Left atrial and ventricular longitudinal strain in embolic stroke of undetermined source

Abstract

Purpose: Left atrial (LA) and left ventricular (LV) remodelling may lead to stroke. The aim of this study was to
analyze LA function and LV strain in patients with embolic stroke of undetermined source (ESUS).
Material and methods: This prospective study included 35 ESUS patients and 37 age and sex-matched
controls. All participants underwent brain computed tomography (CT), conventional and diffusion-weighted
magnetic resonance imaging (MRI), CT or MR angiography, 12 lead ECG, transthoracic echocardiography, and
48 hour Holter ECG monitoring. LA volume and function were determined by echocardiography. LA reservoir and
LV strains were measured longitudinally by speckle-tracking method. CHA2DS2-VASc, The National Institutes
of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) scores were calculated.
Results: Major cardiovascular risk factors were similar between the two groups. The mean CHA2DS2-VASc
score was 2.6±1.2. NIHSS was 3.9±3.0 and mRS was 1.3±0.8. Atrial electromechanical coupling intervals and
delays, LA emptying fraction and volumes were similar between the two groups. LA reservoir strain was lower than
controls (25.2±7.2% vs. 29.7±8.8%, p=0,019). LV global longitudinal strain was lower than controls (-14.7±4.2%
vs -16.4±3.9%, p=0,031). There was no correlation between LA, LV strains and the scores (CHA2DS2-VASc,
NIHSS, mRS).
Conclusions: ESUS patients had lower LA reservoir and LV longitudinal global strains than controls. Left atrial
volume index, LA emptying fraction did not differ between the two groups. Echocardiographic quantification of
LA and LV remodelling has great potential for secondary prevention from ESUS. Further studies are needed to
confirm our findings.

Keywords

• Embolic stroke
• left atrial function
• left ventricular function
• left atrial strain
• left ventricular strain

Kaynağı belirlenemeyen embolik inmede sol atriyal ve ventriküler longitudinal strain

Abstract

Amaç: Sol atriyal ve sol ventriküler yeniden şekillenme inmeye neden olabilir. Bu çalışmanın amacı, kaynağı
belirsiz embolik inme (ESUS) hastalarında sol atriyum fonksiyonlarını ve sol ventrikül strain değerlerini analiz
etmektir.
Gereç ve yöntem: Bu prospektif çalışma cinsiyet ve yaş açısından benzer olan 35 adet ESUS’lu hasta (61±10
yaşında) ve 37 adet kontrol grubunu (60±10 yaşında) içeriyordu. Tüm hastalara beyin bilgisayarlı tomografisi (BT),
konvansiyonel ve difüzyon manyetik rezonans görüntüleme (MRG), BT veya MR anjiyografi, 12 derivasyonlu
EKG, transtorasik ekokardiyografi ve 48 saat Holter EKG monitörizasyonu yapıldı. Sol atriyum hacimleri ve
fonksiyonları ekokardiyografi ile belirlendi. Sol atriyum rezervuar ve ventrikül strain değerleri speckle-tracking
metoduyla longitudinal olarak ölçüldü. CHA2DS2-VASc, Amerikan Ulusal Sağlık Enstitüsü İnme Skalası
(NIHSS), Modifiye Rankin Skalası (mRS) skorları hesaplandı.
Bulgular: Major kardiyovasküler risk faktörleri iki grup arasında da benzerdi. ESUS’lu hastaların ortalama
CHA2DS2-VASc skoru 2,6±1,2, NIHSS 3,9±3,0 ve mRS 1,3±0,8 saptandı. Atrial elektromekanik süreler ve
gecikme zamanları, sol atriyum boşalma fraksiyonu ve hacim indeksleri 2 grup arasında benzer bulundu. Sol
atriyal rezervuar strain, kontrol grubuna göre düşük saptandı (25,2±%7,2 vs. 29,7±%8,8, p=0.019). Sol ventrikül
global longitudinal strain kontrol grubuna göre düşük saptandı (-14,7±%4,2 vs -16,4±%3,9, p=0.031). Sol
atriyum rezervuar ve sol ventrikül strain değerleri ile skorlar arasında korelasyon saptanmadı (CHA2DS2-VASc,
NIHSS, mRS).
Sonuç: ESUS’lu hastalar, kontrol grubuna göre daha düşük sol atriyal rezervuar ve sol ventriküler global
longitudinal straine sahipti. Sol atriyal hacim indeksleri, sol atriyum boşalma fraksiyonu ve elektromekanik süreler
2 grup arasında farklılık göstermemektedir. Sol atriyal ve ventriküler yeniden şekillenmesinin ekokardiyografik
ölçümü, ESUS’tan ikincil koruma için büyük bir potansiyele sahiptir. Bulgularımızın doğrulanması için daha fazla
çalışmaya ihtiyaç vardır.

