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January 07, 2020; 94 (1) Article

Undetermined stroke genesis and hidden cardiomyopathies determined by cardiac magnetic resonance

View ORCID ProfileAna Catarina Fonseca, View ORCID ProfileJoão Pedro Marto, Daniela Pimenta, Tatiana Guimarães, Pedro N. Alves, Nuno Inácio, View ORCID ProfileMiguel Viana-Baptista, Teresa Pinho e Melo, View ORCID ProfileFausto J. Pinto, View ORCID ProfileJosé M. Ferro, Ana G. Almeida
First published December 2, 2019, DOI: https://doi.org/10.1212/WNL.0000000000008698
Ana Catarina Fonseca
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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  • ORCID record for Ana Catarina Fonseca
João Pedro Marto
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Daniela Pimenta
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Tatiana Guimarães
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Pedro N. Alves
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Nuno Inácio
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Miguel Viana-Baptista
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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  • ORCID record for Miguel Viana-Baptista
Teresa Pinho e Melo
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Fausto J. Pinto
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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José M. Ferro
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Ana G. Almeida
From the Department of Neurology (A.C.F., D.P., P.N.A., T.P.e.M., J.M.F.), Hospital de Santa Maria, Institute of Molecular Medicine, University of Lisboa; Department of Neurology (J.P.M., M.V.-B.), Hospital Egas Moniz; Department of Cardiology (T.G., F.J.P., A.G.A.), Hospital de Santa Maria, University of Lisboa; and Department of Neurology (N.I.), Hospital Beatriz Ângelo, Lisbon, Portugal.
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Citation
Undetermined stroke genesis and hidden cardiomyopathies determined by cardiac magnetic resonance
Ana Catarina Fonseca, João Pedro Marto, Daniela Pimenta, Tatiana Guimarães, Pedro N. Alves, Nuno Inácio, Miguel Viana-Baptista, Teresa Pinho e Melo, Fausto J. Pinto, José M. Ferro, Ana G. Almeida
Neurology Jan 2020, 94 (1) e107-e113; DOI: 10.1212/WNL.0000000000008698

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Abstract

Objective To determine whether cardiac magnetic resonance imaging (CMR) could be useful in identifying previously undiagnosed cardiomyopathies in a cohort of patients with ischemic stroke who underwent standard etiologic investigation and to describe the type and frequency of these cardiomyopathies.

Methods We performed a subanalysis of a previously collected prospective cohort of patients with ischemic stroke. Patients with structural changes on echocardiography that are considered causal for stroke in the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification were excluded. A 3T CMR was performed. We compared the frequency of the cardiomyopathies that we found with reference values for the general population.

Results One hundred thirty-two patients with a mean age of 68.4 years were included. In 7 patients (5.3%, 95% confidence interval 2.59%–10.54%) CMR identified cardiomyopathy. Four patients had hypertrophic cardiomyopathy, 2 had restrictive cardiomyopathy, and 1 had noncompaction cardiomyopathy. Six of these patients had been classified after standard evaluation as having undetermined stroke and 1 patient as having cardioembolic stroke (atrial fibrillation). We found a higher frequency of hypertrophic cardiomyopathy in the entire cohort and in the undetermined cause group compared to the general population (3.03% and 5.81% vs 0.2%, respectively, p = 0.001 and p < 0.001). The frequency of noncompaction cardiomyopathy was also higher in our cohort (0.76% vs 0.05%, respectively, p < 0.001).

Conclusions Although rare, cardiomyopathies should be considered as a possible cause of ischemic stroke classified as of undetermined etiology after standard evaluation.

Glossary

AF=
atrial fibrillation;
A-S-C-O=
atherosclerosis, small vessel disease, cardiac source, and other cause;
CMR=
cardiac magnetic resonance imaging;
CI=
confidence interval;
HCM=
hypertrophic cardiomyopathy;
LA=
left atrial;
LGE=
late gadolinium enhancement;
LV=
left ventricular;
NCC=
noncompaction cardiomyopathy;
NT-proBNP=
N-terminal pro-B-type natriuretic peptide;
RCM=
restrictive cardiomyopathy;
TOAST=
Trial of Org 10172 in Acute Stroke Treatment

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 14

  • CME Course: NPub.org/cmelist

  • Received March 18, 2019.
  • Accepted in final form August 1, 2019.
  • © 2019 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Author response: Undetermined stroke genesis and hidden cardiomyopathies determined by cardiac magnetic resonance
    • Ana C. Fonseca, Neurologist, Hospital de Santa Maria, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa
    • José M. Ferro, Neurologist, Hospital de Santa Maria, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa
    Submitted January 08, 2020
  • Reader response: Undetermined stroke genesis and hidden cardiomyopathies determined by cardiac magnetic resonance
    • Simona Lattanzi, MD, PhD, Marche Polytechnic University
    • Mauro Silvestrini, MD, Marche Polytechnic University
    Submitted December 30, 2019
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