Ability of the number of territories involved on DWI-MRI to predict occult systemic malignancy in cryptogenic stroke patients

Abstract Background During flight, atmospheric pressure drop, low humidity and restricted motion occur. The environmental change can evoke the stroke occurrence. However, description of in-flight stroke case series has been limited until now. We investigated the clinical and flight trip characteristics of in-flight stroke cases in Korea. Method Since the opening of Incheon international airport, which is used by about 50 million people a year, in 2001, our hospital branch has been located at the airport and all the emergency stroke patients have been referred to our hospital. We performed retrospective review of the prospectively collected stroke registry and the information about the flight from January 2001 to December 2018. Results During the study period, 31 in-flight stroke cases were identified among total 1,452 ischemic stroke patients (17 men, 62±15 years old). Twenty-six patients had cerebral infarction, and four patients had transient ischemic attack. On etiological classification of cerebral infarction, 19 large artery atherothrombosis (61.3%), 1 septic embolism, 3 cryptogenic stroke, 3 cardioembolism (9.7%) and 1 cerebral venous thrombosis were identified. Six patients had Patent Foramen Ovale. Twenty-two patients reported to experience symptom around landing. Fourteen patients had flight for six hours or longer. Compared to the patients with long flight time (≥6 hrs), those with short flight time had the higher incidence of stroke occurrence around landings (32 vs 68%) and low incidence of unclear stroke onset. Poor outcome, defined as mRS 4 or higher, was associated with old age, unclear stroke onset, and early neurologic deterioration. Conclusion In-flight stroke is uncommon, and can easily be neglected during flight, which result in poor outcome. The stroke risk seems to be relatively high around landing, especially in the travelers with short flight time. The possibility of paradoxical embolism related to motion restriction seems low for stroke occurrence. Old age and unclear stroke onset are associated with poor outcomes.

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B-PO01-028 UTILIZATION OF CARDIAC MONITORING FOR ATRIAL FIBRILLATION IN CRYPTOGENIC STROKE PATIENTS

Heart Rhythm ◽

10.1016/j.hrthm.2021.06.174 ◽

2021 ◽

Vol 18 (8) ◽

pp. S62

Author(s):

Matthew R. Reynolds ◽

Candace L. Gunnarsson ◽

Michael P. Ryan ◽

Sarah Rosemas ◽

Paul D. Ziegler ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

Stroke Patients

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Abstract WP239: Real Time Prospective Measurement of aPTT Predicts Paradoxical Embolism in Cryptogenic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wp239 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Bo Song ◽

Wenjun Deng ◽

Lindsay Fisher ◽

I-ying Chou ◽

Max Oyer ◽

...

Keyword(s):

Real Time ◽

Protein C ◽

Cryptogenic Stroke ◽

Protein S ◽

Paradoxical Embolism ◽

Proof Of Concept ◽

Stroke Patients ◽

Neurologic Diseases ◽

Coagulation Testing ◽

Coagulation Status

Patent foramen ovale (PFO) is an important underlying source of cryptogenic stroke (CS) associated with hematologic procoagulability. However, the association of genetically identified hyperocagulability and paradoxical embolism has been difficult to establish due to retrospective analysis and the limited numbers of of known genetically identified hypercoagulable conditions. In this study, we explored the utility of conventional coagulation status in PFO related stroke, as the patients may harbor genetically unidentified hyperocoagulable conditions. Method: Eligible pts were prospectively recruited in accordance with IRB, and underwent conventional coagulation testing (PT/PTT) testing within 12 hours of stroke. All patients underwent full cryptogenic workup such as MRI/MRA, mobile cardiac outpatient telemetry (>30 days), cardiac echo, and hypercoagulable testing. Results: We screened 4,831 pts admitted with acute neurologic diseases, and recruited 358 eligible acute ischemic stroke pts. 54 (15.1%) pts had CS and 32 pts had PFO related stroke. While there is no difference between PFO-related CS and PFO-unrelated CS on full hypercaogulable screen (protein S, protein C, FVL, PTGM, ATIII, APLAb, LA, hcy), aPTT was statistically significantly shortened in PFO-related stroke patients (PFO CS vs. non-PFO CS: aPTT 27.2±4.1s vs. 29.9±2.3s). ROC curve indicates early shortened aPTT can predict PFO related stroke (sensitivity 70%, specificity 81.5%, p=0.017) (see Figure). Conclusion: We found real time aPTT to be significantly shortened in patients eventually diagnosed with paradoxical embolism related to PFO. While studies in larger pt cohorts accounting for other potential confounders are underway, this proof-of-concept study demonstrates the importance and utility of early conventional coagulation testing in identifying paradoxical embolism. Pts with shortened aPTT may need additional workup for other underlying hypercoagulable conditions.