Keywords

• Embolik inme
• sol atriyal fonksiyon
• sol ventriküler fonksiyon
• sol atriyal strain
• sol ventriküler strain

References

1. References 1. Lamassa M, Di Carlo A, Pracucci G, et al. Charasteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: Data from a multicenter multinational hospital-based registery (The European Community Stroke Project) Stroke 2001;32:392-398. https://doi.org/10.1161/01.str.32.2.392
2. 2. Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989;25:382-390. https://doi.org/10.1002/ana.410250410
3. 3. Kamel H, Okin PM, Longstreth WT Jr, Elkind MS, Soliman EZ. Atrial cardiopathy: a broadened concept of left atrial thromboembolism beyond atrial fibrillation. Future Cardiol 2015;11:323-331. https://doi.org/10.2217/fca.15.22
4. 4. Weimar C. Stroke of undetermined cause: workup and secondary prevention. Curr Opin Neurol 2016;29:4-8. https://doi.org/10.1097/WCO.0000000000000280
5. 5. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22:107-133. https://doi.org/10.1016/j.echo.2008.11.023
6. 6. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1-39.e14. https://doi.org/10.1016/j.echo.2014.10.003
7. 7. Voigt JU, Pedrizzetti G, Lysyansky P, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2015;16:1-11. https://doi.org/10.1093/ehjci/jeu184
8. 8. Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014;370:2467-2477. https://doi.org/10.1056/NEJMoa1311376

9. 9. Sanna T, Diener HC, Passman RS, et al. Cryptogenic Stroke and Underlying Atrial Fibrillation. N Engl J Med 2014; 370:2478-2486. https://doi.org/10.1016/j.ahj.2010.03.032
10. 10. Bayar N, Üreyen ÇM, Erkal Z, et al. Evaluation of the association between stroke/transient ischemic attack and atrial electromechanical delay in patients with paroxysmal atrial fibrillation. Anatol J Cardiol 2016;16:572-578. https://doi.org/10.5152/AnatolJCardiol.2015.6424
11. 11. Skaarup KG, Christensen H, Høst N, et al. Diagnosing paroxysmal atrial fibrillation in patients with ıschemic strokes and transient ıschemic attacks using echocardiographic measurements of left atrium function. Am J Cardiol 2016;117:91-99. https://doi.org/10.1016/j.amjcard.2015.10.022
12. 12. Jordan K, Yaghi S, Poppas A, et al. Left atrial volume index is associated with cardioembolic stroke and atrial fibrillation detection after embolic stroke of undetermined source. Stroke 2019;50:1997-2001. https://doi.org/10.1161/STROKEAHA.119.025384
13. 13. Biering-Sørensen T, Christensen LM, Krieger DW, et al. LA emptying fraction improves diagnosis of paroxysmal AF after cryptogenic ischemic stroke: results from the SURPRISE study. JACC Cardiovasc Imaging 2014;7:962-963. https://doi.org/10.1016/j.jcmg.2014.02.003
14. 14. Sanchis L, Montserrat S, Obach V, et al. Left atrial function is impaired in some patients with stroke of undetermined etiology: potential implications for evaluation and therapy. Rev Esp Cardiol (Engl Ed) 2016;69:650-656. https://doi.org/10.1016/j.rec.2015.11.033
15. 15. Haffajee JA, Lee Y, Alsheikh-Ali AA, Kuvin JT, Pandian NG, Patel AR. Pre-operative left atrial mechanical function predicts risk of atrial fibrillation following cardiac surgery. JACC Cardiovasc Imaging 2011;4:833-840. https://doi.org/10.1016/j.jcmg.2011.03.019
16. 16. Leong DP, Joyce E, Debonnaire P, et al. Left atrial dysfunction in the pathogenesis of cryptogenic stroke: novel insights from speckle-tracking echocardiography. J Am Soc Echocardiogr 2017;30:71-79. https://doi.org/10.1016/j.echo.2016.09.013
17. 17. Russo C, Jin Z, Sera F, et al. Left ventricular systolic dysfunction by longitudinal strain is an independent predictor of incident atrial fibrillation: a community-based cohort study. Circ Cardiovasc Imaging 2015;8:e003520. https://doi.org/10.1161/CIRCIMAGING.115.003520
18. 18. Sade LE, Keskin S, Can U, et al. Left atrial mechanics for secondary prevention from embolic stroke of undetermined source. Eur Heart J Cardiovasc Imaging. 2022;23:381-391. https://doi.org/10.1093/ehjci/jeaa311
19. 19. Kamel H, Okin PM, Elkind MS, Iadecola C. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke 2016;47:895-900. https://doi.org/10.1161/STROKEAHA.115.012004