Acute Hemorrhagic Leukoencephalitis with Concurrent Retinal Vasculitis in an Elderly Japanese Patient: A Case Report.

A 68-year-old Japanese man developed a fever, headache, hiccups, and altered consciousness. Brain magnetic resonance imaging (MRI) revealed a hemorrhagic lesion in the right temporal lobe and multiple high-intensity white matter lesions. A brain biopsy showed pathological findings consistent with acute disseminated encephalomyelitis (ADEM), suggesting a diagnosis of acute hemorrhagic leukoencephalitis (AHLE), an aggressive ADEM variant. The patient also developed myodesopsia and was diagnosed with retinal vasculitis, likely due to a hyperimmune state caused by AHLE. Corticosteroids enabled full recovery. Although AHLE is uncommon in elderly individuals, clinicians should be aware of its occurrence in this patient subgroup and recognize potential retinal manifestations associated with AHLE.

Carotid Artery Stenting Using Stent-in-Stent Technique with a Closed-Cell Stent and a Dual-Layer Micromesh Stent: A Case Report.

Objective: Recent studies evaluating plaque protrusion at carotid artery stenting (CAS) using optical coherence tomography showed not a few cases of plaque protrusion when using double-layer micromesh stents. We report a case of symptomatic internal carotid artery (ICA) stenosis with at-risk unstable plaques in which CAS was successfully performed using a stent-in-stent technique by the combined use of a closed-cell stent and a dual-layer micromesh stent. Case Presentation: An 87-year-old Japanese man with dysarthria and right hemiparesis was diagnosed with atheromatous cerebral embolism caused by severe left ICA stenosis on MRI and DSA. MRI with T1-weighted black blood methods showed high intensities in the plaques of the left ICA, suggesting unstable plaque characteristics with intraplaque hemorrhage components. On day 20, CAS was performed. After the pre-stent dilation under proximal and distal protection, a Carotid WALLSTENT was placed to cover the stenotic lesion. Then, a CASPER Rx was placed from the proximal left ICA to the common carotid artery to cover the Carotid WALLSTENT. Although visible plaque debris was recognized in the aspirated blood, the debris became invisible after aspiration of 1300 mL. Postoperative angiography showed enough dilation of the left ICA, with no plaque protrusion or acute stent thrombosis. The patient had an uneventful postoperative course and was discharged without any neurological sequelae. Conclusion: The present case suggests that the combined stent-in-stent technique using a closed-cell stent and a micromesh stent can be considered as one of the treatment strategies for preventing plaque protrusion and procedural ischemic complications in patients with high-risk carotid plaques.

Treatment of aneurysmal subarachnoid hemorrhage in subacute phase; retrospective comparison of treatment in sub- and hyper-acute phases.

OBJECTIVE: As soon as possible treatment initiation for aneurysmal subarachnoid hemorrhage (aSAH) is recommended. However, some patients require treatment in "subacute" phase of aSAH, defined in this study as "more than one day after the onset". To establish an optimal treatment strategy for these patients, we retrospectively analyzed the clinical experience of treating ruptured aneurysm with either clipping or coiling in subacute phase. METHODS: Patients treated for aSAH between 2015 and 2021were analyzed. Patients were divided into the hyperacute phase (within 24 h) and subacute phase (later than 24 h) groups. The subacute group was analyzed to determine whether the selected procedure and its timing affected postoperative course and clinical outcomes. In addition, we conducted a multivariate logistic regression analysis to determine the independent factors that affect clinical outcomes. RESULTS: Of 215 patients, 31 were treated in the subacute phase. While cerebral vasospasm at initial imaging was more frequently observed in subacute group, there was no difference in incidence of postoperative vasospasms. Patients in subacute group seemed to have better clinical outcomes due to the milder severity at the time of treatment initiation. Risk of angiographic vasospasm seemed to be higher in patients treated with clipping than coiling, while no difference was seen in clinical outcomes. Multivariate logistic regression analysis showed that the timing and selected treatment did not significantly affect the clinical outcome or the occurrence of delayed vasospasm. CONCLUSIONS: Treatment of aSAH in the subacute phase may also result in favorable clinical outcomes, similar to patients treated in the hyperacute phase with mild presentation. However, further investigations are required to establish the optimal treatment strategies for such patients.

Clinical characteristics of endovascular treatment for acute ischemic stroke with atherosclerotic etiology: Factors associating its clinical outcome.

