13 research outputs found

    Multiphase CT Angiography Improves Prediction of Intracerebral Hemorrhage Expansion

    Get PDF
    Angiography; Intracerebral hemorrhage; PredictionAngiografía; Hemorragia intracerebral; PredicciónAngiografia; Hemorràgia intracerebral; PrediccióPurpose To determine the prevalence of the spot sign and the accuracy of using the spot sign to predict intracerebral hemorrhage (ICH) expansion with standardized multiphase computed tomographic (CT) angiography. Materials and Methods This prospective observational cohort study included 123 consecutive patients with acute ICH (onset 33% or >6 mL) at 24 hours. Associations between the presence of the spot sign and substantial hematoma expansion were assessed by using the Pearson χ2 test. Results The later the phase of CT angiography, the higher the frequency of the spot sign. The spot sign was seen in 29.3% of patients in phase 1, 43.1% of patients in phase 2, and 46.3% of patients in phase 3 (P B > C > D > no spot sign (P = .002). Conclusion Multiphase CT angiography can help differentiate among different forms of spot sign presentation and can help stratify patients at risk for hematoma expansion. The more arterial the spot sign pattern, the greater the frequency and extent of expansion

    Diagnóstico Avanzado en la Fase Aguda del Ictus Criptogénico

    Get PDF
    Introducció L'abordatge diagnòstic de la causa de l'ictus isquèmic és d'especial importància atès que les recurrències són habitualment fruit de la mateixa patologia que l'ictus previ. Fins a un 25% dels ictus són catalogats com ictus criptogènic o de causa desconeguda després d'un ingrés hospitalari. L'objectiu és implementar un protocol diagnòstic en la fase aguda de l'ictus criptogènic que identifiqui etiologies d'alt potencial embolígeno causants d'ictus severs per a l'optimització de la prevenció secundària de l'ictus. mètodes: Anàlisi prospectiu de pacients amb ictus criptogénicos amb disseny d'estratègies per a la detecció de fonts embòliques, Es va avaluar en un cohort de pacients la monitorització cardíaca amb Holter tèxtil d'inici precoç en fase hospitalària i de manera continuada fins a complir 28 dies de monitorització ambulatòria. Es van analitzar la taxa de detecció de Fibril·lació Auricular (FA) i els marcadors predictius de detecció mitjançant una anàlisi multimodal combinant predictors clínics, de neuroimatge i cardíacs basals de cada pacient. En una altra cohort de pacients es va avaluar la utilitat de la ecocardioscopia de mà ultra portàtil per a la detecció de cardiopaties embolígenes majors identificades com a fracció d'ejecció severament deprimides o valvulopaties embolígenes i la seva fiabilitat pel que fa a l'estudi ecocardiogràfic estàndard, es van analitzar els predictors de detecció de fonts cardioembólicas gran mitjançant estudis ecocardiogràfics focalitzats en la fase aguda de l'ictus criptogènic. resultats Entre 296 pacients, 264 pacients van completar el monitoratge amb una taxa de detecció de FA paroxística de l'23,1% (61/264) després de monitorització durant 28 dies de manera precoç i contínua. Els pacients amb detecció de FA van ser més grans [odds ratio (OR) 1.04, interval de confiança 95% (CI) 1.01-1.08], van tenir majors taxes de transformació hemorràgica (OR 4.03, 95% CI 1.44-11.22), van presentar major detecció d'oclusió de gran vas intracranial (OR 4.29, 95% CI 2.31-7.97) (P <0.0001), van tenir volums indexats de aurícula esquerra més grans (OR 1.03, 95% CI 1.01-1.1) (P = 0.0002) i van tenir nivells analítics majors de pèptid natriurètic cerebral (OR 1.01, 95% CI 1.0-1.1). La major edat i la presència d'oclusió de got intracranial van estar independentment associats a la detecció de FA paroxística (OR 1.06, 95% CI 1.00-1.16, i OR 4.58, 95% CI 2.27- 21.38, respectivament). En una altra cohort es va realitzar un estudi amb ecocardioscopia ultra portàtil de mà en