Takasugi Junji, Yamagami Hiroshi, Noguchi Teruo, Morita Yoshiaki, Tanaka Tomotaka, Okuno Yoshinori, Yasuda Satoshi, Toyoda Kazunori, Gon Yasufumi, Todo Kenichi, Sakaguchi Manabu, Nagatsuka Kazuyuki
From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.).
Stroke. 2017 Sep;48(9):2434-2440. doi: 10.1161/STROKEAHA.117.018263. Epub 2017 Aug 17.
We aimed to use contrast-enhanced cardiac magnetic resonance (CE-CMR) imaging to elucidate the prevalence of left ventricular (LV) thrombus in patients suspected of embolic stroke of undetermined source (ESUS) with previous myocardial infarction or LV dysfunction (LV ejection fraction [LVEF] <50%).
We prospectively investigated 797 consecutive patients who presented to our hospital with acute ischemic stroke between 2014 and 2015. Patients with myocardial infarction or LVEF<50% underwent CE-CMR imaging. ESUS was diagnosed according to proposal criteria based on transthoracic echocardiography findings.
The prevalence of ESUS was 22% (178 of 797) on initial diagnosis. Among 60 patients with myocardial infarction or LVEF<50%, the stroke subtypes were as follows: small artery disease, 17% (10 of 60); large artery atherosclerosis, 5% (3 of 60); cardioembolic stroke, 49% (29 of 60); ESUS, 23% (14 of 60); and undetermined causes other than ESUS, 6% (4 of 60). Of 60 patients examined via CE-CMR, LV thrombus was confirmed in 12 patients, whereas only 1 had been detected on transthoracic echocardiography (=0.04). Importantly, 29% (4 of 14) of patients with ESUS had LV thrombus. A prediction model based on CE-CMR findings showed higher performance in LV thrombus detection, permitting a net improvement of 0.46 (95% confidence interval, 0.08-0.82; =0.016) in cardioembolic stroke reclassification. Compared with patients without LV thrombus, those with LV thrombus had lower LVEF (median: 26% versus 40%; =0.003). Notably, 42% (5 of 12) of patients with LV thrombus had LVEF≥30%.
When ESUS-suspected patients have myocardial infarction or LV dysfunction, CE-CMR may help improve detection of cardioembolic stroke and provide relevant information for anticoagulation therapy.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02251665.
我们旨在运用对比增强心脏磁共振成像（CE-CMR）来阐明在既往有心肌梗死或左心室功能障碍（左心室射血分数[LVEF]<50%）且疑似不明来源栓塞性卒中（ESUS）的患者中左心室（LV）血栓的患病率。
我们对2014年至2015年间连续797例因急性缺血性卒中就诊于我院的患者进行了前瞻性研究。患有心肌梗死或LVEF<50%的患者接受了CE-CMR成像检查。ESUS根据基于经胸超声心动图检查结果的推荐标准进行诊断。
初始诊断时ESUS的患病率为22%（797例中的178例）。在60例患有心肌梗死或LVEF<50%的患者中，卒中亚型如下：小动脉疾病，17%（60例中的10例）；大动脉粥样硬化，5%（60例中的3例）；心源性栓塞性卒中，49%（60例中的29例）；ESUS，23%（60例中的14例）；以及ESUS以外的不明原因，6%（60例中的4例）。在通过CE-CMR检查的60例患者中，12例确诊有LV血栓，而经胸超声心动图仅检测到1例（P=0.04）。重要的是，29%（14例中的4例）的ESUS患者有LV血栓。基于CE-CMR检查结果的预测模型在LV血栓检测方面表现更佳，在将心源性栓塞性卒中重新分类方面净改善了0.46（95%置信区间，0.08-0.82；P=0.016）。与无LV血栓的患者相比，有LV血栓的患者LVEF较低（中位数：26%对40%；P=0.003）。值得注意的是，42%（12例中的5例）有LV血栓的患者LVEF≥30%。
当疑似ESUS的患者有心肌梗死或LV功能障碍时，CE-CMR可能有助于改善心源性栓塞性卒中的检测，并为抗凝治疗提供相关信息。
