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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
An Approach to Working Up Cases of Embolic Stroke of Undetermined Source
Sookyung Ryoo1, Jong-Won Chung1, Mi Ji Lee1
1Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Insights
Differentiating causes of cryptogenic stroke is crucial for treatment. This study identified distinct clinical and radiological features for aortic arch atheroma, patent foramen ovale, and atrial fibrillation, aiding in etiologic diagnosis.
Area of Science:
- Neurology
- Cardiology
- Radiology
Background:
- Differentiating causes of embolism in cryptogenic stroke is vital for effective therapy.
- Key causes include aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation.
- Understanding distinct features aids in etiologic workup.
Purpose of the Study:
- To investigate clinical and radiological characteristics of three common cryptogenic embolism sources.
- To develop decision-making models for identifying stroke etiology.
- To differentiate between aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation.
Main Methods:
- Multinomial logistic regression analysis of clinical and diffusion-weighted imaging factors.
- Inclusion of 321 patients with acute infarcts from cryptogenic embolism.
- Validation in an external cohort (n=117).
Main Results:
- Distinct clinical and radiological features were observed among the three etiological groups.
- Patent foramen ovale group: healthy vascular risk profile, posterior circulation involvement.
- Paroxysmal atrial fibrillation group: higher NIHSS scores, larger lesions.
- Aortic arch atheroma group: similar to AF but with small, scattered lesions in multiple territories.
- A predictive model incorporating age, NIHSS, lesion size, multiplicity, and territory involvement showed good performance (AUC=0.78).
Conclusions:
- Patients with cryptogenic embolic stroke exhibit unique clinical and radiological profiles based on their underlying cause.
- These findings support the development of targeted diagnostic strategies.
- Distinctive features aid in distinguishing between aortic arch atheroma, PFO, and PAF as stroke sources.
Background:
From a therapeutic viewpoint, it is important to differentiate the underlying causes of embolism in patients with cryptogenic stroke, such as aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation. We investigated the clinical and radiological characteristics of these 3 common causes of cryptogenic embolism to develop models for decision making in etiologic workups.
Methods And Results:
A total of 321 consecutive patients with acute infarcts from cryptogenic embolism were included. Patients were divided into 3 groups-aortic arch atheroma (n=40), patent foramen ovale (n=153), and paroxysmal atrial fibrillation (n=128)-based on extensive cardiologic workups. We used a multinomial logistic regression analysis to detect the clinical and diffusion-weighted imaging factors associated with the probability of aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation. Clinical and radiological features differed among the groups. The patent foramen ovale group had a healthy vascular risk factor profile and showed posterior circulation involvement compared with other groups (P<0.01). In contrast, paroxysmal atrial fibrillation-related strokes had higher initial National Institutes of Health Stroke Scale (NIHSS) scores and larger lesions than the other groups (P<0.001). The aortic arch atheroma group had clinical features similar to those of the paroxysmal atrial fibrillation group but showed small lesions scattered in multiple vascular territories (P<0.001). Multivariate regression analysis revealed that age, initial NIHSS score, lesion size (≥20 mm), multiple (≥3) lesions, and involvement of posterior circulation or multiple vascular territories differentiated the 3 groups (pseudo, R(2)=0.656). The prediction ability of this model was validated in the external validation cohort (n=117, area under the curve 0.78).
Conclusions:
Our data indicate that patients with cryptogenic embolic stroke show distinct clinical and radiological features depending on the underlying causes.
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