la fase aguda de l'ictus en 130 pacients, amb una concordança de l'0.95 pel que fa a l'estudi estàndard, es van detectar cardiopaties embolígenes al 16% (17/104) dels ictus criptogénicos en l'estudi focalitzat amb ecocardioscopia ultra portàtil. L'oclusió de gran vas intracranial (OR: 4.24, 95% CI: 1.01-17.85) i la insuficiència cardíaca crònica (OR: 13.25, 95% CI: 3.54-49.50) van ser predictors independents de detecció de cardiopatia embolígena més gran. conclusions Les estratègies diagnòstiques mitjançant estudis focalitzats amb ecocardioscopia ultra portàtil de mà en fase aguda i la tecnologia tèxtil Holter wearable d'inici precoç i continuada són útils en l'estudi etiològic de l'ictus criptogènic. L'oclusió de gran vas intracranial, l'edat de l'pacient i l'antecedent d'insuficiència cardíaca van ser marcadors independents de detecció de font embòlica i de detecció de FA.Introducción El abordaje diagnóstico de la causa del ictus isquémico es de especial importancia dado que las recurrencias son habitualmente fruto de la misma patología que el ictus previo. Hasta un 25% de los ictus son catalogados como ictus criptogénico o de causa desconocida tras un ingreso hospitalario. El objetivo es implementar un protocolo diagnóstico en la fase aguda del ictus criptogénico que identifique etiologías de alto potencial embolígeno causantes de ictus severos para la optimización de la prevención secundaria del ictus. Métodos: Análisis prospectivo de pacientes con ictus criptogénicos con diseño de estrategias para la detección de fuentes embólicas, Se evaluó en un cohorte de pacientes la monitorización cardiaca con Holter textil de inicio precoz en fase hospitalaria y de manera continuada hasta cumplir 28 días de monitorización ambulatoria . Se analizaron la tasa de detección de Fibrilación Auricular (FA) y los marcadores predictivos de detección mediante un análisis multimodal combinando predictores clínicos, de neuroimagen y cardíacos basales de cada paciente. En otra cohorte de pacientes se evaluó la utilidad de la ecocardioscopia de mano ultra portátil para la detección de cardiopatías embolígenas mayores identificadas como fracción de eyección severamente deprimidas o valvulopatías embolígenas y su fiabilidad con respecto al estudio ecocardiográfico estándar, se analizaron los predictores de detección de fuentes cardioembólicas mayores mediante estudios ecocardiográficos focalizados en la fase aguda del ictus criptogénico. Resultados Entre 296 pacientes, 264 pacientes completaron la monitorización con una tasa de detección de FA paroxística del 23,1% (61/264) tras monitorización durante 28 días de manera precoz y continua. Los pacientes con detección de FA fueron mayores [odds ratio (OR) 1.04, intervalo de confianza 95% (CI) 1.01-1.08], tuvieron mayores tasas de transformación hemorrágica (OR 4.03, 95% CI 1.44-11.22), presentaron mayor detección de oclusión de gran vaso intracraneal (OR 4.29, 95% CI 2.31-7.97) (P < 0.0001), tuvieron volúmenes indexados de aurícula izquierda más grandes (OR 1.03, 95% CI 1.01-1.1) (P =0.0002) y tuvieron niveles analíticos mayores de péptido natriurético cerebral (OR 1.01, 95%CI 1.0-1.1). La mayor edad y la presencia de oclusión de vaso intracraneal estuvieron independientemente asociados a la detección de FA paroxística (OR 1.06, 95% CI 1.00-1.16, y OR 4.58, 95% CI 2.27- 21.38, respectivamente). En otra cohorte se realizó un estudio con ecocardioscopia ultra portátil de mano en la fase aguda del ictus en 130 pacientes, con una concordancia del 0.95 con respecto al estudio estándar, se detectaron cardiopatías embolígenas en el 16% ( 17/104) de los ictus criptogénicos en el estudio focalizado con ecocardioscopia ultra portátil . La oclusión de gran vaso intracraneal (OR: 4.24, 95% CI: 1.01-17.85) y la insuficiencia cardíaca crónica (OR: 13.25, 95% CI: 3.54-49.50) fueron predictores independientes de detección de