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Adding Cardiac CT to the Hyperacute Stroke CT Protocol: Don't Leave the CT Scanner Without Imaging the Heart


Around 25% of ischemic strokes remain “cryptogenic” after a comprehensive workup.1 This led to the concept of Embolic Stroke of Uncertain Source (ESUS), with the underlying implication that many of those patients have undetected atrial fibrillation (AF). However, with the negative results of the randomized clinical trials comparing anticoagulation vs antiplatelet therapy for patients with ESUS,2,3 it is apparent that the link between AF and ischemic stroke is more complex.4 A thrombogenic substrate may occur with or without preceding AF, with the concept of an atrial myopathy well-recognized, albeit not so clearly characterized. Indeed, AF may occur because of the atrial myopathy process (often years after stroke), and the risk factors for the development of both conditions are shared (e.g., hypertension, diabetes, obesity, and alcohol excess). The fact that atrial thrombus can occur without preceding AF might explain the potentially futile process of extended periods of ECG monitoring in patients with ESUS to capture so-called sub-clinical AF.



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