title: An Approach to Working Up Cases of Embolic Stroke of Undetermined Source.
abstract: BACKGROUND
  From a therapeutic viewpoint, it is important to differentiate the underlying causes of embolism in patients with cryptogenic stroke, such as aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation. We investigated the clinical and radiological characteristics of these 3 common causes of cryptogenic embolism to develop models for decision making in etiologic workups.
  
  
  RESULTS
  A total of 321 consecutive patients with acute infarcts from cryptogenic embolism were included. Patients were divided into 3 groups-aortic arch atheroma (n=40), patent foramen ovale (n=153), and paroxysmal atrial fibrillation (n=128)-based on extensive cardiologic workups. We used a multinomial logistic regression analysis to detect the clinical and diffusion-weighted imaging factors associated with the probability of aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation. Clinical and radiological features differed among the groups. The patent foramen ovale group had a healthy vascular risk factor profile and showed posterior circulation involvement compared with other groups (P<0.01). In contrast, paroxysmal atrial fibrillation-related strokes had higher initial National Institutes of Health Stroke Scale (NIHSS) scores and larger lesions than the other groups (P<0.001). The aortic arch atheroma group had clinical features similar to those of the paroxysmal atrial fibrillation group but showed small lesions scattered in multiple vascular territories (P<0.001). Multivariate regression analysis revealed that age, initial NIHSS score, lesion size (≥20 mm), multiple (≥3) lesions, and involvement of posterior circulation or multiple vascular territories differentiated the 3 groups (pseudo, R(2)=0.656). The prediction ability of this model was validated in the external validation cohort (n=117, area under the curve 0.78).
  
  
  CONCLUSIONS
  Our data indicate that patients with cryptogenic embolic stroke show distinct clinical and radiological features depending on the underlying causes.
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Sookyung
authors.initials: S
authors.lastname: Ryoo
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Jong-Won
authors.initials: JW
authors.lastname: Chung
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Mi Ji
authors.initials: MJ
authors.lastname: Lee
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Suk Jae
authors.initials: SJ
authors.lastname: Kim
authors.affiliation: Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, South Korea.
authors.forename: Jin Soo
authors.initials: JS
authors.lastname: Lee
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Gyeong-Moon
authors.initials: GM
authors.lastname: Kim
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Chin-Sang
authors.initials: CS
authors.lastname: Chung
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Kwang Ho
authors.initials: KH
authors.lastname: Lee
authors.affiliation: Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, South Korea.
authors.forename: Ji Man
authors.initials: JM
authors.lastname: Hong
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea ohyoung.bang@samsung.com.
authors.forename: Oh Young
authors.initials: OY
authors.lastname: Bang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000473:pathology; D001018:Aortic Diseases / Q000150:complications / Q000175:diagnosis* / Q000473:pathology; D001027:Aortography; D050197:Atherosclerosis / Q000150:complications / Q000175:diagnosis* / Q000473:pathology; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis*; D002560:Cerebrovascular Circulation; D019091:Critical Pathways; D003661:Decision Support Techniques; D038524:Diffusion Magnetic Resonance Imaging; D004185:Disability Evaluation; D017548:Echocardiography, Transesophageal; D015716:Electrocardiography, Ambulatory; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D016015:Logistic Models; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D064847:Multimodal Imaging / Q000379:methods; D015999:Multivariate Analysis; D058226:Plaque, Atherosclerotic; D011237:Predictive Value of Tests; D011379:Prognosis; D015203:Reproducibility of Results; D056910:Republic of Korea; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D057188:Workflow
keywords: cerebral infarction; diagnosis; embolic stroke of undetermined etiology; embolism