Potential Embolic Sources Research Articles

Carotid artery webs in embolic stroke of undetermined source with large intracranial vessel occlusion.

Whether carotid artery web can be considered as a potential source of arterial thromboembolism in ischemic stroke remains uncertain. In a large sample of individuals with large intracranial artery occlusion, we compared the prevalence of carotid artery webs between patients with and without embolic stroke of undetermined source. In a single-center study of consecutive patients with anterior circulation ischemic stroke referred for mechanical thrombectomy, the presence of carotid artery web was systematically assessed by two independent readers. Thereafter, its prevalence was compared between patients with and without embolic stroke of undetermined source. Among 466 patients of whom 12% were considered to have had an embolic stroke of undetermined source, ipsilateral carotid artery web was detected in 1.9% (confidence interval 95% = 0.7-3.1). Ipsilateral carotid artery web was more frequent in embolic stroke of undetermined source than in the rest of the sample (10.7% (confidence interval 95% = 2.7-18.7] vs. 0.7% (0-1.5), P < 0.001). This difference remains significant after adjustment for sex, age, and vascular risk factor (odds ratio: 12.5 (2.1-72), P = 0.005) or after exclusion of patients with any other bulb wall thickening (P = 0.025). In contrast, the difference of prevalence of contralateral carotid artery web between the two groups did not reach statistical significance (2.4% vs. 1.9%, P = 0.6). Our results suggest that the presence of a carotid artery web might be considered as a potential source of large intracranial artery embolism. Longitudinal studies are needed to assess the exact risk of recurrence associated with these lesions.

Cardiovascular MRI: A valuable tool to detect cardiac source of emboli in cryptogenic ischemic strokes.

ObjectivesDespite a thorough work‐up including transesophageal echocardiography, 20%–30% of stroke etiology remains cryptogenic. Transesophageal echocardiogram is considered the gold standard procedure to detect cardiac or aortic sources of emboli. In the recent years, cardiovascular MRI has emerged as a noninvasive, sound, and reliable modality to image morphological and functional abnormalities. In this study, we compared none contrast cardiovascular MRI to transesophageal echocardiogram, in the ability to detect cardiovascular source of embolus in cryptogenic ischemic strokes.MethodsA series of 24 patients who were labeled, after a thorough stroke work‐up, as having cryptogenic stroke, were examined with both transesophageal echocardiogram and noncontrast cardiovascular MRI to assess for cardiac or aortic source of emboli. The cardiologist who interpreted the transesophageal echocardiograms was blinded to the results of cardiovascular MRI. At the same time, the radiologist who interpreted the cardiovascular MRI was also blinded to the results of transesophageal echocardiogram. The cardiac lesions, with potential source of emboli that were assessed in our study included left ventricular thrombus, atrial septal aneurysm, and aortic atherosclerotic disease. The ability of cardiovascular MRI to identify potential source of cardiac embolus was then compared to that of transesophageal echocardiogram.ResultsTransesophageal echocardiogram detected ascending or arch aortic atherosclerotic plaque in 14 of the 24 patients. Other abnormalities detected include two atrial septal aneurysms and two left ventricular thrombus. Cardiovascular MRI was able to identify aortic atheroma in 13 patients; as well as three atrial septal aneurysms and two left ventricular thrombus. The accuracy of cardiovascular MRI to detect aortic atheroma, atrial septal aneurysm or left ventricular thrombus was great; 96%, 95.83%, and 100%, respectively.ConclusionThis small study suggests that, in patients with cryptogenic stroke, cardiovascular MRI is comparable to transesophageal echocardiogram in detecting cardiac and aortic source of emboli.

Abstract WP261: The Left Atrial Septal Pouch: A New Stroke Risk Factor?