cardiopatía embolígena mayor. Conclusiones Las estrategias diagnósticas mediante estudios focalizados con ecocardioscopia ultra portátil de mano en fase aguda y la tecnología textil Holter wearable de inicio precoz y continuada son útiles en el estudio etiológico del ictus criptogénico. La oclusión de gran vaso intracraneal, la edad del paciente y el antecedente de insuficiencia cardíaca fueron marcadores independientes de detección de fuente embólica y de detección de FA.Introduction: The diagnostic approach to the cause of ischemic stroke is of special importance, because stroke recurrences are usually the result of the same pathology as the previous one, up to 25% of strokes are classified as cryptogenic stroke or of unknown cause after hospital admission. The objective is to implement a diagnostic protocol in the acute phase of cryptogenic stroke to identify etiologies of high embolic potential that cause severe strokes for the optimization of secondary stroke prevention. Methods: Prospective analysis of patients with cryptogenic strokes to analyze strategies designed for the detection of embolic sources. In a cohort of patients, cardiac holter textile monitoring was assessed at the early onset of the acute stroke in the hospital phase, and continuously monitoring was carried until 28 days of outpatient stage. The detection rate of Atrial Fibrillation and the predictive detection markers were analyzed by means of a multimodal analysis combining different clinical, neuroimaging and baseline cardiac predictors of each patient. In another cohort of patients, the utility of ultra-portable hand-held echocardiography was evaluated for the detection of major cardio embolic heart disease, that were identified as severely depressed ejection fraction or embolic valve disease. It has been evaluated the reliability of hand held echocardiography in comparison to the standard echocardiographic study as well as the predictors of major cardioembolic source detection. Results Among 296 patients, 264 patients completed monitoring with a paroxysmal AF detection rate of 23.1% (61/264) after early and continuous monitoring for 28 days. Patients with detection of AF were older [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.08], had higher rates of hemorrhagic transformation by neuroimaging (OR 4.03, 95% CI 1.44-11.22), presented greater detection of large intracranial vessel occlusion (OR 4.29, 95% CI 2.31-7.97) (P <0.0001), had larger indexed left atrial volumes (OR 1.03, 95% CI 1.01-1.1) (P = 0.0002) and had higher analytical levels of brain natriuretic peptide (OR 1.01, 95% CI 1.0-1.1) compared to patients without AF detection. The elderly age and the presence of intracranial vessel occlusion were independently associated with the detection of paroxysmal AF (OR 1.06, 95% CI 1.00-1.16, and OR 4.58, 95% CI 2.27- 21.38, respectively). In another cohort, a study with ultra-portable handheld echocardiography was carried out in the acute phase of stroke in 130 patients with a concordance of 0.95 in comparison to the standard study. Major cardio embolic source was detected in 16% (17/104) of cryptogenic strokes in the focused study with ultra-portable echocardiography. Large vessel occlusion of intracranial vessel (odds ratio [OR]: 4.24, 95% confidence interval [CI]: 1.01_17.85) and chronic heart failure (OR: 13.25, 95% CI: 3.54_49.50) were independent predictors of detection of major cardioembolic source. Conclusions Diagnostic strategies through focused studies with ultra-portable hand-held echocardiography in the acute phase and early-onset continuous holter wearable textile are useful in the etiological study of cryptogenic stroke. Large intracranial vessel occlusion, age of the patient and chronic heart failure were independent markers of embolic sources and detection of Atrial Fibrillation.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