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Abstract P630: Detection of Atrial Fibrillation by Prolonged Cardiac Monitoring in Cryptogenic and Known Stroke Etiology

Stroke ◽

10.1161/str.52.suppl_1.p630 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Michal krawczyk ◽

Sebastián Fridman ◽

Maria Bres Bullrich ◽

Palak Shah ◽

Juan C Vargas-Gonzalez ◽

...

Keyword(s):

Atrial Fibrillation ◽

Logistic Regression ◽

Cryptogenic Stroke ◽

Left Atrial Volume ◽

Cardiac Monitoring ◽

Volume Index ◽

Multivariate Logistic Regression Model ◽

Stroke Patients ◽

Cross Sectional ◽

Therapeutic Decisions

Introduction: Approximately 25% of strokes are classified as cryptogenic (CS), while greater than 50% have an identifiable or ‘known’ etiology (KS). Several studies have demonstrated that prolonged cardiac monitoring (PCM) after cryptogenic stroke substantially increases the detection of atrial fibrillation (AF), but the yield of PCM in KS stroke is unknown. As a result, the majority of guidelines recommend restricting PCM to patients with cryptogenic stroke. If the detection of AF in KS is no different to cryptogenic stroke, it would suggest that this group too would similarly benefit from PCM, with the potential to impact therapeutic decisions (e.g. initiating anticoagulation). Methods: In a cross-sectional study, we compared AF detection by PCM (minimum of 48 hrs) between CS and KS patients without a previous diagnosis of AF. We developed a multivariate logistic regression model by including known and significant clinical, echocardiographic, and radiological factors known to be associated with the detection of AF. We reported results as odds ratios (OR) and 95% confidence intervals (95% CI). Results: We included 561 ischemic stroke patients, 376 with CS and 185 with KS. The median duration of PCM was 167h for CS and 48h for KS. AF was detected in 30 of 376 (8%) CS patients, and 20 of 185 (7.9%) KS patients. Age, history of thyroid disease, clinical presentation of dysarthria, wake-up stroke, and left atrial volume index on echocardiography were significantly associated with a new diagnosis of AF after stroke in the univariable analysis and were thus included in the logistic regression analysis. Additionally, duration of PCM was included in the multivariate model. After adjustment for potential confounders, AF detection by PCM was not significantly higher for CS than KS (OR 0.95, 95% CI 0.25-3.32, P=0.94). Conclusion: To the best of our knowledge this is the first study directly comparing the incidence of AF between CS and KS as the pre-specified primary outcome. Our findings suggest that CS and KS patients have similar rates of AF detection by PCM. Future prospective research is required to confirm these findings and to determine the cost-effectiveness of PCM in non-cryptogenic stroke patients.

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A Modified Anatomical-Functional-RoPE (AF-RoPE) Score Improves Patient Selection for Patent Foramen Ovale Closure

International Cardiovascular Forum Journal ◽

10.17987/icfj.v12i0.461 ◽

2018 ◽

Vol 12 ◽

Cited By ~ 2

Author(s):

Gianluca Rigatelli ◽

Marco Zuin ◽

Fabio Dell'Avvocata ◽

Luigi Pedon ◽

Roberto Zecchel ◽

...

Keyword(s):

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Stepwise Logistic Regression ◽

Foramen Ovale ◽

Stroke Patients ◽

Stepwise Logistic Regression Analysis ◽

Grade 5 ◽

Risk Patients ◽

Selection For ◽

Pfo Closure

Background: RoPE score calculator has been proposed to stratify the patients in whom PFO may be considered not a confounding but presumably a causative factor.Objectives To implement the RoPE score calculator.Methods. We reviewed the medical data of 1040 consecutive patients (mean age 47.3±17.1 years) prospectively enrolled in two centres over a 13 years period for management of PFO in order to select anatomic and functional parameters to be incorporated in a modified RoPE score. A scoring system (AF-RoPE) was build up and applied in a prospective blind fashion to a cohort of 406 consecutive patients (mean age 43.6 ±17. 5 years, 264 females) with cryptogenic stroke and PFO comparing its performance with the standard RoPE.Results. Multiple stepwise logistic regression analysis demonstrated that right-to-left (R-L) shunt at rest (OR 5.9), huge ASA (> 20 mm) (OR 3.9), long tunnelized PFO (> 12 mm) (OR 3.5), and massive R-L shunt (grade 5 by TCD) (OR 1.9) conferred the highest risk of recurrent stroke. The AF-RoPE score resulted in a more precise separation of patients with RoPE score 8-10. Patients with AF-RoPE score > 11 had more stroke recurrences and more diffuse area of stroke on MRI in the medical history than those ranging 10 to 7 or less.Conclusion. The AF-RoPE score discriminates cryptogenic stroke patients who are more likely to develop recurrent stroke compared with a RoPE score between 8-10. These highest risk patients may be more likely to benefit from PFO closure.

