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Among patients with atrial fibrillation, the risk of stroke is highest for those with a history of stroke; however, oral anticoagulants can lower the risk of recurrent stroke by two-thirds. No consensus has been reached about how atrial fibrillation should be investigated in patients with stroke, and its prevalence after a stroke remains uncertain. We did a systematic review and meta-analysis to estimate the proportion of patients newly diagnosed with atrial fibrillation after four sequential phases of cardiac monitoring after a stroke or transient ischaemic attack. We searched PubMed, Embase, and Scopus from 1980 to June 30, 2014. We included studies that provided the number of patients with ischaemic stroke or transient ischaemic attack who were newly diagnosed with atrial fibrillation. We stratified cardiac monitoring methods into four sequential phases of screening: phase 1 (emergency room) consisted of admission electrocardiogram (ECG); phase 2 (in hospital) comprised serial ECG, continuous inpatient ECG monitoring, continuous inpatient cardiac telemetry, and in-hospital Holter monitoring; phase 3 (first ambulatory period) consisted of ambulatory Holter; and phase 4 (second ambulatory period) consisted of mobile cardiac outpatient telemetry, external loop recording, and implantable loop recording. The primary endpoint was the proportion of patients newly diagnosed with atrial fibrillation for each method and each phase, and for the sequential combination of phases. For each method and each phase, we estimated the summary proportion of patients diagnosed with post-stroke atrial fibrillation using random-effects meta-analyses. Our systematic review returned 28 290 studies, of which 50 studies (comprising 11 658 patients) met the criteria for inclusion in the meta-analyses. The summary proportion of patients diagnosed with post-stroke atrial fibrillation was 7·7% (95% CI 5·0–10·8) in phase 1, 5·1% (3·8–6·5) in phase 2, 10·7% (5·6–17·2) in phase 3, and 16·9% (13·0–21·2) in phase 4. The overall atrial fibrillation detection yield after all phases of sequential cardiac monitoring was 23·7% (95% CI 17·2–31·0). By sequentially combining cardiac monitoring methods, atrial fibrillation might be newly detected in nearly a quarter of patients with stroke or transient ischaemic attack. The overall proportion of patients with stroke who are known to have atrial fibrillation seems to be higher than previously estimated. Accordingly, more patients could be treated with oral anticoagulants and more stroke recurrences prevented. Heart and Stroke Foundation of Canada, and Natural Science and Engineering Research Council of Canada.

In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery. NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results. Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019). Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke. Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.

We assessed the impact of the coronavirus disease 19 (COVID-19) pandemic on code stroke activations in the emergency department, stroke unit admissions, and referrals to the stroke prevention clinic at London’s regional stroke center, serving a population of 1.8 million in Ontario, Canada. We found a 20% drop in the number of code strokes in 2020 compared to 2019, immediately after the first cases of COVID-19 were officially confirmed. There were no changes in the number of stroke admissions and there was a 22% decrease in the number of clinic referrals, only after the provincial lockdown. Our findings suggest that the decrease in code strokes was mainly driven by patient-related factors such as fear to be exposed to the SARS-CoV-2, while the reduction in clinic referrals was largely explained by hospital policies and the Government lockdown.

