title: Characteristic lesion pattern and echocardiographic findings in extra-cardiac shunt-related stroke.
abstract: Among embolic strokes of undetermined source, under-recognized etiology such as extra-cardiac shunt could be a potential risk factor. We sought to characterize infarction patterns on diffusion-weighted imaging (DWI) and transesophageal echocardiography (TEE) findings in extra-cardiac shunt-related stroke. We enrolled 96 consecutive patients with cryptogenic stroke who had an extra- or intra-cardiac shunt. Diagnosis of the shunt was performed using TEE with agitated saline contrast and pulmonary vein isolation. Infarction patterns on DWI and total lesion volume were analyzed. Bubble amounts through the shunt were classified via the International Consensus Criteria (ICC). Short-term prognosis, patterns and size of DWI lesions, and involved vascular territories were not significantly different between two groups. Multivariate analysis revealed that extra-cardiac shunt group has a smaller total infarct volume (odds ratio [OR]=0.427, 95% confidence interval [95% CI] 0.228-0.799, p=0.008), and significantly higher bubble grade during resting state and lower grade during the Valsalva maneuver (OR= 0.539, 95% CI 0.438-0.663, p<0.001). Stroke related to an extra-cardiac shunt presented smaller infarct volume, favorable clinical outcomes and characteristic finding on TEE with agitated saline contrast. Further study is needed to confirm whether the extra-cardiac shunt is an independent risk factor.
authors.affiliation: Departments of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Jun Kyu
authors.initials: JK
authors.lastname: Mun
authors.affiliation: Departments of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Sung Ji
authors.initials: SJ
authors.lastname: Park
authors.affiliation: Departments 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: Departments of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Oh Young
authors.initials: OY
authors.lastname: Bang
authors.affiliation: Departments 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: Departments 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: Departments of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Electronic address: kimgm@skku.edu.
authors.forename: Gyeong-Moon
authors.initials: GM
authors.lastname: Kim
mesh_terms: D000328:Adult; D038524:Diffusion Magnetic Resonance Imaging; D017548:Echocardiography, Transesophageal; D005260:Female; D006343:Heart Septal Defects / Q000150:complications*; D006801:Humans; D016015:Logistic Models; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D020521:Stroke / Q000000981:diagnostic imaging* / Q000209:etiology*; D014636:Valsalva Maneuver / Q000502:physiology*
keywords: Cryptogenic stroke; Diffusion-weighted imaging (DWI); Extra-cardiac shunt; Transesophageal echocardiography (TEE); Valsalva maneuver