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Biomarker level improves the diagnosis of embolic source in ischemic stroke of unknown origin

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Abstract

The risk of recurrent stroke is likely related to etiology. Therefore it is important to identify which patients are at highest early risk. We evaluated whether selected blood biomarkers may aid in the diagnosis of stroke etiology. We studied consecutive non-lacunar stroke patients between November 2006 and January 2007, and selected undetermined origin strokes. Blood samples were drawn at arrival to test brain natriuretic peptide (BNP), D-dimer, CK-MB, myoglobin, and troponin. Second harmonic transthoracic echocardiography (SHTTE) and ECG-24 h monitoring were also performed within the first 24 h. We evaluated 294 patients with ischemic stroke; 89 had an initial undetermined origin. After a cardiological work-up, 49 were diagnosed as embolic including atrial fibrillation (4), severe aortic arch atheromatosis (24), severe wall abnormalities (12), valve disease (3), dilated cardiomyopathy (1), and patent foramen (5). Higher levels of CK-MB, BNP, and myoglobin were found in patients with embolic source in SHTTE, but only CK-MB >1.5 ng/ml and BNP >64 pg/ml remained as independent predictors: BNP (OR 8.86; CI 95 % 2.79–28.09), CK-MB (OR 6.28; CI 95 % 1.66–23.69). BNP showed specificity of 75 %, sensitivity of 63.4 %, and positive predictive value (PPV) of 75.6 %. CK-MB had specificity of 85 %, sensitivity of 47.9 %, and PPV of 79.3 %. Measuring both biomarkers improves the finding of embolic source, increasing specificity to 95 % and PPV to 88.2 %. High-level CK-MB and BNP during the acute phase of ischemic stroke are associated with an embolic source. Measurement of both biomarkers may improve the diagnosis, guiding the need to perform a heart exploration.

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Acknowledgments

The diagnostic kits were kindly donated by Inverness. Neurovascular Research Laboratory takes part into the Spanish stroke research network (RENEVAS, RD06/0026/0010) and the European Stroke Network (EUSTROKE 7FP Health F2-08-202213) and is partially funded by grants from the Fondo de Investigaciones Sanitarias (FIS 11/176) for stroke biomarkers studies. P.D. is supported by Miguel Servet senior research contracts (CP09/00136) and T.G-B. by a predoctoral fellowship (FI09/00017) from the Carlos III Health Institute.

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Authors and Affiliations

  1. Neurovascular Research Laboratory, Hospital Vall Hebron, Barcelona, Spain

    A. Penalba, T. García-Berrocoso, P. Delgado & J. Montaner

  2. Department of Echocardiography, Hospital Vall Hebron, Barcelona, Spain

    T. González-Alujas & A. Evangelista

  3. Neurovascular Unit, Hospital Vall Hebron, Barcelona, Spain

    E. Santamarina, M. Quintana, M. Ribó, O. Maisterra, C. A. Molina & J. Álvarez-Sabín

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  1. E. Santamarina
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  2. A. Penalba
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  3. T. García-Berrocoso
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Correspondence to E. Santamarina.

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Santamarina, E., Penalba, A., García-Berrocoso, T. et al. Biomarker level improves the diagnosis of embolic source in ischemic stroke of unknown origin. J Neurol 259, 2538–2545 (2012). https://doi.org/10.1007/s00415-012-6532-4

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  • DOI: https://doi.org/10.1007/s00415-012-6532-4

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