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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EApproximately 20% of all ischemic strokes are caused by cardiac embolism [Freeman WD et al. \u003Cem\u003ENeurotherapeutics\u003C\/em\u003E 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. This article discusses on advances in cardiac imaging, prolonged rhythm monitoring for detection of silent atrial fibrillation (AF), the potential use of biomarkers to improve identification of cardiogenic embolism, as well as the cost-effectiveness of screening patients for AF and selection of patients for screening for AF for secondary stroke prevention\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EImaging Modalities\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIschemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiac Imaging Techniques\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EImaging Modalities\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeurology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIschemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiac Imaging Techniques\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EApproximately 20% of all ischemic strokes are caused by cardiac embolism [Freeman WD et al. \u003Cem\u003ENeurotherapeutics\u003C\/em\u003E 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.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe 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. \u003Cem\u003EEur J Echocardiogr\u003C\/em\u003E 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. \u003Cem\u003ECerebrovasc Dis\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003ECardiac 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\u0027s condition.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIn 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. \u003Cem\u003ECerebrovasc Dis\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EProf. 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.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EAlejandro 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. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. Paroxysmal AF (PAF) can be difficult to detect due to its asymptomatic, brief, and episodic nature.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ETo 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 [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01325545\u0026amp;atom=%2Fspmdc%2F13%2F1%2F26.atom\u0022\u003ENCT01325545\u003C\/a\u003E] 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.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe 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 \u0026gt;30 seconds. In noncryptogenic stroke cases, PAF was more common in patients aged \u0026gt;65 years (p=0.86) than in patients aged \u0026lt;65 years (p=0.07; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EDr. Rabinstein said that although AF is a major cause of stroke, \u201cit is unclear whether PAF detected by the new prolonged ambulatory methods has the same pathogenic significance\u201d as AF detected by ECG.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EFrank Sharp, MD, University of California, Davis, California, USA, reported on the potential use of biomarkers to improve identification of cardiogenic embolism.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003ERNA from 194 blood samples from 76 acute ischemic stroke patients was analyzed with a microarray to determine genes that distinguish cardioembolic stroke from large-vessel stroke at 3, 5, and 24 hours after stroke onset [Jickling GC et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/1\/26\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022PAF Occurrence in Patients With Noncryptogenic Stroke Is Age-Dependent\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1512246372\u0022 data-figure-caption=\u0022PAF Occurrence in Patients With Noncryptogenic Stroke Is Age-Dependent\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/1\/26\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/1\/26\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/1\/26\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12926\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EPAF Occurrence in Patients With Noncryptogenic Stroke Is Age-Dependent\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EPAF=paroxysmal atrial fibrillation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from A Rabinstein, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EA 40-gene profile differentiated between cardioembolic stroke and large-vessel stroke with \u0026gt;95% specificity and sensitivity. Cardioembolic stroke due to AF could be differentiated from non-AF causes with a separate 37-gene profile with \u0026gt;90% specificity and sensitivity. Genes found to be unique to cardioembolic strokes compared with controls included those involved in renin-angiotensin signaling, thrombopoietin signaling, NF-kB activation, and a cardiac hypertrophy role of nuclear factors of activated T-cells.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EIn a later study, the cardioembolic stroke gene profiles and gene profiles for arterial and lacunar strokes were used to predict the cause of cryptogenic strokes [Jickling GC et al. \u003Cem\u003EStroke\u003C\/em\u003E 2012]. RNA from the peripheral blood of 131 patients with cryptogenic stroke was compared with 149 patients with strokes of known cause. Together with infarct location, gene expression predicted 58% of the cryptogenic strokes to be cardioembolic, 18% arterial, 12% lacunar, and 12% unclear etiology.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EDr. Sharp said that these studies were proof-of-principle studies limited by small numbers of subjects, and a large population study is needed to re-derive gene profiles for cardioembolic, large-vessel, and lacunar strokes.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003ES. Claiborne Johnston, MD, PhD, University of California, San Francisco, California, USA, presented on the cost-effectiveness of screening patients for AF and selection of patients for screening for AF for secondary stroke prevention.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003ETo determine whether it was feasible to monitor all patients with prior TIA or stroke for AF, a cost-effectiveness analysis was run using a systematic review to create inputs and typical cost-utility methods to develop a model [Kamel H et al. \u003Cem\u003EStroke\u003C\/em\u003E 2010]. The primary outcome was cost per quality-adjusted life year (QALY). Primary results are shown in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E. The cost-utility ratio was $13,000 per QALY. Generally, any amount \u0026lt;$50,000 per QALY is considered reasonable for a health intervention, so the results indicate it is cost effective to monitor most patients with a previous TIA or stroke for AF.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12927\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12927\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12927\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-19\u0022 class=\u0022first-child\u0022\u003ECost-Effectiveness Analysis of Monitoring Patients for Atrial Fibrillation\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-24\u0022\u003EDr. Johnson concluded that if certain patients are going to be selected for monitoring, a composite prediction score needs to be developed and validated that takes risk factors for AF into account. These risk factors include age, cryptogenicity, cortical infarct, normotension, brain natriuretic peptide, premature atrial contractions, and heart disease.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/1\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzo3k1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzo3k1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzo3k1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}