Background: The left atrial septal pouch (LASP) is a common anatomic variant produced by the incomplete fusion of septa primum and secondum at the inter-atrial septum, thus creating a potential embolic source from an open flap or blind pouch in the left atrium. Our prior work demonstrated increased prevalence of LASP in cryptogenic strokes (Frontiers Neurology 3-24-15). The aim of the current study was to examine the prevalence of LASP in a separate, more recent group of stroke patients and control subjects who underwent transesophageal echocardiography (TEE). Methods: We examined consecutive TEE studies performed between July, 2011 and December, 2018 at UC Irvine Medical Center. Prevalence of LASP was determined in TEE studies referred for ischemic stroke or TIA (“stroke subjects”), and compared to LASP prevalence in patients undergoing TEE for other reasons (“control subjects”). Stroke subtyping was performed using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Results: TEE studies were performed on 221 cerebrovascular cases and 164 control subjects. Age and sex were 57±1 years (mean±SE) and 53% male for stroke subjects, and 56±1 years and 62% male for control subjects. Prevalence of LASP was 24% (40/164) in control subjects, 17% (24/138) in non-cryptogenic stroke subjects, and 36% (30/83) in cryptogenic stroke subjects. LASP prevalence was significantly higher for cryptogenics compared to the other groups (p=0.007). There was no significant difference between LASP prevalence in controls vs non-cryptogenic stroke. Elimination from analysis of subjects with other inter-atrial septal abnormalities (ie, patent foramen ovale or atrial septal defect) did not significantly change results. Conclusions: These findings demonstrate an increased prevalence of LASP in cryptogenic stroke, confirming our prior published findings. Given the plausibility of LASP acting as a thromboembolic nidus, additional studies are needed to determine the generalizability of these findings and their therapeutic implications.

388 Persistent Left Superior Vena Cava With Unusual Drainage

Persistent left superior vena cava (PLSVC) can lead to thromboembolic phenomena including transient ischaemic attacks and stroke. This case report signifies the importance of its identification through simple investigations like echocardiography. The management of this condition described in literature is predominantly surgical. Treatment of this condition with anticoagulation, as described in our paper is a novel approach in managing this condition. A 64-year-old man with a background of dyslipidemia and hypertension presented with symptoms of aphasia and confusion. He was diagnosed with a bi-hemispheric stroke on MRI brain. A transoesophageal echocardiogram was performed as a part of the stroke work up. A bolus of agitated gelofusine administered via a left-sided cannula showed immediate contrast opacification of the left atrium before the right atrium, indicative of a venous to systemic shunt. When agitated gelofusine was injected via the right arm, normal contrast filling was demonstrated in the right atrium first. A cardiac CT confirmed the presence of a PLSVC draining into the left side of the heart. He was commenced on apixaban as secondary prevention for recurrent paradoxical embolisation and remains symptom free one year after initial presentation. In a setting of cryptogenic stroke, a venous-to-arterial shunt caused by a PLSVC should be considered as a potential source of embolus. Echocardiography with contrast injections from both arms should be carried out to assess possible anomalous thoracic venous drainage. Making the diagnosis of venous-to-systemic shunt would help formulate appropriate management to prevent recurrence of embolic phenomena.

P918 Screening protocol of patent foramen ovale in cryptogenic stroke

Abstract Introduction Cryptogenic stroke reaches a prevalence of 30% and entails a significant risk of recurrence. Transesophageal echocardiography is the gold standard in identifying potential proximal embolic sources, including patent foramen ovale (PFO). Based on recent evidence, PFO percutaneous closure is recommended in selected cases of cryptogenic stroke, especially if associated with high risk features. Since PFO is present in up to 27% of the general population, the real challenge is to define which patients have a pathogenic PFO. Purpose To develop a pathogenic PFO screening protocol in patients with cryptogenic stroke, aimed at secondary prevention. Methods We revised the literature, analysing published articles in PubMed in the last 5 years, with the keywords "patent foramen ovale and cryptogenic stroke". Subsequently, we produced a screening algorithm based on cryptogenic stroke definition, on RoPE (Risk of Paradoxical Embolism) Score and on the inclusion and exclusion criteria of the CLOSE, REDUCE and RESPECT studies, which showed promising results of PFO closure in this context. Results Our protocol establishes that patients who present with ischemic stroke should be evaluated for risk factors and undergo a detailed etiological study. When the study is inconclusive, the RoPE score is applied to determine the probability of finding a pathogenic or an incidental PFO. If equal or greater than 7 points, in the absence of predefined exclusion criteria, a transesophageal echocardiogram is performed. If the screening is positive, the patient will be referred to the Cardiology Department for therapeutic guidance. If negative, alternative complementary diagnostic methods may be considered. Conclusion Through the application of this protocol, patients with high probability of having a pathogenic PFO and, consequently, those who may benefit from percutaneous closure, will be selected to undergo a screening transesophageal echocardiogram. The implementation of a PFO screening protocol in patients who present with cryptogenic stroke is relevant, by proposing to reduce its recurrence rate through the early referral of young patients with indication for an invasive strategy.

