conclusion: TEE has proved to be a very useful tool in diagnosing causes of ischemic stroke .The benefit was not only seen in young age (˂45 years old), but also in those in older age groups . Key words: Mitral valve prolapse, patent foramen ovale, interatrial septal aneurysm , complex aortic ahteroma ,Transesophageal Echocardiography.

Thromboembolism Prevention via Transcatheter Left Atrial Appendage Closure with Transeosophageal Echocardiography Guidance

Atrial fibrillation (AF) is an independent risk factor for stroke. Anticoagulation therapy has a risk of intracerebral hemorrhage. The use of percutaneous left atrial appendage (LAA) closure devices is an alternative to anticoagulation therapy. Echocardiography has a leading role in LAA closure procedure in patient selection, during the procedure and during followup. A comprehensive echocardiography study is necessary preprocedural in order to identify all the lobes of the LAA, evaluate the size of the LAA ostium, look for thrombus or spontaneous echo contrast, and evaluate atrial anatomy, including atrial septal defect and patent foramen ovale. Echocardiography is used to identify potential cardiac sources of embolism, such as atrial septal aneurysm, mitral valve disease, and aortic debris. During the LAA occlusion procedure transeosophageal echocardiography provides guidance for the transeptal puncture and monitoring during the release of the closure device. Procedure-related complications can be evaluated and acceptable device release criteria such as proper position and seating of the occluder in the LAA, compression, and stability can be assessed. Postprocedural echocardiography is used for followup to assess the closure of the LAA ostium. This overview paper describes the emerging role of LAA occlusion procedure with transeosophageal echocardiography guidance as an alternative to anticoagulation therapy in patients with AF.

Unique Congenital Malformation of the Mitral Valve Associated with Anomalous Coronary Arteries and Stroke

A 55-year-old male presented with stroke. Transesophageal echocardiogram and cardiac computed tomography revealed an unrecognized congenital malformation of the anterior mitral leaflet associated with anomalous left coronary circumflex artery, arising from the right coronary artery, diagnosed first by echocardiogram. This case represents a unique unforeseen mitral valve anomaly that might be considered as potential cardiac source of embolism. This finding broadens the spectrum of known mitral valve anomalies.

Is Isolated Aphasia a Typical Presentation of Presumed Cardioembolic Transient Ischemic Attack or Stroke?

Background: Previous studies have suggested that patients with a transient ischemic attack (TIA) or minor ischemic stroke and isolated aphasia should be carefully screened for a potential cardiac source of embolism. Most of these publications, however, were case reports or small-series. The purpose of this study was to assess the relationship between isolated aphasia and atrial fibrillation (AF) as the cause of presumed cardioembolic TIA or stroke within the setting of 2 large multicenter trials. Methods: The frequency of isolated aphasia was compared between patients with a TIA or minor ischemic stroke either with AF [European Atrial Fibrillation Trial (EAFT), n = 1,001] or without AF [Dutch TIA Trial (DTT), n = 3,150]. We analyzed data with univariable and multivariable logistic regression. Isolated aphasia was defined as aphasia without dysarthria, visual-field defects or motor or sensory deficits of the arm, leg or face. Because dysarthria can be difficult to detect in aphasic patients, a second analysis was done without excluding dysarthric patients. In a third analysis, we excluded patients with a symptomatic lacunar infarct from the DTT, as these patients were overrepresented due to the exclusion of patients with AF. Subgroup analysis was performed for patients presenting with TIA and minor stroke. Results: Of 4,151 patients, 210 (5.1%) had isolated aphasia, 109 from the EAFT and 101 from the DTT, crude odds ratio (OR) 3.69, 95% confidence interval (CI) 2.79-4.89. Patients with isolated aphasia were older (mean age 70.3 vs. 66.8 years, p < 0.01), more often female (OR 1.87, 95% CI 1.41-2.46), and more often had diabetes (OR 1.73, 95% CI 1.16-2.59) and hypercholesterolemia (OR 1.83, 95% CI 1.11-3.03) than those without aphasia. After simultaneous adjustment for age, sex, diabetes and hypercholesterolemia, patients with isolated aphasia still had AF more often than patients without isolated aphasia (adjusted OR 2.94, 95% CI 2.16-4.01). Both after inclusion of patients with dysarthria in the group of patients with isolated aphasia and after exclusion of patients with a symptomatic lacunar infarct, essentially the results remained the same. Patients presenting with isolated aphasia due to a TIA tended to have AF more often than patients with a minor ischemic stroke. Conclusions: Isolated aphasia is an independent sign of AF in patients with a TIA or minor ischemic stroke. Careful cardiac screening seems warranted in patients with isolated aphasia, as secondary prevention is different in patients with a cardiac source of embolism.

Abstract WMP82: The Association Between Cerebral Microbleeds And Arterial Stiffness