OBJECTIVE: Clinical characteristics of endovascular treatment (EVT) for acute ischemic stroke (AIS) secondary to atherosclerosis are not fully delineated. An optimal treatment strategy with considerations of stroke etiology has not yet been established. Here-in, we performed retrospective analysis of EVT for atherosclerotic AIS. METHODS: Data from patients with AIS who underwent EVT between 2017 and 2022 were analyzed. Clinical characteristics, procedural data, and outcomes were assessed. Further analysis was conducted to elucidate the factors associated with clinical outcomes. And data of patients with poor clinical outcomes (mRS, 5 or 6) were evaluated further to determine the primary cause. RESULTS: Among 194 patients who received EVT, 40 (20.6%) were diagnosed with AIS with an atherosclerotic etiology. The rates of successful reperfusion (TICI 2b or 3) and good clinical outcomes (mRS, 0-2) were 95.0% and 45.0%, respectively. No procedure-related complications were noted. Older age (p = 0.007), more severe baseline NIHSS score (p = 0.004), lesion in the posterior circulation (p = 0.025), and recanalization failure (p = 0.027) were more frequently observed in patients with poor clinical outcomes. Brainstem infarction and postprocedural intracerebral hemorrhage were the main reasons for poor clinical outcomes. CONCLUSION: The EVT for atherosclerotic AIS were effective and safe. Older age, more severe NIHSS score, lesions in the posterior circulation, and recanalization failure were the factors associated with poor clinical outcomes. It is important to recognize that these factors may aggravate the clinical response to this promising therapy, even in patient successful recanalization was attained.

Long-term outcome and factors associated with restenosis after combination therapy of balloon angioplasty and stenting for symptomatic intracranial stenosis.

BACKGROUND: The optimal treatment for intracranial artery stenosis (ICAS) has not been established. We retrospectively examined the initial and long-term outcomes associated with restenosis of a combination therapy of balloon angioplasty and stenting for symptomatic atherosclerotic ICAS. METHODS: Consecutive patients who underwent balloon angioplasty and/or stenting for ≥ 70% ICAS between 2006 and 2020 were analyzed. Patients within 48 h of stroke onset were excluded. The following procedures were established as standards at our institution: (1) primary balloon angioplasty alone was initially performed; (2) stenting for insufficient dilatation, recoiling, or dissection was conducted; and (3) stenting was considered for restenosis. Intracranial ischemic and hemorrhagic complications within 30 days after treatment were used to evaluate periprocedural safety. Recurrent ischemic events, restenosis and restenosis related factors were used to be evaluate the long-term outcome. RESULTS: A total of 160 patients were recruited. Initial treatment consisted of balloon angioplasty (n = 101) and stenting (n = 59). Intracranial complications within 30 days after treatment were ischemic in five (3.1%) and hemorrhagic in four patients (2.5%). The incidence of these complication was 3.1% in the stenting group and 2.5% in the balloon angioplasty group. The mean follow-up period was 53.9 months. Restenosis was found in 42 patients (26%). Recurrent ischemic events during follow-up were noted in 14 patients (8.8%), of which six patients had TIA and eight patients had ischemic stroke. Restenosis-associated factors included diabetes, coronary artery disease, percent stenosis after treatment, and balloon angioplasty in logistic univariate analysis. Multivariate Cox regression analysis showed that diabetes (HR: 2.084, CI: 1.039-4.180, p = 0.0386), length of lesion (HR; 1.358, CI: 1.174-1.571, p < 0.0001), and balloon angioplasty (HR: 4.194, CI: 1.083-16.239, p = 0.0379) were independent predictors for restenosis. CONCLUSION: Combination therapy of balloon angioplasty and stenting for symptomatic ICAS had a low perioperative stroke rate and may improve long-term outcome. Balloon angioplasty, diabetes, and length of lesion were significantly associated with restenosis.

[Unique visual symptom of amaurosis fugax: a case report].

We describe an unusual case of a 73-year-old man with amaurosis fugax. He had repeated transient monocular symptoms, one of which features lighting bolt-shaped glittering in the full visual field of the right eye since medical treatment for hypertension and diabetes mellitus started. A few days later, he felt difficulty in speech as well as sensory and motor disturbance in the left upper extremity, which finally brought him to our hospital. An MR scan unveiled subacute infarctions dotted in the right cerebral hemisphere and severe carotid stenosis on the same side with a delayed distal flow. He was hospitalised with diagnosed an ischemic stroke. Despite being treated with antithrombotic agents, he had suffered similar visual symptoms repeatedly and therefore, carotid artery stenting was performed on Day 16 starting from the onset. The right ophthalmic artery and choroidal crescent became depicted angiographically after our surgery had been completed. His visual disturbance has never appeared since then. Consequently, it is suggested that the optic disorders were attributed to a hemodynamically precarious state in the area of the ophthalmic artery.

Outcomes of Balloon Angioplasty and Stenting for Symptomatic Intracranial Atherosclerotic Stenosis at a High Volume Center.

