학술논문
Diagnóstico Avanzado en la Fase Aguda del Ictus Criptogénico
Document Type
Dissertation/Thesis
Author
Source
TDX (Tesis Doctorals en Xarxa)
Subject
Language
Spanish; Castilian
Abstract
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 Medicina
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 Medicina