P1461 Concomitant potential cardioembolic sources in a patient with an acute ischemia of the limb

Abstract Introduction Transesophageal echocardiography (TEE) is the gold standard exam to look for a cardioembolic source in a patient with an otherwise unexplained suspected systemic ischemic event. Purpose: This clinical case aims to illustrate the importance of a thorough TEE evaluation in the presence of a suspected systemic emboli, and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected. Case presentation: We present the case of a 55-year-old man, obese (BMI 30kg/m2), active smoker, with no past medical history or medication, and whose father died from an unspecified cardiovascular cause at 45 years-old. He was admitted to the hospital because of an acute ischemia of the right lower limb, for which he underwent urgent percutaneous femoral embolectomy of the limb, with success. During hospitalization, he was referred for a TEE, which showed valves and cavities with no evidence of potential embolic sources. However, he had a thin and hypermobile atrial septum, with no obvious defect after color flow mapping, but with a patent foramen oval (PFO) that was detected after agitated saline injection associated with a Valsalva maneuver, with the passage of 5-25 microbubbles (grade 2/4 shunt) and an atrial septum aneurysm (ASA), with an excursion of the fossa ovalis towards the left atrium of 10.1mm (Figure 1). The ascending aorta was normal, but the descending aorta depicted 2 hypermobile masses, 1 starting at 35cm from the dental arch (transversal area: 0,52cm2), the longest (7cm) starting at 32cm and ending at the aortic arch (transversal area: 1,76cm2). An angio-CT was immediately performed, which depicted an atheromatous calcified plaque in the terminal portion of the aortic arch, giving rise to the image suggestive of thrombus, and extending for about 6cm to the medium third of the descending thoracic aorta. The remaining portions of the aorta and iliac arteries depicted diffuse atheromatous and partially calcified plaques (Figure 2). The patient was submitted to an urgent thoracic endovascular aortic repair with a 26x10cm prosthesis implantation with occlusion of the left subclavian artery and an adequate final clinical result. Syphilis and auto-immune disease were excluded and a diffuse atheromatous disease of the aorta was assumed as the cause of the thrombus and the embolic event. After 16 days, he was discharged asymptomatic and with no signs of chronic ischemia, treated with oral anticoagulation with rivaroxabano, high-dose statin and strict smoking cessation. Conclusion: Cardioembolic source is a heterogeneous entity. In this patient, 2 potential cardioembolic sources were detected: while the PFO and ASA are minor or unclear risk sources of emboli, TEE also allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta, which was considered a major risk source, thus implying urgent surgery to obviate the risk of further embolic events. Abstract P1461 Figure. Fig.1.POF and ASA;Fig.2.Aortic Thrombus

Prevalence of Microembolic Signals in Embolic Stroke of Undetermined Source and Other Subtypes of Ischemic Stroke.

