Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke

Abstract

Background: Occult paroxysmal atrial fibrillation (PAF) is a common and potential treatable cause of cryptogenic stroke (CS). We sought to prospectively identify independent predictors of atrial fibrillation (AF) detection in patients with CS and sinus rhythm on baseline electrocardiogram (ECG), without prior AF history. We had hypothesized that cardiac arrhythmia detection during neurosonology examinations (Carotid Duplex (CDU) and Transcranial Doppler (TCD)) may be associated with higher likelihood of AF detection. Methods: Consecutive CS patients were prospectively evaluated over a six-year period. Demographics, clinical and imaging characteristics of cerebral ischemia were documented. The presence of arrhythmia during spectral waveform analysis of CDU/TCD was recorded. Left atrial enlargement was documented during echocardiography using standard definitions. The outcome event of interest included PAF detection on outpatient 24-h Holter ECG recordings. Statistical analyses were performed using univariate and multivariate logistic regression models. Results: A total of 373 patients with CS were evaluated (mean age 60 ± 11 years, 67% men, median NIHSS-score 4 points). The rate of PAF detection of any duration on Holter ECG recordings was 11% (95% CI 8%–14%). The following three variables were independently associated with the likelihood of AF detection on 24-h Holter-ECG recordings in both multivariate analyses adjusting for potential confounders: age (OR per 10-year increase: 1.68; 95% CI: 1.19–2.37; p = 0.003), moderate or severe left atrial enlargement (OR: 4.81; 95% CI: 1.77–13.03; p = 0.002) and arrhythmia detection during neurosonology evaluations (OR: 3.09; 95% CI: 1.47–6.48; p = 0.003). Conclusion: Our findings underline the potential utility of neurosonology in improving the detection rate of PAF in patients with CS.

Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

“…Cryptogenic stroke was defined using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, 8 and after excluding patients with incomplete evaluation, as previously described. [9][10][11][12][13] All patients underwent investigations with transthoracic and transesophageal echocardiogram where indicated. [9][10][11][12][13] The presence of left atrial enlargement was diagnosed according to the guidelines of the American Society of Echocardiography.…”

“…[9][10][11][12][13] All patients underwent investigations with transthoracic and transesophageal echocardiogram where indicated. [9][10][11][12][13] The presence of left atrial enlargement was diagnosed according to the guidelines of the American Society of Echocardiography. 14 All patients received neuroimaging with brain computed tomography (CT) and / or magnetic resonance imaging (MRI) and vascular imaging with the modality left at the discretion of the treating physician (cervical duplex ultrasound, transcranial Doppler, CT angiography and / or magnetic resonance [MR] angiography).…”

“…[9][10][11][12][13] Stroke severity on admission was assessed with the use of the National Institute of Health Stroke Scale (NIHSS) score by certified neurologists. [9][10][11][12][13] Strategies of Heart Rhythm Monitoring All patients recruited during the 8-year period underwent 24-hour Holter echocardiogram (ECG; H12+ digital Holter recorder; Mortara Instrument) during hospitalization as standard of care. In the years 2013 to 2017 patients with a negative 24-hour Holter-ECG investigation during their hospitalization were followed in our outpatient clinic with repeat 24-hour Holter-ECGs at the discretion of treating stroke physicians.…”

“…In the years 2013 to 2017 patients with a negative 24-hour Holter-ECG investigation during their hospitalization were followed in our outpatient clinic with repeat 24-hour Holter-ECGs at the discretion of treating stroke physicians. 9,10 All ECG recordings from 24-hour Holter monitoring were analyzed by 2 experienced cardiologists in our institution who were blinded to demographics and outcomes of the patients, using dedicated analysis software. Total time in atrial fibrillation (AF) was calculated as the sum of each individual AF episode for patients with multiple episodes during monitoring.…”

“…Total time in atrial fibrillation (AF) was calculated as the sum of each individual AF episode for patients with multiple episodes during monitoring. 9,10 PAF diagnosis thresholds of 30 seconds and 2 minutes were used for 12-lead ECG and 24-hour Holter-ECGs, respectively, as previously described. 9 In the year 2017, we implemented the use of an ICM device (Reveal LINQ; Medtronic) for the prolonged outpatient cardiac monitoring of patients with cryptogenic strokes or TIAs and at least one negative 24-hour Holter-ECG during hospitalization.…”