PURPOSE: This study investigated the periprocedural complication rates, long-term outcome, and restenosis of endovascular treatment for intracranial atherosclerotic stenosis (ICS) at our hospital. METHODS: We retrospectively analyzed the clinical data of 217 patients comprising 256 endovascular treatments for high-grade symptomatic ICS. The lesion was located in the internal carotid artery in 77, the middle cerebral artery in 111, the basilar artery in 29, and the vertebral artery in 39. Patients were divided into two groups, before (early-phase group, 1999-2013) and after approval of Wingspan (late-phase group, 2014-2017). RESULTS: In the early-phase group (n = 163), 157 lesions were treated by balloon angioplasty and 31 (17%) by coronary stenting. In the late-phase group (n = 54), 33 lesions were treated by balloon angioplasty and 35 (52%) by Wingspan stenting. Overall technical success rates were 96% in the balloon angioplasty and 100% in stenting groups. The 30-day rate of stroke, TIA, and death were 4.8% in the early-phase group and 4.4% in the late-phase group. There was one minor stroke and two TIAs during the follow-up period in the late-phase group. CONCLUSIONS: Endovascular treatment for symptomatic ICS in this study appeared to be safe and effective if patients are properly selected. However, future well-designed randomized trials with different techniques and modified patients selection criteria are certainly warranted.

Preprocedural Carotid Plaque Echolucency as a Predictor of In-Stent Intimal Restenosis after Carotid Artery Stenting.

OBJECTIVES: In-stent intimal restenosis (ISR) caused by neointimal hyperplasia can develop <24 months after carotid artery stenting (CAS). The utility of plaque imaging by carotid ultrasonography (US) or magnetic resonance imaging (MRI) has been investigated for the prediction of ipsilateral stroke. We aimed to investigate whether these imaging techniques are useful for detecting carotid plaques prone to ISR. MATERIALS AND METHODS: We examined 133 patients (mean age of 72.1 ± 8.4 years old) that received CAS at a single hospital from 2014 to 2018. A pre-CAS carotid plaque evaluation was performed by carotid angiography, duplex carotid US, and black-blood carotid artery MRI (BB-MRI). The mean stenosis rate was 71.0 ± 12.3% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methods. Follow-up carotid angiography was performed 6 months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosed based on the NASCET criteria. The selection of the stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis. RESULTS: Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than two stents were deployed. Univariate logistic regression analyses demonstrated echolucent lesion, floating plaque, complete occlusive or pseudo-occlusive lesion, and closed-cell stent use as significantly associated with ISR (>50%). Multivariate logistic regression analysis demonstrated that echolucent lesion (OR 4.667, 95% CI 1.849-11.779) and closed-cell stent use (OR .378, 95% CI .148-.968) were significantly associated with ISR. CONCLUSIONS: Preprocedural plaque characterization by carotid US appeared to be useful to predict ISR 6 months after CAS.

Effects of Aspiration and Re-transfusion Technique with Carotid Artery Stenting.

Objective: Embolic stroke is the most serious complication after carotid artery stenting (CAS). The incidence rate of embolic stroke is reduced by the use of embolic protection devices (EPDs); however, there is no consensus on which EPD is the most effective. The aspiration and re-transfusion technique (ART) with CAS under distal balloon protection was adopted at our center to reduce the incidence of embolic complications. This retrospective study investigated the effects of ART. Methods: From November 2010, 243 consecutive patients treated by CAS under distal balloon protection were included. ART was performed on 202 patients (ART group) and the other 40 patients only received distal balloon protection (non-ART group). In ART, the blood from the aspiration catheter was continuously returned through a filter to the femoral vein. The amount of debris was assessed intermittently using a small blood sample and the rest was returned. We investigated the diffusion-weighted imaging (DWI)-positive rate and symptomatic ischemic stroke one day after CAS. Results: Compared with the non-ART group, the incidence of DWI-positive lesions (22.7% vs 37.5%, P = 0.07) and frequency of symptomatic ischemic stroke (0.9% vs 5.0%, P = 0.12) were reduced in the ART group. The hemoglobin reduction rate was significantly reduced by ART (11.1% vs 14.9%, P <0.01). In the ART group, the frequency of multiple lesions (more than 5) and large lesions (more than 10 mm) was lower than that in the non-ART group (P <0.01, P = 0.14). Conclusion: CAS under distal balloon protection with ART was effective at reducing the incidence of DWI-positive lesions and may be useful to reduce the incidence of symptomatic ischemic stroke.

Contrast-enhanced carotid ultrasonography and MRI plaque imaging to identify patients developing in-stent intimal hyperplasia after carotid artery stenting.