Background and Purpose- Embolic stroke of undetermined source (ESUS) has been proposed to cause thromboembolic infarction from unknown but potential embolic sources. However, an embolus remains undetected in ESUS. The goal of this study was to characterize the prevalence and risk factors of microembolic signals (MESs) in ESUS. Methods- We examined 108 patients with acute ischemic stroke in the internal carotid artery territory or transient ischemic attack within 14 days of symptom onset and who were admitted to our hospital between April 2017 and March 2019. MESs were monitored in the middle cerebral artery on transcranial Doppler for 60 minutes. We examined the prevalence and number of MES in ESUS and other stroke subtypes, such as cardioembolism, large artery atherosclerosis, cerebral small vessel disease, and transient ischemic attack. The present study was registered in University Hospital Medical Information Network Clinical Trials Registry (UMIN000031913). Results- MESs were detected in 33 (31%) of 108 patients. ESUS showed the highest proportion (12/24 [50%]), followed by large artery atherosclerosis (8/20 [40%]), cardioembolism (6/18 [33%]), transient ischemic attack (4/24 [17%]), and cerebral small vessel disease (3/21 [14%]). Univariate analysis showed that higher systolic blood pressure, body mass index, hemoglobin A1c, and ESUS were significantly associated with MES. In multiple logistic regression analysis, ESUS remained significantly associated with MES after adjustment for described covariates from univariate analysis (odds ratio, 2.86 [95% CI, 1.01-8.08]). Conclusions- This study demonstrated significant association of ESUS with MES, supporting the embolic nature of this stroke subtype. Registration- URL: https://upload.umin.ac.jp. Unique identifier: UMIN000031913.

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.

Etiology of Cryptogenic Stroke

Ischemic stroke is a heterogeneous syndrome with a plurality of potential etiological factors. The routine diagnosis does not always allow the cause of acute cerebrovascular accident to be found, in such cases we talk about cryptogenic ischemic stroke, which incidence is 20-40%. The category of patients with cryptogenic stroke was first characterized and assigned to a separate group in the database of the National Institute of Neurological Diseases and Stroke in the USA, and later in the TOAST study. The diagnosis of cryptogenic stroke is usually based on the exclusion of well-known causes of acute cerebrovascular accidents, such as atherosclerosis, cardiac arrhythmias, arterial hypertension. Due to the considerable variability of concepts for cryptogenic stroke, the term ESUS (Embolic Stroke of Undetermined Source) appeared in 2014 and formulated criteria which accurately characterized these patients: non-lacunar cerebral infarction by CT and/or MRI, no atherosclerotic lesion stenosing a stroke-associated artery of more than 50%, no sources of high-risk cardioembolism, no other causes of stroke such as dissection of the artery supplying the area of infarction in the brain, migraine, arteritis. Among the potential causes and sources of cerebral embolism in patients with cryptogenic stroke are heart, veins of lower extremities and pelvis, nonstenosing atherosclerosis of brachiocephalic artery, atheroma of aortic arch, paradoxical embolism non-atherosclerotic vasculopathy, monogenic diseases, hypercoagulable states, and others. We should note that there is a lot of studies on the possible causes of cryptogenic stroke in the available literature, but no common approach to classification of etiologic factors and examination algorythms were developed. The high incidence of cryptogenic stroke, the significant heterogeneity of its etiopathogenetic mechanisms and the need for differentiated approaches to the secondary prevention of this type of acute cerebrovascular accident determine the relevance of further studies in this field.

P2469The yield of transoesophageal echocardiography in embolic stroke of unknown source