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The Prevalence of Fabry Disease Among Young Cryptogenic Stroke Patients

Cureus ◽

10.7759/cureus.9415 ◽

2020 ◽

Author(s):

Mohammed A Alhazzaa ◽

Ahmed Mujtaba ◽

Mohammed A Aljohani ◽

Fatimah Alqarni ◽

Roaa Roaa Alsharif

Keyword(s):

Fabry Disease ◽

Cryptogenic Stroke ◽

Stroke Patients

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Differential Lesion Patterns on T2WI and FLAIR Sequences in Cryptogenic Stroke Patients With Patent Foramen Ovale

The Neurologist ◽

10.1097/nrl.0000000000000058 ◽

2015 ◽

Vol 20 (5) ◽

pp. 75-79 ◽

Cited By ~ 1

Author(s):

Yang-Yang Huang ◽

Bei Shao ◽

Xian-Da Ni ◽

Jian-Ce Li ◽

Xiao-Ting Niu ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Stroke Patients

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Abstract W MP70: Characteristics of Patients With Microemboli Detected With Transcranial Doppler Monitoring

Stroke ◽

10.1161/str.45.suppl_1.wmp70 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Lauren Koffman ◽

Zubair Ahmed ◽

Rebecca Michael ◽

Leasa Baus ◽

Larry Raber ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Care Center ◽

Cerebral Arteries ◽

Tertiary Care ◽

Cryptogenic Stroke ◽

Final Analysis ◽

Stroke Patients ◽

Artery Disease ◽

Wbc Count

Introduction: TCD emboli monitoring (TCDe) is a non-invasive tool used to detect the presence of ongoing microembolic signals (MES) in the intracranial arterial vessels. The clinical utility of this test in the evaluation of acute stroke patients has been debated. Our goal was to evaluate clinical factors associated with MES in ischemic stroke patients who underwent TCDe to determine which patient population may benefit from TCDe. Methods: Retrospective cohort study of adult patients admitted to our tertiary care center for TIA or ischemic stroke from 2011 to 2012 who underwent TCDe. Monitoring was performed for 20 minutes using a standardized protocol. Inclusion criteria included insonatation of both middle cerebral arteries and completion of TCD bubble study (TCB). Repeat TCDe performed on the same patient were excluded from the analysis. Demographic, clinical and objective data were collected using our EMR system. Results: Of the 113 patients included in the final analysis, mean age was 57.9 years and 46.9% were female. MES occurred in 33.6% patients. Mean # of MES was 9.3 (SD 60.6). Patients with MES were significantly younger (51.8 years vs 61.0, p.006) and had fewer vascular risk factors: diabetes (10.5% vs 33.3%, p 0.006), hyperlipidemia (23.7% vs 49.3%, p 0.007), hypertension (47.4% vs 17.33%, p 0.067), atrial fibrillation (7.9% vs 17.33 %, p 0.16), congestive heart failure (5.3% vs 10.7%, p 0.32) and coronary artery disease (18.4 % vs 29.3%, p 0.2). Cryptogenic stroke and the presence of right to left shunt (RLS) was more frequent in patients with MES than those without. Mean WBC count and usCRP were both nonsignificantly higher in patients with MES. Conclusions: Clinical characteristics of patients with MES on TCDe differed from those without MES, which may have diagnostic and clinical implications. Patients with MES were younger and had fewer stroke risk factors. MES were seen more often in patients with RLS and in those with cryptogenic stroke, which raises the possibility of an association between these two factors. Interestingly, patients with MES also had higher usCRP and WBC values, suggesting a possible inflammatory component to the occurrence of MES. More research is needed with a larger sample size to better define the significance of the above findings.