Background and significance: Increased arterial stiffness causes vessel damage of the end-organs. Thus, in the brain, small vessels may be susceptible to increased arterial stiffness. Cerebral microbleeds (CMBs) are topographically categorized as non-lobar type, mostly due to hypertensive vasculopathy and lobar type, due to cerebral amyloid angiopathy. When considering CMBs in the nonlobar region are associated with small vessel pathology, arterial stiffness may be related with CMBs in the nonlobar region. We investigated relationship between CMBs by using brachial ankle pulse wave velocity (baPWV) representing arterial stiffness. Method: Between June 2006 and January 2012, we included 1290 consecutive patients with acute ischemic stroke admitted to hospital within 7 days after symptom onset and who underwent baPWV and brain gradient echo (GRE) and Fluid Attenuated Inversion Recovery (FLAIR) MRI. Patients with potential cardiac sources of embolism or peripheral arterial occlusive disease were not included. BaPWV was measured during ankle-brachial index examination using an automatic device. CMBs were classified as lobar and nonlobar type. Severity of leukoaraiosis was determined using the Fazekas’ scoring system. Binary and multinomial logistic regression analyses were performed to determine variables that were associated with presence and location of CMBs. Results: Mean age of the patients was 64±12 years and 61.9% (799/1290) were male. Of 1290 patients, CMBs were found in 28.6%. The patients with CMBs were older than those without CMBs (69±10 years versus 63±12 years, p=0.001). Mean baPWV was higher in patients with CMBs than those without (2240±512cm/s versus 1896±505cm/s, p=0.001). On multivariate binary logistic analysis, baPWV and high grade leukoaraiosis were independent predictors of the presence of CMBs. However, after adjustment of age, sex and variables with p value of less than 0.1on the univariate analysis, baPWV was independently associated with nonlobar CMBs. Conclusion: Arterial stiffness was independently associated with nonlobar CMBs but not with lobar CMBs. These findings suggest pathophysiologic association between arterial stiffness and CMBs in the nonlobar region.

Cerebral infarction associated with diabetic ketoacidosis in an elderly patient

A 79-year-old woman who had diabetes mellitus for 22 years developed coma 1 day after influenza A virus infection. Diabetic ketoacidosis (DKA) was diagnosed based on high serum glucose levels (902 mg/dL), an arterial pH of 7.19 and large urine ketone (3 + ). Subsequently, the patient was treated with insulin and fluid therapy. After improvement in serum glucose levels, diffusion-weighted magnetic resonance imaging (MRI) showed acute infarction in the bilateral middle and posterior cerebral artery territories (Fig. 1). No severe stenosis in major cerebral arteries on magnetic resonance angiography was detected. Transthoracic and transesophageal echocardiography did not show any potential cardiac source of embolism including patent foramen ovale or thrombi in the left ventricle. In the present patient, brain lesions on MRI were located in the white matter, but not in cortices, suggesting microcirculatory impairment by hyperglycemia-induced hypercoagulability and/or hyperviscosity. DKA is associated with thrombotic risks, such as abnormalities in coagulation factors, platelet activation and blood volume, and cerebral edema as a result of DKA might predispose to stroke; however, DKA associated with stroke is rare in adults.

Repeated Thrombolytic Therapy in Patients with Recurrent Acute Ischemic Stroke

Background and PurposeWidespread use of thrombolytic treatments, along with improved chances of survival after an initial ischemic stroke, increases the possibility of repeated thrombolysis. There are few reports, however, regarding repeated thrombolysis in patients who have suffered acute ischemic stroke. We explored the number and outcome of patients with repeated thrombolytic therapy in the era of multimodal thrombolytic treatments.MethodsWe investigated patients with acute ischemic stroke who had received thrombolytic treatments for a period of 10 years. Number of thrombolysis was determined in each patient. Recanalization was defined as Thrombolysis in Cerebral Infarction grading ≥2a. Symptomatic hemorrhagic transformation was defined as any increase in the National Institutes of Health Stroke Scale score that could be attributed to intracerebral hemorrhage. A good outcome was defined as a modified Rankin scale score ≤2.ResultsOf the 437 patients who received thrombolytic treatments, only 7 underwent repeated thrombolysis (1.6%). The median age at the time of repeated thrombolytic therapy was 71 years old; 4 of the patients were female. All patients had 1 or more potential sources of cardiac embolism. Recanalization was achieved in all patients, in both the first and the second thrombolysis. No symptomatic intracranial hemorrhage occurred after repeated thrombolytic treatments. Five patients (71.4%) showed good outcomes at 3 months.ConclusionsRepeated thrombolysis for recurrent acute ischemic stroke appears to be safe and feasible. Among patients who experience recurrent acute ischemic stroke, thrombolytic therapy could be considered even if the patient has had previous thrombolytic treatments.

Atrial Septal Aneurysm Is Always Linked To Right-Left Shunt and Cardio embolic Risk

Atrial septal aneurysm when associated to other cardiac abnormalities, such as patent foramen ovale, Chiari network or Eustachian Membrane, is a well-known recognised risk factor for cerebral embolism. Aim of study is to assess if isolated atrial septal aneurysm could be considered statistically related to cryptogenic stroke, considering the strong clinical impact that this association could have on these patients outcome. 579 patients were investigated for a suspected patent foramen ovale using transthoracic echocardiography, in order to evaluate the presence of atrial septal aneurysm and to identify other potential cardiac embolic sources. The patients with atrial septal aneurysm underwent transcranic echodoppler and transoesophageal echocardiography examination with contrast solution during Valsalva manoeuvre.209/579 (36%) patients where we made diagnosis of atrial septal aneurysm. In this cohort of patients transcranic echodoppler showed a patent foramen ovale in 114/209 (54%), whereas transoesophageal echocardiography in 111/209 (53%); 6/114 (5%) pa-tients with a positive transcranic echodoppler had a normal transoesophageal echocardiography examination and 3/95 (3%) with normal transcranic echodoppler had a positive transoesophageal echocardiography. Transcranic echodoppler vs. transoesophageal echocardiography sensibility was 97% and specificity 94%. Only 13/98 (13%) of patients with isolated atrial septal aneurysm and 23/111 (26%) with patent foramen ovale had history of cryptogenic stroke. According to our data, isolated atrial septal aneurysm could not be considered an independent risk factor for cryptogenic stroke.