Abstract Purpose Transthoracic echocardiography (TTE) and transoesophageal (TOE) are the main diagnostic tools for the detection of potential cardiac and aortic sources of embolism (PCSE). TOE is superior to TTE. However, its therapeutic impact is questioned. TOE is no longer recommended in ESUS (embolic stroke of unknown source), which is thought to be caused by undiagnosed atrial fibrillation (AF). Recent studies however report an about 10% change in therapeutic management due to TOE. We aimed to assess prospectively, in patients admitted to our stoke unit and diagnosed ESUS, the rate of treatment change induced by TOE. Methods Patients diagnosed with acute (≤7 days) ESUS were included to undergo TOE. ON TTE, PCSE, left ventricular ejection fraction (LVEF, %), left atrial area (LA-A, cm2), indexed left atrial volume (LAV, ml/m2) were recorded. On TOE, PCSE, left atrial appendage area (LAA-A, cm2), left atrial appendage emptying velocity (LAA-EV, cm/s) were recorded. PCSE on TTE and TOE were classified according to EAE guidelines. Results Between October 2016 and May 2018, 1322 TTEs were performed in patients admitted to our newly labelled stroke unit. ESUS was diagnosed in 152 patients, who underwent TOE. Mean delay (95% CI) between stroke onset and TTE was 2.2 days (1.9–2.5). Mean (95% CI) age was 61 years (58–63). 56/152 were female (37%). On TTE, mean (95% CI) LVEF was 62% (61–64), mean LA-A was 19 cm2 (19–20) and mean LA-V was 32 ml/m2 (31–34) ml/m2. In 38 patients, a major PCSE was identified by TTE. In 4 cases, there were 2 potential major PCSE and in one case 3. In 79 patients, at least one minor PCSE was identified by TTE, among which 35 PFO. On TEE, mean (95% CI) LAA-A and LAA-EV were: 5.2 cm2 (4.9–5.5) % and 76 cm/s (72–80) cm/s. In 50 patients, a major PCSE was identified by TOE. Eleven patients had 2 major PCSE. In 115 patients, at least one minor PCSE was identified by TOE, among which 34 PFO. According to EAE guidelines, a treatment change induced by TOE occurred in 12 patients. Anticoagulation in 5 patients (aortic arch thrombus in 2, thrombus of the proximal descending aorta in 1, LAA thrombus in 1, and thrombotic non-infectious vegetations in 2). Surgery in one patient (LAA fibroelastoma), antibiotics in two patients with infectious endocarditis, One patient had aortic fibroelastoma not seen on TTE. Finally, two patients with mobile aortic arch debris had dual antiplatelet therapy (DAT). In two other patients, TOE showed a mitral fibroelastoma and a mobile aortic arch thrombus, but these abnormalities were already seen on TTE, hence not taken into account. When considering the eight patients who had, at neurologist's discretion, the instauration of DAT for complex aortic arch atheroma, 12+8 patients had therapeutic modifications induced by TOE (13%). Conclusion Major PCSE on TOE lead to a treatment change in 12/152 patients (8%) according to EAE guidelines, and 13% when complex aortic arch atheroma was considered.

Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source.

BackgroundWe aimed to assess the prevalence and degree of overlap of potential embolic sources (PES) in patients with embolic stroke of undetermined source (ESUS).Methods and ResultsIn a pooled data set derived from 3 prospective stroke registries, patients were categorized in ≥1 groups according to the PES that was/were identified. We categorized PES as follows: atrial cardiopathy, atrial fibrillation diagnosed during follow‐up, arterial disease, left ventricular disease, cardiac valvular disease, patent foramen ovale, and cancer. In 800 patients with ESUS (43.1% women; median age, 67.0 years), 3 most prevalent PES were left ventricular disease, arterial disease, and atrial cardiopathy, which were present in 54.4%, 48.5%, and 45.0% of patients, respectively. Most patients (65.5%) had >1 PES, whereas only 29.7% and 4.8% of patients had a single or no PES, respectively. In 31.1% of patients, there were ≥3 PES present. On average, each patient had 2 PES (median, 2). During a median follow‐up of 3.7 years, stroke recurrence occurred in 101 (12.6%) of patients (23.3 recurrences per 100 patient‐years). In multivariate analysis, the risk of stroke recurrence was higher in the atrial fibrillation group compared with other PES, but not statistically different between patients with 0 to 1, 2, or ≥3 PES.ConclusionsThere is major overlap of PES in patients with ESUS. This may possibly explain the negative results of the recent large randomized controlled trials of secondary prevention in patients with ESUS and offer a rationale for a randomized controlled trial of combination of anticoagulation and aspirin for the prevention of stroke recurrence in patients with ESUS.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02766205.

P123Big mitral annular calcification (Big MAC) - Dynamic liquefaction necrosis as a potential source of embolism

P123Big mitral annular calcification (Big MAC) - Dynamic liquefaction necrosis as a potential source of embolism

Neurologic Manifestations of Infective Endocarditis

Abstract Infective endocarditis is an infection of the endocardial surface of the heart. Usually, it affects one or more heart valves or an intracardiac device. Neurologic events (silent or symptomatic) account for 20 to 40% of all patients with infective endocarditis. We are presenting the case of a 57 -year-old man with cardiovascular risk factors admitted to our clinic for aphasia. His medical history included a recent stroke and small fiber neuropathy with a gradual onset for the past six months. Despite extensive investigations, no cause for strokes and neuropathy could be found. To identify a potential source of embolism, a transoesophageal echocardiography was performed. It revealed vegetation attached to both aortic and mitral valves. Blood cultures were positive for Streptococcus gallolyticus. The patient underwent emergency aortic and mitral valve replacement and a 6-week course of antibiotic treatment with ceftriaxone and gentamicin with the improvement of both aphasia and peripheral neuropathy. Central nervous system complications such as encephalopathy, seizures, stroke or severe cerebral hemorrhage are commonly described in infective endocarditis, but peripheral nervous system involvement is rarely reported in the literature. Although no cause for neuropathy has been found, it is difficult to asses whether it was a complication of the infective endocarditis.

