The value of transesophageal echocardiography for embolic strokes of undetermined source

Katsanos, Aristeidis H.; Bhole, Rohini; Frogoudaki, Alexandra; Giannopoulos, Sotirios; Goyal, Nitin; Vrettou, Agathi‐Rosa; Ikonomidis, Ignatios; Paraskevaidis, Ioannis; Παππάς, Κωνσταντίνος; Parissis, John; Kyritsis, Athanassios P.; Alexandrov, Anne W.; Triantafyllou, Nikolaos; Malkoff, Marc; Voumvourakis, Konstantinos; Alexandrov, Andrei V.; Tsivgoulis, Georgios

doi:10.1212/wnl.0000000000003063

Cited by 85 publications

(76 citation statements)

References 45 publications

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“…13) In earlier reports concerning ESUS patients, patent foramen ovale was noted in 25% 14) and 28% 13) of the patients which is similar to our study. In one patient (Patient 2), a thrombus was detected by lower limb venous ultrasound in addition to patent foramen ovale, and the patient was diagnosed as paradoxical cerebral embolism.…”

Section: Discussionsupporting

confidence: 92%

Clinical Characteristics of Patients with Embolic Stroke of Undetermined Source Treated by Endovascular Recanalization Therapy

Kurogi

Tsumoto

Miyazaki

et al. 2018

JNET

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Objective: This study was carried out to evaluate the clinical characteristics of patients with embolic stroke of undetermined source (ESUS) treated by endovascular reperfusion therapy for emergent large vessel occlusion (ELVO). Subjects and Methods:Of 87 consecutive acute ischemic stroke patients with ELVO treated by endovascular reperfusion therapy, clinical characteristics, treatments, and outcomes were compared in 14 patients diagnosed with ESUS at discharge and 42 patients with cardioembolic stroke (CES). Results:In the ESUS group, the patients were younger (63.9 vs. 76.4 years, P <0.05), and the percentage of males was lower (21.4% vs. 64.3%, P <0.05), than in the CES group. Most patients in both groups received mechanical thrombectomy, and there was no significant difference in the National Institutes of Health Stroke Scale (NIHSS) score on admission Conclusion:The relatively younger age of the ESUS group compared with the CES group is considered to have contributed to the more favorable outcome.

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Section: Discussionsupporting

confidence: 92%

Clinical Characteristics of Patients with Embolic Stroke of Undetermined Source Treated by Endovascular Recanalization Therapy

Kurogi

Tsumoto

Miyazaki

et al. 2018

JNET

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“…Such a policy may improve overall diagnostic accuracy and quality of cryptogenic IS even during the study course. 33 Factors possibly influencing selection of controls, such as recruiting them from other than population-based sources or unintended selection of persons who are exceptionally excited about their health, may not all be completely avoided, while many of such factors can be taken into account in statistical analyses.…”

Section: Discussionmentioning

confidence: 99%

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Triggers, Causes, and Outcome (SECRETO): Rationale and design

Putaala

Martinez‐Majander

Saeed

et al. 2017

European Stroke Journal

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Background: Worldwide, about 1.3 million annual ischaemic strokes (IS) occur in adults aged <50 years. Of these early-onset strokes, up to 50% can be regarded as cryptogenic or associated with conditions with poorly documented causality like patent foramen ovale and coagulopathies. Key hypotheses/aims: (1) Investigate transient triggers and clinical/sub-clinical chronic risk factors associated with cryptogenic IS in the young; (2) use cardiac imaging methods exceeding state-of-the-art to reveal novel sources for embolism; (3) search for covert thrombosis and haemostasis abnormalities; (4) discover new disease pathways using next-generation sequencing and RNA gene expression studies; (5) determine patient prognosis by use of phenotypic and genetic data; and (6) adapt systems medicine approach to investigate complex risk-factor interactions. Design: Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is a prospective multi-centre case-control study enrolling patients aged 18-49 years hospitalised due to first-ever imaging-proven IS of undetermined etiology. Patients are examined according to a standardised protocol and followed up for 10 years. Patients are 1:1 age-and sex-matched to stroke-free controls. Key study elements include centralised reading of echocardiography, electrocardiography, and neurovascular imaging, as well as blood samples for genetic, gene-expression, thrombosis and haemostasis and biomarker analysis. We aim to have 600 patientcontrol pairs enrolled by the end of 2018. Summary: SECRETO is aiming to establish novel mechanisms and prognosis of cryptogenic IS in the young and will provide new directions for therapy development for these patients. First results are anticipated in 2019.

