MD Conference Express ISC 2013 - (Page 26)

SELECTED UPDATES ON CARDIOEMB OLIC STROKE New Strategies to Detect Cardioembolism Written by Emma Hitt, PhD Peer-Reviewed Highlights From 26 April 2013 Approximately 20% of all ischemic strokes are caused by cardiac embolism [Freeman WD et al. Neurotherapeutics 2011]. Cardioembolic strokes are disproportionately more disabling than strokes caused by nonembolic mechanisms due to occlusion of larger intracranial arteries and larger ischemic brain volume. Hee Joon Bae, MD, PhD, Seoul National University Bundang Hospital, Gyeonggi-do, Korea, reported on advances in cardiac imaging and ultrasound. The European Association of Echocardiography recommends transesophageal echocardiography (TEE) and transthoracic echocardiography when symptoms that could be caused by a cardiac etiology are present, including syncope, cerebrovascular events, and transient ischemic attack (TIA) [Pepi M et al. Eur J Echocardiogr 2010]. However, TEE has several shortcomings: it is semi-invasive, it is difficult to evaluate the aortic arch due to a blind spot, it is not readily available 24 hours a day, and there is a high procedure failure rate in acute stroke patients [Ko SB et al. Cerebrovasc Dis 2010]. Cardiac multidetector computed tomography (MDCT) offers some benefits that TEE does not. It is an electrocardiogram (ECG)-gated scan that provides a better view of the ascending aorta, only takes a short amount of time to scan the patient, is available 24 hours a day, and is less dependent on a patient’s condition. In a study of 75 patients who underwent both cardiac MDCT and TEE following acute ischemic stroke, cardiac MDCT identified a high-risk intracardiac embolic source in 8 patients compared with one identified by TEE. Cardiac MDCT identified 20 patients with extracardiac embolic sources compared with 7 identified by TEE [Ko SB et al. Cerebrovasc Dis 2010]. Prof. Bae concluded that MDCT may provide therapeutic opportunity with respect to the management of cardioembolism and cryptogenic stroke. In addition, cardiac MRI is emerging as another potential option for detection of cardioembolism. Alejandro Rabinstein, MD, Mayo Clinic, Rochester, Minnesota, USA, presented information on prolonged rhythm monitoring for detection of silent atrial fibrillation (AF) in patients with a previous cryptogenic stroke. AF, which is commonly observed in patients with ischemic stroke and TIAs, increases the risk of ischemic stroke by 5-fold [Seet RCS et al. Circulation 2011]. Paroxysmal AF (PAF) can be difficult to detect due to its asymptomatic, brief, and episodic nature. To better understand the role of PAF in patients with cryptogenic stroke, the Detection of Occult Paroxysmal Atrial Fibrillation After Stroke Using Prolonged Ambulatory Cardiac Monitoring trial [NCT01325545] enrolled 132 patients within 3 months of an ischemic stroke without documented AF. It was a case-control study with 66 cases of cryptogenic stroke and 66 control cases with documented stroke causes. Patients were monitored for 3 weeks using the CardioNet Mobile Cardiac Outpatient Telemetry system. The primary endpoint was detection of PAF independently confirmed by blinded cardiologists. In the final analysis, 16 (25%) of 64 cryptogenic cases had PAF compared with 9 (14%) of 64 control cases, indicating that there was not a significant difference in the occurrence of PAF in cryptogenic stroke cases (p=0.12). Only 3 cryptogenic cases and 2 control cases had PAF episodes lasting >30 seconds. In noncryptogenic stroke cases, PAF was more common in patients aged >65 years (p=0.86) than in patients aged <65 years (p=0.07; Figure 1). Dr. Rabinstein said that although AF is a major cause of stroke, “it is unclear whether PAF detected by the new prolonged ambulatory methods has the same pathogenic significance” as AF detected by ECG. Frank Sharp, MD, University of California, Davis, California, USA, reported on the potential use of biomarkers to improve identification of cardiogenic embolism. www.mdconferencexpress.com  http://www.strokeconference.org http://www.mdconferencexpress.com

Table of Contents for the Digital Edition of MD Conference Express ISC 2013

MD Conference Express ISC 2013
Contents
Defending the Stroke Guidelines
Stroke Update: An Overview of What Is Going on in the Area of Stroke
Brain Imaging Does Not Help Identify Patients Who May Benefit From Endovascular Treatments for Acute Ischemic Stroke
MISTIE II Trial: 365-Day Results Demonstrate Improved Outcomes and Cost Benefit
Addition of AMPLATZER PFO Occluder to Medical Therapy Is Beneficial in Patients With Cryptogenic Stroke and PFO
Intraoperative CT-Guided Endoscopic Surgery for ICH [ICES]
The EMBRACE Trial: Prolonged Ambulatory Cardiac Monitoring Improves the Detection and Treatment of Atrial Fibrillation in Patients With Cryptogenic Stroke
DP-b99 Does Not Improve Recovery Following Acute Ischemic Stroke
The Secondary Prevention of Small Subcortical Strokes Trial: Blood Pressure Intervention Results
Final Results of the Solitaire FR Thrombectomy for Acute Revascularization: The STAR Trial
Clopidogrel Plus Aspirin Reduces Risk of Recurrent Stroke: The CHANCE Trial
Reversal of Chronic Hypoperfusion to Improve Cognitive Function: The RECON Trial
Cardioembolic Stroke
IMS III
Novel Anticoagulants in Vascular Neurology Practice
Wake-Up Stroke
Virtual Reality in Stroke Rehabilitation
Reward Improves Long-Term Retention of a Motor Memory Through Induction of Offline Memory Gains

MD Conference Express ISC 2013

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