Ischemic stroke of the “hand knob area”: A case series and literature review

Isolated hand paresis may reflect an infarction of the “hand knob area”, which represents less than 1% of all ischemic strokes. In this type of stroke, a potential source of embolism is often identified. There are no large case series regarding this topic in Latin America. Herein we present the largest cohort of this entity in the region and we compare our results with those previously published. We analyzed all stroke patients admitted to our hospital between May 2015 – June 2018. Only patients with motor +/− sensory deficits restricted to the hand and ischemic stroke confirmed by MRI were included. We assessed stroke mechanism, clinical characteristics and outcome. From 339 patients admitted with ischemic stroke, 12 (3.53%) were included (9 men, 75%). Mean age: 60.4 years-old (range:24–79). Localization of stroke: 8 patients (66%) precentral gyrus, 3 (25%) postcentral; in 1 both gyri were affected. Stroke mechanism according to TOAST classification was as follows: two patients (16%) large artery atherosclerosis, two cardioembolic, one other determined etiology (thrombophilia), seven (58%) undetermined etiology (SUE). Nine patients (75%) received antiplatelets and statins, and three (25%) anticoagulants. The mean follow-up period was 11 months (range 1–26). Stroke recurrence was observed in one patient. At follow up, eight patients (66%) had a modified Rankin Score (mRS) of 0 and one a mRS of 1. In conclusion, in this series the most prevalent stroke mechanism was SUE, mainly embolic stroke of undetermined source. The outcome was excellent regardless of stroke mechanism.

TRANS ESOPHAGEAL ECHOCARDIOGRAM DETECTS TRIPLE THREATS (ATHEROMA, PATENT FORAMEN OVALE AND LARGE LAMBL'S EXCRESCENCE): A CASE OF RECURRENT EMBOLIC STROKE OF UNDETERMINED SOURCE

The majority of (87%) of strokes are due to ischemic etiology and cardio embolic stroke account for 15-40% of cases. A transesophageal echocardiography is performed to identify potential embolic sources and guide therapy. 61 Year old female with past medical history of hypertension, tobacco abuse,

Abstract WP210: Transthoracic Echocardiographic Predictor for Long-Term Outcomes in Real-World Korean Patients With Atrial Fibrillation-Related Stroke: A Multi-Center Cohort Study

Background: While transthoracic echocardiography (TTE) is performed to find out potential embolic sources and certain cardiac abnormalities as a routine workup of stroke, clinical implication of echocardiographic findings for long-term outcomes in atrial fibrillation (AF)-related stroke patients has been unknown. Methods: This was a sub-study of K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts), a multicenter-based cohort composed of prospective stroke registries from 11 tertiary centers. All stroke survivals enrolled in this study underwent TTE during hospitalization. Echocardiographic findings included left atrial (LA) diameter, left ventricular ejection fraction (LVEF), LV end-diastolic dimension (LVEDV), stenosis and regurgitation of mitral and aortic valves, and peak trans-mitral filling velocity/mean mitral annular velocity during early diastole (E/e’ ratio). Indexed-LA size was acquired as dividing LA size by body surface area. LV systolic function was grouped into normal (LVEF≥55%), mild (55%&gt;LVEF&gt;40%), and severe (LVEF≤40%). Level of E/e’ ratio associated with LV filling pressure was divided into normal (&lt;8), borderline (8-15) and increased (≥15). Outcomes of interest were recurrent stroke, coronary artery disease, and vascular, and all-cause death. We used Cox regression multivariable analyses adjusted by confounding factors. Results: A total of 1952 patients were finally included. Over a mean follow-up of 1.72±1.31 years, 140 patients had recurrent stroke, 36 had coronary artery disease, and of 236 fatalities, 33 died of a vascular cause. Multivariable analyses demonstrated that severe LV systolic dysfunction was associated with a higher risk of coronary artery disease (hazard ratio [HR] 3.80, 95% confidence interval [CI] 1.53-9.41), vascular death (HR 3.59, 95% CI 1.42-9.10) and all-cause death (HR 2.29, 95% CI 1.47-3.56). Conclusions: LV ejection fraction could be important predictor for long-term outcomes in AF-related stroke.

