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

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.

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“…However, they also used the modified TOAST criteria and compared a stroke group to a control group without stroke. [ 29 ]…”

Section: Discussionmentioning

confidence: 99%

“…[ 27 , 28 ] and more recently Kapoor et al . [ 29 ] all found an association between cryptogenic stroke and the presence of a LASP.…”

Section: Introductionmentioning

confidence: 99%

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

Steyaert

Rodriguez

Gazagnes

et al. 2022

Journal of Translational Internal Medicine

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“…Some studies have mentioned anticoagulation, while mitral atriotomy was also performed in one case report by removing the septal membrane, which was a nidus for thrombus formation [ 16 ]. More research is needed to determine the prevalence of ASP in the general population, its clinical significance, and guidelines for treatment implications [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Recurrent Cryptogenic Stroke in a Patient With Left Atrial Septal Pouch

Khan¹,

Riasat²,

Ehtesham³

et al. 2022

Cureus

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The incomplete fusion of the septum primum and septum secundum results in the formation of the left atrial septal pouch (LASP). The clinical significance of this entity is a matter of controversy; however, it may act as a nidus for thrombus formation. We report a case of a 57-year-old male who was brought to the hospital by his girlfriend due to his bizarre behavior and confusion for one day. The initial workup for his altered mental status did not yield a diagnosis. The patient was admitted for further workup, which included an MRI of the brain that showed numerous very small-sized foci of restricted diffusion involving bilateral cerebral and cerebellar hemispheres consistent with thromboembolic infarct. The patient did not receive a tissue plasminogen activator (TPA) as he was out of the window for TPA. Transthoracic echocardiogram (TTE) with bubble study did not show patent foramen ovale (PFO) or atrial septal defect (ASD). ECG and telemetry showed normal sinus rhythm and no atrial fibrillation. A transesophageal echocardiogram (TEE) was obtained to find the source of the thromboembolic stroke. TEE discovered a 22 x 8-mm cystic structure in the interatrial septum consistent with a LASP. We hypothesize that the LASP may be a risk factor for cryptogenic stroke. Further research is needed to determine the prevalence of atrial septal pouch (ASP) in the general population, its clinical significance, and guidelines for treatment implications.

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“…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.…”

Section: Rebuttalsmentioning

confidence: 99%

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

Schilling,

Lin,

Mankad

et al. 2023

The FASEB Journal

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There is emerging evidence that the cardiac interatrial septum has an important role as a thromboembolic source for ischemic strokes. There is little consensus on treatment of patients with different cardiac interatrial morphologies or pathologies who have had stroke. In this paper, we summarize the important background, diagnostic, and treatment considerations for this patient population as presented during the Federation of American Societies for Experimental Biology (FASEB) Virtual Catalytic Conference on the Cardiac Interatrial Septum and Stroke Risk, held on December 7, 2022. During this conference, many aspects of the cardiac interatrial septum were discussed. Among these were the embryogenesis of the interatrial septum and development of anatomic variants such as patent foramen ovale and left atrial septal pouch. Also addressed were various mechanisms of injury such as shunting physiologies and the consequences that can result from anatomic variants, as well as imaging considerations in echocardiography, computed tomography, and magnetic resonance imaging. Treatment options including anticoagulation and closure were addressed, as well as an in‐depth discussion on whether the left atrial septal pouch is a stroke risk factor. These issues were discussed and debated by multiple experts from neurology, cardiology, and radiology.

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

Cited by 17 publications

References 28 publications

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

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

Recurrent Cryptogenic Stroke in a Patient With Left Atrial Septal Pouch

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

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