Cardioembolic sources often remain undetected after standard diagnostic stroke workup, contributing to high rates of recurrence. We aimed to assess whether a head-to-neck CT angiography extended at least 6 cm below the carina (extended CT angiography) can increase the detection of cardioaortic thrombi compared with standard-of-care CT angiography (standard CT angiography) in patients with ischaemic stroke or transient ischaemic attack. This single-centre, prospective, randomised, open-label, blinded end-point trial was done at London Health Sciences Centre, Western University, Canada. Eligible patients were adults aged 18 years or older with ischaemic stroke or transient ischaemic attack assessed during acute code strokes. Exclusion criteria were known allergy or concerns about the safety of iodinated contrast agents (eg, severe renal failure) and no intravenous access. Participants were randomly assigned in a 1:1 ratio to receive standard CT angiography or extended CT angiography. Patients, neurologists adjudicating qualifying events, cardiothoracic radiologists, and cardiologists adjudicating study outcomes were masked to randomisation. Adjudicators were considered masked to randomisation as they did not know which patients were crossovers, which patients in the standard of care arm had partial imaging of the left atrial appendage due to normal variations in size and shape, and which patients in the extended CT angiography group also had partial imaging of the left atrial appendage instead of full imaging. The primary efficacy outcome was the detection of a cardioaortic thrombus (modified intention-to-treat population). The primary safety outcome was time to CT angiography completion (as-treated population). The trial was registered at ClinicalTrials.gov, NCT05522244, and is closed. Between July 17, 2023, and May 6, 2024, 963 patients were assessed for inclusion. 133 were excluded because they already had a CT angiography at their local hospital, intracranial haemorrhage was identified on the initial non-contrast CT, a diagnosis of stroke was considered highly unlikely by the treating stroke neurologist, or randomisation was not possible. 830 patients were enrolled and randomly assigned to extended CT angiography (n=415) or standard CT angiography (n=415). One patient withdrew consent and was excluded from the analyses. 364 participants who were later adjudicated as having experienced stroke mimics were excluded. 465 patients with ischaemic stroke or transient ischaemic attack were included in the modified intention-to-treat population (226 in the extended CT angiography group and 239 in the standard CT angiography group). 239 (51%) of 465 patients were female and 226 (49%) were male. Median age of the analysis group at enrolment was 78·0 years (IQR 69·0–84·0). The primary outcome (cardioaortic thrombus) was detected in 20 (8·8%) of 226 patients in the extended CT angiography group and four (1·7%) of 239 in the standard CT angiography group (odds ratio 5·70, 95% CI 1·92–16·96; p=0·002). There were no statistically significant differences in the median time from code stroke activation to CT angiography completion between the extended CT angiography group (21·0 min; IQR 15·8–27·0 min) and the standard CT angiography group (20·0 min, 17·0–26·0 min). The median difference between extended CT angiography and standard CT angiography groups was 1·0 min (–1·0 to 2·5), p=0·67). Performing extended CT angiography during acute code strokes is feasible and results in increased cardioaortic thrombi detection without causing delays in CT angiography completion. Future studies should assess whether extended CT angiography can reduce recurrent stroke risk by prompting early anticoagulation after thrombus detection. Western University, and the Kathleen and Dr Henry Barnett Chair in Stroke Research.

IntroductionIt is unknown which comorbidities and stroke characteristics are associated with elevated cardiac troponin (cTn) levels after stroke. The main objective of this systematic review and meta-analysis is to assess the association of elevated cTn with preexisting cardiovascular comorbidities (eg, coronary artery disease, heart failure and structural heart disease), specific stroke characteristics (eg, infarct/haemorrhage size, stroke severity, insular cortex involvement) and renal failure after ischaemic stroke (IS) or intracranial haemorrhage (ICH). The secondary objective is to evaluate the association of elevated cTn with stroke recurrence and death.Methods and analysisWe will include all cross-sectional, case–control, cohort studies and clinical trials involving IS and ICH adult patients (≥18 years), published between 1 January 1990 and 31 December 2020 in English or Spanish, reporting the proportion with elevated cTn. We will search PubMed, EMBASE and Web of Science by applying predefined search terms. Two reviewers will independently screen titles and abstracts, retrieve full texts, extract the data in a predesigned form, and assess the risk of bias. We will apply random-effects or fixed-effects meta-analyses to estimate the association between cardiovascular comorbidities, stroke characteristics and renal failure with cTn elevation. We will report results as risk ratios or ORs. We will perform sensitivity analyses for subtypes of cTn (cTn-I and cTn-T), regular versus high-sensitivity assays, and type of stroke (IS vs ICH). We will estimate heterogeneity by using t2 Q and I2 measures. We will use funnel plots, Rosenthal’s Fail-Safe N, Duval and Tweedie’s trim and fill procedure, and Egger’s regression intercept to assess publication bias.Ethics and disseminationThis review will be based on published data and does therefore not require ethical clearance. The results will be published in peer-reviewed journals.PROSPERO registration numberCRD42020203126.