Different Clinical Phenotypes of Embolic Stroke of Undetermined Source: A Subgroup Analysis of 86 Patients

Introduction and Study AimEmbolic strokes of undetermined source (ESUS) represent a rather recent diagnostic entity under clinical research for relapse prevention in cryptogenic stroke patients. Despite strict diagnostic criteria, ESUS definition ignores major clinical and radiological aspects, so including heterogeneous cases and probably influencing trial results. This study researches clinically relevant phenotypes among ESUS patients. Patients and MethodsWe evaluated ESUS patients admitted at Trento Stroke Unit over a 4-year period. Vascular risk factors (RFs), neurological deficit severity, presence of potential embolic sources, and ASCOD phenotype were recorded. Ischemic lesions were categorized considering their extension in 4 groups. Subgroup comparisons by predefined differences in age, amount of RFs, history of previous stroke, deficit severity, and stroke lesion extension were done. ResultsESUS cases were 86. Patients younger than 50 years old (n = 17) had a lower prevalence of RFs, left atrial enlargement, left ventricle diastolic dysfunction, a higher proportion of ASCOD score A0 (P < .05). Patients without RFs (n = 18) differed from those with greater than or equal to 3 RFs (n = 23) for a younger age and a lower prevalence of potential causes of embolism (P < .05). Patients without a previous stroke (n = 70) were younger, had a lower prevalence of RFs, left ventricle diastolic dysfunction, a higher prevalence of ASCOD score A0 (P < .05). No differences were observed comparing minor and major clinical and radiological strokes. Discussion and ConclusionsESUS patients can be distinguished in 2 opposite phenotypes defined by a lower and a higher load of atherosclerotic pathology. They may suggest possible underlying pathogenic mechanisms and support interpretation of ongoing trials results.

Association of Embolic Sources With Cause-Specific Functional Outcomes Among Adults With Cryptogenic Stroke

It is unknown whether poststroke outcome varies between different potential causes in patients with cryptogenic stroke. To investigate whether functional outcome differs according to potential embolic sources after cryptogenic stroke. This multicenter, hospital-based, prospective stroke registry cohort study investigated potential embolic sources on admission and assessed 3-month outcome in patients with ischemic stroke hospitalized at 7 stroke centers in the Fukuoka Stroke Registry. This registry enlisted 9866 consecutive patients with acute ischemic stroke who were enrolled from June 11, 2007, to May 31, 2016, in Fukuoka, Japan. Patients with small vessel occlusion (n = 3130), extracranial and intracranial atherosclerosis causing at least 50% luminal stenosis in arteries supplying the area of ischemia (n = 2011), and other specific uncommon causes of stroke identified (n = 301) were excluded. Potential embolic sources were diagnosed in patients with embolic stroke of undetermined source (ESUS) based on the following criteria proposed by the Cryptogenic Stroke/ESUS International Working Group: minor-risk potential cardioembolic sources (MCS) (n = 209), covert paroxysmal atrial fibrillation (CPAF) (n = 43), cancer associated (CA) (n = 79), arteriogenic emboli (AE) (n = 522), paradoxical embolism (PE) (n = 190), and undetermined embolism (unidentified or ≥2 potential embolic sources) (UE) (n = 1120). The association between potential causes and functional outcome was evaluated in reference to cardioembolic stroke (CE) caused by major-risk cardioembolic sources after adjusting for age, sex, National Institutes of Health Stroke Scale score on admission, and reperfusion therapy using logistic regression analysis. Functional dependency (modified Rankin Scale score, 3-5) was evaluated at 3 months after onset. The study enrolled 2261 patients with CE (mean [SD] age, 78.4 [10.7] years, 51.8% male) and 2163 patients with ESUS (mean [SD] age, 72.4 [12.6] years, 57.1% male). Compared with CE (median National Institutes of Health Stroke Scale score, 8 [interquartile range {IQR}, 3-17]), baseline neurological deficits did not differ in MCS (median, 7 [IQR, 2-18]), CPAF (median, 6 [IQR, 2-18]), and CA (median, 5 [IQR, 2-13]) but were less severe in AE (median, 2 [IQR, 1-4]), PE (median, 2 [IQR, 1-4]), and UE (median, 3 [IQR, 1-7]). Multivariable-adjusted odds ratios of functional dependency significantly increased in CA (3.61; 95% CI, 1.52-8.54 vs CE) but decreased in PE (0.33; 95% CI, 0.16-0.71 vs CE). Potential causes are associated with poststroke outcome in patients with cryptogenic stroke. Embolic sources potentially underlying cryptogenic stroke should be considered significant variables associated with outcome.