    Imaging Biomarkers and Prevalence of Complex Aortic Plaque in Cryptogenic Stroke: A Systematic Review

    Get PDF
    Background Complex aortic plaque (CAP) is a potential embolic source in patients with cryptogenic stroke (CS). We review CAP imaging criteria for transesophageal echocardiogram (TEE), computed tomography angiography (CTA), and magnetic resonance imaging and calculate CAP prevalence in patients with acute CS. Methods and Results PubMed and EMBASE databases were searched up to December 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guideline. Two independent reviewers extracted data on study design, imaging techniques, CAP criteria, and prevalence. The Cochrane Collaboration tool and Guideline for Reporting Reliability and Agreement Studies were used to assess risk of bias and reporting completeness, respectively. From 2293 studies, 45 were reviewed for CAP imaging biomarker criteria in patients with acute CS (N=37 TEE; N=9 CTA; N=6 magnetic resonance imaging). Most studies (74%) used ≥4 mm plaque thickness as the imaging criterion for CAP although ≥1 mm (N=1, CTA), ≥5 mm (N=5, TEE), and ≥6 mm (N=2, CTA) were also reported. Additional features included mobility, ulceration, thrombus, protrusions, and assessment of plaque composition. From 23 prospective studies, CAP was detected in 960 of 2778 patients with CS (0.32 [95% CI, 0.24–0.41], I2=94%). By modality, prevalence estimates were 0.29 (95% CI, 0.20–0.40; I2=95%) for TEE; 0.23 (95% CI, 0.15–0.34; I2=87%) for CTA and 0.22 (95% CI, 0.06–0.54; I2=92%) for magnetic resonance imaging. Conclusions TEE was commonly used to assess CAP in patients with CS. The most common CAP imaging biomarker was ≥4 mm plaque thickness. CAP was observed in one‐third of patients with acute CS. However, high study heterogeneity suggests a need for reproducible imaging methods

    Large vessel occlusion is independently associated with atrial fibrillation detection

    No full text
    [Background and purpose]: Covert paroxysmal atrial fibrillation (pAF) is the most frequent cause of cardiac embolism. Our goal was to discover parameters associated with early pAF detection with intensive cardiac monitoring.[Method]: Crypto‐AF was a multicentre prospective study (four Comprehensive Stroke Centres) to detect pAF in non‐lacunar cryptogenic stroke continuously monitored within the first 28 days. Stroke severity, infarct pattern, large vessel occlusion (LVO) at baseline, electrocardiography analysis, supraventricular extrasystolia in the Holter examination, left atrial volume index and brain natriuretic peptide level were assessed. The percentage of pAF detection and pAF episodes lasting more than 5 h were registered.[Results]: Out of 296 patients, 264 patients completed the monitoring period with 23.1% (61/264) of pAF detection. Patients with pAF were older [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01–1.08], they had more haemorrhagic infarction (OR 4.03, 95% CI 1.44–11.22), they were more likely to have LVO (OR 4.29, 95% CI 2.31–7.97) (P 5 h [29.6% (21/71) vs. 8.3% (12/144); OR 4.62, 95% CI 2.11–10.08; P < 0.001]. In a mean follow‐up of 26.82 months (SD 10.15) the stroke recurrence rate was 4.6% (12/260).[Conclusions]: Large vessel occlusion in cryptogenic stroke emerged as an independent marker of pAF.This work was supported by a research grant (grant number PI15/02265) from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain), within the National Research Program Scientific and Innovation Research National Plan 2013–2016, reference co‐funded with the European Regional Development Fund

    B‐type natriuretic peptide over N‐terminal pro‐brain natriuretic peptide to predict incident atrial fibrillation after cryptogenic stroke

