TABLE 2.
Algorithm for advanced stroke and TIA evaluation
| Type of evaluation | Examination | Purpose and clinical comments |
|---|---|---|
| Extended vascular evaluation | High‐resolution MRA or three‐dimensioned/contrast ultrasound of pre‐ and cerebral vessels | Intensified seek for artery‐to artery embolism (aortic arch atheroma, mild stenosis of a relevant artery, or significant stenosis of non‐relevant artery); plaque extension into small perforators or other non‐atherosclerotic inflammatory or non‐inflammatory arteriopathies |
| and | ||
|
CTA or MRA of the aorta Transcranial Doppler monitoring for emboli |
cardiogenic embolism (minor‐risk cardioembolism sources 1 ) | |
| Vasculitis test/autoimmune evaluationCSF examination Brain biopsy | May in selected cases lead to confirmation of suspected vasculitis as well as identification of other uncommon diagnoses | |
| Extended cardiac evaluation | Prolonged rhythm monitoring >72 h up to 1 year: long‐term | Intensified seek for undiagnosed AF and other transient arrhythmias |
| noninvasive 2 or invasive monitoring (ICM) | Risk‐factor and biomarker‐based predictive scores 3 | |
| CT and MRI of the heart | Intensified seek for minor‐risk cardioembolism sources 1 and paradoxical venous embolism | |
| To determine several cardiovascular parameters (left ventricular mass, left atrial volume, identifying cardiac shunt, scaring, or fibrosis in the myocardium) | ||
| In case TEE cannot be tolerated | ||
| Genetic testing |
Mitochondrial diseases Monogenic disease (CADASIL) Fabry's disease and other genetic causes |
To exclude other uncommon causes of brain ischemia |
| Work‐up for occult cancer |
Physical examination and patient's history CT thorax, abdomen, pelvis Mammography PET‐CT, Diagnostic biomarkers |
Age‐ and sex‐appropriate screening Adenocarcinomas, lung and pancreatic cancer types most frequent |
Abbreviations: AF, Atrial fibrillation; CADASIL, Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, PET‐CT, Positron emission tomography CT; CSF, Cerebrospinal fluid; CT, Computed tomography; CTA, Computed tomography angiography; ICM, Insertable cardiac monitor; MRA Magnetic resonance tomography angiography; MRI, Magnetic resonance tomography; TEE, Transesophageal echocardiography.
Minor‐risk cardioembolic source: mitral valve prolapse, mitral annular calcification, aortic valve stenosis, calcific aortic valve, atrial high‐rate episodes, atrial appendage stasis with reduced flow velocities or spontaneous echodensities, atrial septal aneurysm, Chiari network, moderate systolic or diastolic dysfunction of left ventricle, endomyocardial fibrosis, patent foramen ovale, atrial septal defect.
Noninvasive monitoring strategies: mobile cardiac telemetry, patch monitor, event recorder, external loop recorder.
AF predictors: older age, hypertension, left ventricle hypertrophy, heart failure, coronary artery disease, left atrial enlargement, alcohol abuse, large vessel occlusion, multi‐territory and cortical lesions, chronic brain infarctions/leukoaraiosis, atrial premature beats, prolonged PR interval on ECG, P‐wave terminal force in lead V1.