Prevalence of left atrial septal pouch among patients with embolic stroke of undetermined source or stroke of known etiology: A retrospective study

Abstract

Background and objectives Cryptogenic strokes can be defined by the criteria established for an embolic stroke of undetermined source (ESUS). Some embolic events might be caused by a left atrial septal pouch (LASP), due to the potential of thrombus formation. In this study we aimed to determine if LASP is a risk factor for ESUS when compared to a population of strokes of known origin, the LASP screening rate in our institution and if LASP dimensions influences the risk of ESUS. Methods We retrospectively analyzed transesophageal echocardiograms (TEEs) in a large cohort of patients that had experienced ischemic strokes. Two authors performed blinded, independent searches for LASPs by reviewing 1152 TEEs from patients that had experienced a stroke or transient ischemic attack. We excluded 26 TEEs, due to incorrect imaging. Next, we reviewed patient medical files. Results Among the 1126 included patients, 148 had an ESUS (ESUS+ group) and 978 had strokes of known origin (ESUS– group). A LASP was present in 176 patients, including 32 patients (21.6% of LASPs) in the ESUS+ group and 144 patients (14.7% of LASPs) in the ESUS– group. In multivariate analysis, LASP was independently associated with ESUS (P = 0,019). 61.9% of LASPs that we found were not mentioned in reports from the original TEE operators. Conclusion This study demonstrated that LASPs were more prevalent in patients with ESUS than in patients with strokes of known origin. Our results gave rise to the question of whether anticoagulation would be appropriate for some patients with ESUS. New large-scale, prospective studies should be conducted to address this issue. Additionally, considering the low rate of LASP descriptions, we concluded that the awareness of operators should be raised to improve their success in identifying LASPs.

The 2022 FASEB Virtual Catalyst Conference on the Cardiac Interatrial Septum and Stroke Risk, December 7, 2022

“…Ruchi Kapoor: While it is true that more robust and prospective studies are needed, the odd ratios in the retrospective studies to date are consistently greater than one in favor of the LASP as an independent risk factor for stroke. 20,57,62,68,70,71,[79][80][81] Based on the data that have been compiled so far, the LASP does not appear to require other cofactors to increase the risk of stroke. To this end, two case reports demonstrated the LASP associated with stroke without other risk factors.…”

“…57 Similarly, another group, Steyaert et al in Brussels, analyzed TEEs in patients with ischemic strokes using stricter criteria for embolic strokes of undetermined source (ESUS), and showed an increased prevalence of the LASP in the ESUS group, with an odds ratio of 1.6, and who were more likely to be younger and less likely to have traditional risk factors such as diabetes and hypertension. 71 Currently, the understanding of the LASP may be in its infancy, analogous to the earlier years when the role of PFO in stroke was being elucidated. It is known that in cryptogenic stroke, there is an odds ratio of 2.9 in favor of an association with a PFO, and that the odds ratio for the LASP ranges between 1.5 and 2.4 comparable to that of smoking and diabetes, two of the well-acknowledged risk factors for stroke.…”

“…Similarly, another group, Steyaert et al in Brussels, analyzed TEEs in patients with ischemic strokes using stricter criteria for embolic strokes of undetermined source (ESUS), and showed an increased prevalence of the LASP in the ESUS group, with an odds ratio of 1.6, and who were more likely to be younger and less likely to have traditional risk factors such as diabetes and hypertension 71 …”

Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction

“…In addition, some rare etiologies, such as embolic stroke of undetermined source, are also associated with severe stroke. [ 9 ] Large infarction is the leading cause of severe stroke. In anterior circulation, imaging features of large infarction associated with malignant prognosis include parenchymal hypoattenuation on brain computed tomography (CT) >1/3 MCA territory within 6 h after onset, [ 10 ] >1/2 MCA territory after 6 h, [ 11 ] or the infarct volume on diffusion-weighted imaging (DWI) >80 cm 3 within 6 h, [ 12 ] >82 cm 3 within 10 h, [ 13 ] or >145 cm 3 within 14 h. [ 14 ] In posterior circulation, the extent of brain infarction could be assessed by the posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS), as early ischemic changes on non-contrast CT or hypoattenuation on CT angiography (CTA), [ 15 ] and the arterial occlusion burden could be assessed by the Basilar Artery on Computed Tomography Angiography (BATMAN) score on CTA.…”

Danshen injection mitigated the cerebral ischemia/reperfusion injury by suppressing neuroinflammation via the HIF-1α/CXCR4/NF-κB signaling pathway

“…Ischemic stroke (IS), characterized by edema of brain cells and necrosis, is one of the most common cerebrovascular diseases in clinical practice, leading to significant global mortality rates and long-term disability [1,2]. An assortment of metabolic disturbances, amino acid-induced excitotoxicity, oxidative stress and inflammatory reactions induced by cerebral ischemia have been identified as contributors to the onset of IS [3].…”