    No full text
    [Background and purpose] B‐type natriuretic peptide (BNP) and N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) are well‐known surrogates of atrial fibrillation (AF) detection but studies usually present data on either BNP or NT‐proBNP. The aim was to determine and directly compare the validity of the two biomarkers as a tool to predict AF and guide prolonged cardiac monitoring in cryptogenic stroke patients.[Methods] Non‐lacunar acute ischaemic stroke (<72 h) patients over 55 years of age with cryptogenic stroke after standard evaluation were included in the Crypto‐AF study and blood was collected. BNP and NT‐proBNP levels were determined by automated immunoassays. AF was assessed by 28 days’ monitoring. Highest (optimizing specificity) and lowest (optimizing sensitivity) quartiles were used as biomarker cut‐offs to build predictive models adjusted by sex and age. The integrated discrimination improvement index (IDI) and DeLong test were used to compare the performance of the two biomarkers.[Results] From 320 patients evaluated, 218 were included in the analysis. AF was detected in 50 patients (22.9%). NT‐proBNP (P < 0.001) and BNP (P < 0.001) levels were higher in subjects with AF and their levels correlated (r = 0.495, P < 0.001). BNP showed an increased area under the curve (0.720 vs. 0.669; P = 0.0218) and a better predictive capacity (IDI = 3.63%, 95% confidence interval 1.36%–5.91%) compared to NT‐proBNP. BNP performed better than NT‐proBNP in a specific model (IDI = 3.7%, 95% confidence interval 0.87%–6.5%), whilst both biomarkers performed similarly in the case of a sensitive model.[Conclusions] Both BNP and NT‐proBNP were increased in cryptogenic stroke patients with AF detection. Interestingly, BNP outperforms NT‐proBNP, especially in terms of specificity.This work was supported by a Research Grant (grant number PI15/02265) from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain), within the National Research Program Scientific and Innovation Research National Plan 2013–2016, reference co‐funded with European Regional Development Fund. The Neurovascular Research Laboratory acknowledges funding for this project by PI18/00804 from Fondo de Investigaciones Sanitarias. The Spanish stroke research network INVICTUS+ (RD16/0019/00021) of the Instituto de Salud Carlos III (co‐financed by the European Regional Development Fund, FEDER) is also acknowledged. EP has received a predoctoral grant from Vall D'Hebron Institute of Research

    Cardioembolic Ischemic Stroke Gene Expression Fingerprint in Blood: a Systematic Review and Verification Analysis

    No full text
    An accurate etiological classification is key to optimize secondary prevention after ischemic stroke, but the cause remains undetermined in one third of patients. Several studies pointed out the usefulness of circulating gene expression markers to discriminate cardioembolic (CE) strokes, mainly due to atrial fibrillation (AF), while only exploring them in small cohorts. A systematic review of studies analyzing high-throughput gene expression in blood samples to discriminate CE strokes was performed. Significantly dysregulated genes were considered as candidates, and a selection of them was validated by RT-qPCR in 100 patients with defined CE or atherothrombotic (LAA) stroke etiology. Longitudinal performance was evaluated in 12 patients at three time points. Their usefulness as biomarkers for AF was tested in 120 cryptogenic strokes and 100 individuals at high-risk for stroke. Three published studies plus three unpublished datasets were considered for candidate selection. Sixty-seven genes were found dysregulated in CE strokes. CREM, PELI1, and ZAK were verified to be up-regulated in CE vs LAA (p = 0.010, p = 0.003, p < 0.001, respectively), without changes in their expression within the first 24 h after stroke onset. The combined up-regulation of these three biomarkers increased the probability of suffering from CE stroke by 23-fold. In cryptogenic strokes with subsequent AF detection, PELI1 and CREM showed overexpression (p = 0.017, p = 0.059, respectively), whereas in high-risk asymptomatic populations, all three genes showed potential to detect AF (p = 0.007, p = 0.007, p = 0.015). The proved discriminatory capacity of these gene expression markers to detect cardioembolism even in cryptogenic strokes and asymptomatic high-risk populations might bring up their use as biomarkers.Neurovascular Research Laboratory acknowledges funding for this project by PI15/00354 and PI18/804 grant from Fondo de Investigaciones Sanitarias and takes part in the Spanish stroke research network INVICTUS+ (RD16/0019/0021) of the Instituto de Salud Carlos III (co-financed by the European Regional Development Fund, FEDER). Moreover, it has been partially financed by 201528-30-31-3 grant from Fundació la Marató de TV3. A.B is supported by a Juan Rodés research contract JR16/00008 from the Instituto de Salud Carlos III

    Balloon‐Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions

    No full text
    Background Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. Methods We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. Results A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) (P<0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) (P=0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P=0.673). Conclusions In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency
    corecore