A Case Report of Left Atrial Appendage Invagination in Post Operation Setting

Introduction: The left atrial appendage (LAA) lies within the confines of the pericardium in close relation to the free wall of the left ventricle. The LAA is long and thin with a narrow base. The LAA is best evaluated by transesophageal echocardiography. Surgeons may ligate the LAA during mitral valve (MV) replacement to remove a potential source of embolism. Unfortunately, a high rate of unsuccessful LAA occlusion has been reported, regardless of the technique employed. Case Presentation: A 57-year-old woman underwent cardiac surgery (mitral valve, aortic valve and tricuspid valve replacement and LAA closure). In post pump intra-operational transesophagial echocardiography (TEE) we detected a hypoechogenic mass in left atrium. It has no interference with mechanical MV prosthesis and pulmonary veins. Because of its new presentation after cardiac surgery, we suggested that it might be invaginated LAA. After confirmation, this complication was treated by pulling it out. Conclusions: The inversion of LAA is a rare complication. This diagnosis should be considered when a pedunculated mass is encountered in these setting. To prevent this complication, we suggest the use of intraoperative TEE to avoid unnecessary work up and fatal complications.

Frequency and features of embolic stroke of undetermined source in young adults.

The sources of emboli in those with embolic stroke of undetermined source may differ in old and young. We assessed the frequency, features and potential embolic sources of younger vs. older embolic stroke of undetermined source patients in the embolic stroke of undetermined source Global Registry. Cross-sectional study of consecutive patients over age 18 years, with recent ischaemic strokes at 19 centres conducted in 2013-2014. Characteristics of embolic stroke of undetermined source patients who aged ≤50 years were analysed and compared with embolic stroke of undetermined source patients who aged >50 years. Among 2144 patients with ischaemic stroke, 323 (15.1%, 95% confidence interval: 13.6-16.7%) were ≤50 years old and, 1821 >50 years. 24% (n = 78) of young vs. 15% (n = 273) of older patients met embolic stroke of undetermined source criteria. The mean age of young embolic stroke of undetermined source patients was 40 years (standard deviation +/-9), 33% were women and the most prevalent vascular risk factor was hypertension (38%). Conventional vascular risk factors were less frequent in younger embolic stroke of undetermined source patients. Fewer young embolic stroke of undetermined source patients (63%) had potential minor risk embolic sources identified vs. older embolic stroke of undetermined source patients (77%) (p = 0.02). Stroke severity on admission was similar in younger vs. older patients (National Institute of Health Stroke Scale (NIHSS) 3 vs. 4, p = 0.06). Young embolic stroke of undetermined source patients comprise an important subset of ischaemic stroke patients around the world. Severity of stroke on admission and 30-day mortality rates are similar among young and older patients. However, there are important differences between younger vs. older embolic stroke of undetermined source patients with respect to risk factors, and potential embolic sources that could affect response to anticoagulants vs. antiplatelet therapies. This study provides a benchmark for the global frequency and characteristics of young embolic stroke of undetermined source patients and shows consistent high frequency of embolic stroke of undetermined source in young adults.