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Abstract 2922: Patent Foramen Ovale Is A Cause Of Ischemic Stroke In Patients With Antiphospholipid Syndrome

Stroke ◽

10.1161/str.43.suppl_1.a2922 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Yoshiaki Shimada

Keyword(s):

Ischemic Stroke ◽

Antiphospholipid Syndrome ◽

Patent Foramen Ovale ◽

Multiple Logistic Regression Analysis ◽

Cryptogenic Stroke ◽

Control Group ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

Stroke Patients ◽

Significant Difference

Background: The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, and can be an independent risk factor for a first-ever ischemic stroke especially in young female patients. Patent foramen ovale (PFO) has been established as a cause of cryptogenic stroke. Atrial septal aneurysm (ASA) is associated with PFO. Until recently, the precise pathophysiology of APS as causing ischemic stroke has been essentially unknown. In the present study, we investigated the relationship between APS and potential embolic sources including PFO and ASA using transesophageal echocardiography (TEE). Methods: This study was a retrospective case series design. From July 2006 to June 2008, 120 patients with ischemic stroke who admitted to Juntendo University Hospital underwent TEE. In this study period, consecutive ischemic stoke patients diagnosed as APS based on the modified Sapporo criteria were enrolled and classified into APS group. Controls were selected among age- and gender-matched stroke patients without APS who also underwent TEE. We assessed clinical characteristics and presence of embolic sources including PFO and atrial septal aneurysm (ASA) between APS and Control groups. Results: Nine of ischemic stroke patients with APS and 41 controls were included. Primary APS was present in one patient (11.1%) of the APS group, and APS with SLE were found in eight patients (88.9%). There is no significant difference in age, risk factors for ischemic stroke, and MRI findings between two groups. The prevalence of PFO and ASA were significantly higher in APS group compared to Control group (89% vs 41%, P=0.027; 67% vs 20%, P=0.015, respectively). C reactive protein was relatively higher in APS group. Multiple logistic regression analysis showed that PFO (OR: 13.71; 95% CI: 1.01 to 185.62; P=0.049) and ASA (OR: 8.06; 95% CI: 1.17 to 55.59; P=0.034) were independently associated with the APS group. Conclusion: Atrial septal abnormalities including PFO and ASA are strongly associated with APS group, and could be potential embolic sources in ischemic stroke patients with APS.

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Abstract 13915: Atrial Fibrillation Begets Atrial Fibrillation in Cryptogenic Stroke Patients: Results from the Crystal-AF Trial

Circulation ◽

10.1161/circ.130.suppl_2.13915 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Rod S Passman ◽

Jodi L Koehler ◽

Paul D Ziegler

Keyword(s):

Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Secondary Stroke Prevention ◽

Stroke Patients ◽

Cardiac Monitor ◽

Long Duration ◽

Episode Duration ◽

Duration Information ◽

The Impact ◽

Insertable Cardiac Monitor

Introduction: Initial episodes of atrial fibrillation (AF) detected following a cryptogenic stroke (CS) may be brief in duration and the clinical relevance of such episodes is uncertain. Hypothesis: We investigated whether an initial brief episode of AF was predictive of subsequent long duration AF episodes in CS patients (pts) with an insertable cardiac monitor (ICM). Methods: CS pts (n=208, age 61.6±11.3 years, 66% male) randomized to the ICM arm of the CRYSTAL-AF study and inserted with a device (Reveal® XT) were followed for 21±9 months. AF episodes (>30 seconds) were independently adjudicated and the first adjudicated AF episode was classified as brief (<1 hour) or long (≥1 hour). The incidence of subsequent long duration AF episodes among pts with an initially brief episode was computed. The impact of episode duration on prescription of oral anticoagulation (OAC) therapy was also assessed. Results: Among 36 pts with an adjudicated AF episode for which duration information was available, the initial episode was classified as brief in 18 (50%) pts and long in 18 (50%) pts. Among those with initially brief episodes, 10 (56%) experienced only subsequent brief episodes while 8 (44%) went on to experience at least one long AF episode. The median time between the initial brief episode and first long AF episode was 75 days [interquartile range: 27-624 days]. OAC was prescribed in 7/10 pts (70%) with only brief AF episodes compared to 26/26 pts (100%) with at least one long episode of AF (p=0.017). Conclusion: Initial AF episodes in pts with CS are equally likely to be of short or long duration. However, nearly half of CS pts with initially brief episodes of AF subsequently have long duration episodes detected much later via prolonged monitoring with ICMs. Therefore, early detection of brief AF episodes may merit more rigorous monitoring of AF with ICMs since physicians were significantly more likely to prescribe OAC for secondary stroke prevention in response to longer duration episodes.

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