An 82-year-old hypertensive woman with a history of myocardial infarction is admitted
with aphasia and weakness of the right arm and leg. Admission electrocardiogram shows
sinus rhythm. During telemetry at the stroke unit, no episodes of atrial fibrillation
(AF) are detected. Using transthoracic echocardiography, mitral valve prolapse, moderate-severe
aortic stenosis, reduced left ventricular systolic ejection fraction and regional
akinesia of the left ventricular wall are identified. Would you consider one of these
findings as the cause of her stroke? If yes, which one? Carotid ultrasound reveals
a left carotid plaque causing a 40% stenosis without signs of ulceration. Would this
change your diagnosis for the underlying cause? If the carotid plaque was ulcerated,
would it alter your diagnosis? Subsequently, a 48-h Holter ECG detects 12 s of AF.
Would this change your estimate for the etiology of her stroke? Would you recommend
oral anticoagulation (OAC)? Next day, transoesophageal echocardiography reveals a
patent foramen ovale (PFO). Would this affect your diagnosis? Would you recommend
percutaneous closure if there was a large right-to-left shunt? A loop recorder for
long-term ECG monitoring is implanted, and an episode of 7 min of AF is detected after
11 months of continuous cardiac rhythm monitoring. How does this affect your diagnosis
for the underlying etiology? After all this diagnostic work, what is your final diagnosis?
How confident are you for this? Are additional diagnostic investigations indicated?
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References
- Embolic stroke of undetermined source: JACC review topic of the week.J Am Coll Cardiol. 2020; 75: 333-340
- Embolic stroke of undetermined source and detection of atrial fibrillation on follow-up: how much causality is there?.J Stroke Cerebrovasc Dis. 2016; 25: 2975-2980
- Temporal relationship between subclinical atrial fibrillation and embolic events.Circulation. 2014; 129: 2094-2099
- Apixaban in patients with atrial fibrillation.N Engl J Med. 2011; 364: 806-817
- Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial.Lancet Neurol. 2017; 16: 282-290
- Subclinical atrial fibrillation in older patients.Circulation. 2017;
- Prevalence and overlap of potential embolic sources in patients with embolic stroke of undetermined source.J Am Heart Assoc. 2019; 8e012858
- Closure of patent foramen ovale versus medical therapy in patients with cryptogenic stroke or transient ischemic attack: updated systematic review and meta-analysis.Stroke. 2018; 49: 412-418
- Heterogeneity of treatment effects in an analysis of pooled individual patient data from randomized trials of device closure of patent foramen ovale after stroke.JAMA. 2021; 326: 2277-2286
- Supracardiac atherosclerosis in embolic stroke of undetermined source: the underestimated source.Eur Heart J. 2021; 42: 1789-1796
- Antithrombotic treatment in patients with stroke and supracardiac atherosclerosis.Neurology. 2020; 95: e499-e507
- Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: a systematic review.Eur J Intern Med. 2022; 99: 38-44https://doi.org/10.1016/j.ejim.2022.01.024
- The AtRial cardiopathy and antithrombotic drugs in prevention after cryptogenic stroke randomized trial: rationale and methods.Int J Stroke. 2019; 14: 207-214
- Apixaban for treatment of embolic stroke of undetermined source (ATTICUS) randomized trial – update of patient characteristics and study timeline after interim analysis.Eur Heart J. 2021; : 42
- Recurrent stroke with rivaroxaban compared with aspirin according to predictors of atrial fibrillation: secondary analysis of the navigate esus randomized clinical trial.JAMA Neurol. 2019; 76: 764-773
Article info
Publication history
Published online: February 19, 2022
Accepted:
February 15,
2022
Received:
February 11,
2022
Identification
Copyright
© 2022 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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Access this article on ScienceDirectLinked Article
- Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: A systematic reviewEuropean Journal of Internal MedicineVol. 99
- PreviewThe majority of cryptogenic strokes are likely embolic; these have been termed “embolic strokes of undetermined source’’ (ESUS) [1]. One out of four ischemic strokes occurring in young (≤50 years) patients fulfills diagnostic criteria for ESUS [2]. In ESUS, a complete evaluation has failed to identify an atherosclerotic or cardiac embolic source, while in many patients there are more than one overlapping potential embolic sources (heart, arterial disease, cancer, etc) [3, 4].
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