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“…29 Therefore, it is important to perform a comprehensive and targeted diagnostic workup in ESUS that may include transoesophageal echocardiography exam to uncover additional cardioembolic sources of embolism (mitral annular calcification, aortic valve stenosis or calcification, atrial appendage stasis, patent foramen ovale, left ventricle dysfunction, myxoma, infective endocarditis), aortic arch atherosclerosis, cancer-related stroke (hypercoagulability syndrome, marantic endocarditis), as well as high resolution vessel wall imaging that may disclose nonstenotic, unstable, high-risk atherosclerotic plaques in extra-and intracranial arteries, or alternatively branch atheromatous disease. 11,12,[29][30][31] Interestingly, nonstenotic carotid plaques with 3 mm thickness were more prevalent ipsilateral than contralateral to the location of cerebral infarction in ESUS patients. 32 Furthermore, the ESUS Global Registry reported a prevalence of nonstenotic carotid artery plaques and aortic arch atherosclerosis of 79 and of 28%, respectively.…”

Section: Discussionmentioning

confidence: 93%

Clinical and Neuroimaging Characteristics in Embolic Stroke of Undetermined versus Cardioembolic Origin: A Population‐Based Study

Tsivgoulis

Kargiotis

Katsanos

et al. 2019

Journal of Neuroimaging

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BACKGROUND AND PURPOSE: Evidence suggests that cardioembolism represents the underlying mechanism in the minority of embolic strokes of undetermined source (ESUS). In this population-based study, we sought to compare the clinical and imaging characteristics as well as outcomes in patients with ESUS and cardioembolic stroke (CE). METHODS: We included consecutive patients with first-ever ischemic stroke (IS) from the previously published populationbased Evros-Stroke-Registry identified as ESUS or CE according to standardized criteria. Baseline characteristics, admission NIHSS scores, cerebral edema, hemorrhagic transformation, stroke recurrence, functional outcomes (determined by modified Rankin Scale [mRS] scores), and mortality rates were recorded during the 1-year follow-up period. RESULTS: We identified 21 ESUS (3.7% of IS) and 211 CE (37.1% of IS) cases. Patients with ESUS were younger (median age: 68 years [interquartile range [IQR]: 61-75] vs 80 years [IQR: 75-84]; P < .001), had lower median admission NIHSS scores (4 points [IQR: 2-8] vs 10 points [IQR: 5-17]; P < .001), and lower prevalence of cerebral edema on neuroimaging studies (0 vs. 33.3%, P = .002). Functional outcomes were more favorable in ESUS at 28 (median mRS score: 2 [IQR: 1-3] vs 4 [IQR: 4-5]; P < .001), 90 (median mRS score: 1 [IQR: 0-2] vs 4 [IQR: 3-5]; P < .001), and 365 days (median mRS score: 1 [IQR: 0-2] vs 4 [IQR: 2-4]; P < 0.001). At 1-year, the mortality rate was lower in ESUS (0% [95% confidence interval [CI]: 0-13.5%] vs 34.6% [95% CI: 28.2-41.0%]; P < .001); the 1-year recurrent rate was also lower numerically (0% [95% CI: 0-13.5%] vs 9.5% [95% CI: 5.5-13.4%]; P = .140) but this difference failed to reach statistical significance due to the small study population. CONCLUSIONS: The clinical and neuroimaging profiles as well as clinical outcomes vary substantially between ESUS and CE indicating different underlying mechanisms.

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The value of transesophageal echocardiography for embolic strokes of undetermined source

Abstract: Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.

Cited by 85 publications

References 45 publications

Clinical Characteristics of Patients with Embolic Stroke of Undetermined Source Treated by Endovascular Recanalization Therapy

Clinical Characteristics of Patients with Embolic Stroke of Undetermined Source Treated by Endovascular Recanalization Therapy

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Triggers, Causes, and Outcome (SECRETO): Rationale and design

Clinical and Neuroimaging Characteristics in Embolic Stroke of Undetermined versus Cardioembolic Origin: A Population‐Based Study

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