IntroductionThe underlying pathophysiology of atrial fibrillation (AF) detected after stroke (AFDAS) is relatively unknown. Preliminary evidence suggests AFDAS has a lower prevalence of cardiovascular comorbidities and higher incidence of insular cortex involvement than AF known to exist before stroke occurrence (KAF). This favours a neurogenic AF substrate (autonomic dysregulation) in which the presence of underlying heart disease is not necessary for AF to occur. The main objective of this systematic review and meta-analysis is to compare the prevalence of cardiovascular comorbidities and echocardiographic abnormalities in patients with AFDAS, KAF and no AF (NAF). Secondary objectives are to compare the proportion with insular cortex involvement, stroke recurrence and death in the three rhythm groups.Methods and analysisWe will perform a systematic review including cross-sectional, case–control, cohort studies and clinical trials involving ≥18 years patients, with ischaemic stroke or transient ischaemic attack published between inception and 31 December 2020 in any language, and reporting the proportion of patients with AFDAS, KAF and NAF. We will search PubMed, EMBASE and Scopus by applying predefined search terms. Two reviewers will independently screen titles and abstracts and retrieve full texts, extract data in a predesigned form, and assess the risk of bias. We will perform a meta-analysis of all included studies and we will report the results of the main outcome as proportions. We will report results of secondary outcomes as risk ORs. We will estimate heterogeneity across studies by using t2, Q and I2 measures. We will use funnel plots, Rosenthal’s Fail-Safe N and Egger’s regression intercept to assess publication bias.Ethics and disseminationThis study will be based on published data and does therefore not require ethical clearance. The results will be published in peer-reviewed journals.PROSPERO registration numberCRD42020202622.

Eastern Sicily is characterised by fast tectonic uplift, intricate GPS-derived velocity fields, and significant seismic activity. Mount Etna, the largest subaerial active volcano in Europe, dominates the landscape, influencing the development of large-scale instability processes on the facing continental margin. South of Etna, the Malta Escarpment discloses crustal thinning, with active tectonics, extensional faults, and half grabens. Indications of active tectonics extend to northern sectors, suggesting a lithospheric tear and interaction with the Calabria-Peloritani uplift. This area has been affected by historical seismicity, with the 1693 earthquake triggering tsunami waves up to 15m high. Offshore seismic events, including the one in 1908, induced slope failures and turbidity currents on the Ionian abyssal plain, witnessed by several breaks in submarine cables. The continental margins of this region are generally characterized by narrow shelves and tectonically-controlled steep slopes, which are susceptible to different mass-wasting processes.

Globally, up to 1·5 million individuals with ischaemic stroke or transient ischaemic attack can be newly diagnosed with atrial fibrillation per year. In the past decade, evidence has accumulated supporting the notion that atrial fibrillation first detected after a stroke or transient ischaemic attack differs from atrial fibrillation known before the occurrence of as stroke. Atrial fibrillation detected after stroke is associated with a lower prevalence of risk factors, cardiovascular comorbidities, and atrial cardiomyopathy than atrial fibrillation known before stroke occurrence. These differences might explain why it is associated with a lower risk of recurrence of ischaemic stroke than known atrial fibrillation. Patients with ischaemic stroke or transient ischaemic attack can be classified in three categories: no atrial fibrillation, known atrial fibrillation before stroke occurrence, and atrial fibrillation detected after stroke. This classification could harmonise future research in the field and help to understand the role of prolonged cardiac monitoring for secondary stroke prevention with application of a personalised risk-based approach to the selection of patients for anticoagulation.

[...]we performed a meta-analysis in which we assessed diagnostic yields of different monitoring methods in the context of standardized phases of AF screening accounting for these factors and we found that, through a sequence of monitoring strategies, AF can be detected in up to 23.7% (95% CI 17.2 to 31.0) of patients with stroke or transient ischemic attack without previously known AF.2 In their recent study, Choe et al3 propose 12 months of monitoring by implantable loop recorders (ILR) after ischemic stroke as the gold standard for the detection of poststroke AF.