Al-Khalidi, AH

Bangee, M

Benedetto, V

Bray, EP

Chatterjee, K

Chauhan, U

Clegg, AJ

Georgiou, RF

Gibson, J

Lane, DA

Lightbody, CE

Lip, GYH

McMahon, NE

Sekhar, A

Watkins, CL

University of Liverpool Repository

Aetiologic workup in cases of cryptogenic stroke: a systematic review and comparison of international clinical practice guidelinesBangee, M1, McMahon, NE1, Benedetto, V1, Bray, EP1, Georgiou, RF1, Gibson, J1, Lane, DA2, Al-Khalidi, AH3, Chatterjee, K4,Chauhan, U5, Clegg, AJ1, Lip, GYH2, Lightbody, CE1, Sekhar, A6, Watkins, CL11Faculty of Health and Wellbeing, University of Central Lancashire, 2Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, 3Medtronic Limited, UK, 4Countess of Chester Hospital, Chester, 5Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, 6The Walton Centre NHS Foundation Trust, LiverpoolIntroductionIdentifying the aetiology of ischaemic stroke is essential in order to initiate appropriate and timely secondary prevention measures to reduce the risk of recurrence (Hart et al, 2014). In 30% of ischaemic strokes, existing investigative protocols fail to establish the exact aetiology (Yaghi et al, 2017; Li et al, 2015). Such strokes are classed as ‘cryptogenic’ or as a stroke of unknown origin. However, there is a lack of international consensus on the optimum timing and type of investigations to identify stroke aetiology. Aim: To systematically evaluate and compare international recommendations in clinical practice guidelines that relate to the assessment and investigation of the aetiology of ischaemic stroke, and any subsequent evaluation of cryptogenic stroke. MethodSearches for clinical practice guidelines published from 2009-2019 were conducted using electronic databases (MEDLINE, HMIC, EMBASE, and CINAHL), relevant websites of national and international professional organisations, and reference lists of included guidelines. Two reviewers independently screened titles, abstracts and full guidelines using a pre-defined relevance criteria form. From each included guideline, definitions of cryptogenic stroke, and recommendations related to assessment and investigation of the aetiology of stroke was extracted. Quality of the included guidelines was assessed using the AGREE II tool. DiscussionAll included publications were in agreement about investigations which should be routinely performed for all acute stroke patients (‘standard evaluation’), but there was a lack of consistency and detail about additional investigations for patients in whom a cause is not identified through standard evaluation. This review has highlighted the need for well-designed primary research to identify an optimal pathway to expedite the identification of rare and very rare stroke aetiologies in a timely and cost-effective manner.ReferencesHart RG, Diener H-C, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13(4):429-38.Li L, Yiin GS, Geraghty OC, Schulz UG, Kuker W, Mehta Z, et al. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology. 2015;14:903-913.Saver JL. Cryptogenic stroke. The New England Journal of Medicine. 2016;374:2065-2074.Yaghi S, Bernstein RA, Passman R, Okin PM, Furie KL. Cryptogenic stroke: research and practice. Circ Res. 2017;120:527-540.ResultsOf 8442 citations identified, 23 guidelines were included in the review (see Figure 1). The recommendations identified were organised into six categories of investigations (see Figure 2). Overall, the guidelines recommended that all patients with suspected stroke should routinely undergo brain imaging, non-invasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Only three guidelines provided recommendations of further investigations for rare causes of stroke.Figure 1: PRISMA flow diagram Figure 2: Six categories of investigations identifiedEmail: mbangee2@uclan.ac.ukBrain imagingVascular imaging Cardiac rhythmLaboratory investigationsCardiac structureOtherThis research was funded by the Liverpool Clinical Commissioning Group (LCCG) Research Capability Funding grant (Investigating the Detection of CRYPTogenic stroke (ID-CRYPT)). CW, NM, VB, and AC are part-funded through the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the LCCG, NIHR or the Department of Health and Social Care. “Patient, I cannot say for sure.”“Doctor, will it happen again?”Data synthesisAll formal recommendations describing aetiologic workup in acute ischemic stroke were collated for further assessment. The included recommendations were then organised into categories reflective of a recently published algorithm for aetiologic workup in cryptogenic stroke(Saver, 2016).Records identified through database searching (n = 8442)Records screened on title and abstract (n = 4566)Full-text articles assessed for eligibility (n = 114)Guidelines included in synthesis (n = 23) Standard evaluation for all patientsEvaluation of autoimmune diseases, prothrombotic states (e.g. antiphospholipid syndrome), Fabry disease, and thrombophilia.Advanced/ specialised evaluation for selected patients

Diagnostic workup in cases of cryptogenic stroke: a systematic review and comparison of international clinical practice guidelines

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Diagnostic workup in cases of cryptogenic stroke: a systematic review and comparison of international clinical practice guidelines

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