AIM: In-stent intimal hyperplasia (ISH) observed after carotid artery stenting (CAS) may lead to in-stent restenosis. We aimed to investigate whether contrast-enhanced carotid ultrasonography (CEUS) and magnetic resonance imaging (MRI) plaque imaging prior to CAS are predictive for ISH at 6 months after CAS. MATERIAL AND METHOD: A total of 14 patients (13 men, 1 woman; mean age, 74.2 years) were prospectively enrolled. CEUS and MRI plaque imaging were performed before CAS. ISH was diagnosed by carotid angiography at 6 months after CAS. Patients were divided into two groups based on the thicknessof ISH and age, risk factors, enhancement in CEUS, MRI plaque imaging and number of replaced stents were compared between groups. RESULTS: Carotid angiography at 6 months after CAS revealed ISH in 10 patients. Plaque enhancement on CEUS was observed in 6 patients, all of whom showed ISH. A significant association was seen between plaque enhancement on CEUS and development of ISH (χ2 test, CEUS enhancement (+) 100% vs. CEUS enhancement (-) 50% p=0.040). Carotid plaques in 12 patients were diagnosed as unstable by MRI plaque imaging. Presence of ISH was significantly associated with unstable plaque diagnosed by MRI plaque imaging (χ2 test, unstable 83% vs. stable 0%; p=0.016). CONCLUSION: Carotid plaque MRI and CEUS may be useful to predict ISH after CAS.

Contrast-enhanced transoral carotid ultrasonography for the evaluation of plaque protrusion after carotid artery stenting.

A 67 year-old man was admitted to our hospital because of mild left hemiparesis and was diagnosed with cerebral infarction caused by right internal carotid artery stenosis. He was treated with dual antiplatelet therapy and scheduled for carotid artery stenting 14 days after onset. The preoperative right carotid angiogram showed 60% stenosis by the NASCET criteria, with an ulcer. The postoperative angiogram suggested protrusion in the stent, which could not be seen on conventional carotid ultrasonography because of its high location. On transoral carotid ultrasonography, clear delineation of the lesion was not possible due to color blurs. Contrast-enhanced transoral carotid ultrasonography (CETOCU) clearly demonstrated the protrusion and delineated the lumen within the stent.

Long-Term Outcome of Balloon Angioplasty Without Stenting for Symptomatic Middle Cerebral Artery Stenosis.

PURPOSE: A recent randomized controlled trial demonstrated that aggressive medical management was superior to angioplasty with stenting for intracranial stenosis. The purpose of this study was to assess initial and long-term outcomes of balloon angioplasty without stenting for symptomatic middle cerebral artery (MCA) stenosis. METHODS: We retrospectively analyzed the clinical data of 72 patients (mean age, 58.9 years old) with 84 balloon angioplasties without stenting for high-grade (>70%) atherosclerotic stenosis of the main trunk of the MCA. All patients had experienced recurrent transient ischemic attack or minor stroke resistant to medical treatment. We assessed perioperative and long-term outcomes such as restenosis and the recurrence of strokes. The follow-up period was a median of 63 months (range, 6-171 months). RESULTS: Balloon angioplasty was successful in 97% of procedures. During the 30-day perioperative period, a total of 3 patients suffered from stroke (4.2%) without death. A total of 23 (31.9%) patients had restenosis at a time point that varied from 6 to 111 months. Diabetes mellitus (DM) was noted significantly more often in the restenosis group (39%) than in the nonrestenosis group (13%). Multivariate logistic regression analysis revealed DM (odds ratio, 4.84; 95% confidence interval, 1.196-19.62; P = .027) as an independent predictor of restenosis. Restenosis and DM were indicated as independent predictors of the recurrence of ischemic stroke and transient ischemic attack. CONCLUSIONS: Balloon angioplasty without stenting for symptomatic MCA stenosis can be performed with a high successful rate and a low risk of complications. Long-term outcome data suggest that this procedure reduces the risk of further strokes.

Effects of Pretreatment Cerebral Blood Volume and Time to Recanalization on Clinical Outcomes in Endovascular Thrombectomy for Acute Ischemic Stroke.

BACKGROUND: Faster time to recanalization leads to better clinical outcomes in patients treated with endovascular thrombectomy. Whether the association between time to recanalization and clinical outcomes depends on cerebral blood volume (CBV) obtained from pretreatment computed tomography (CT) perfusion (CTP) imaging was investigated. METHODS: In consecutive patients with acute ischemic stroke who achieved recanalization by endovascular thrombectomy for intracranial internal carotid artery or M1 occlusion, the effects on clinical outcome of time to recanalization and the relative CBV value (rCBV) assessed by pretreatment CTP were evaluated. The patient population was divided into 2 groups according to rCBV: normal rCBV group (rCBV ≥ .9) and low rCBV group (rCBV < .9). In each group, time to recanalization was compared between the good and the poor clinical outcome groups. RESULTS: Sixty-four patients were eligible for this study. Twenty-six patients (40.6%) achieved good clinical outcomes. In the normal rCBV group, no association was found between clinical outcome and time to recanalization. In the low rCBV group, time to recanalization from CTP (101 minutes versus 136 minutes, P = .040) was significantly shorter in the good clinical outcome group. On binary logistic regression modeling, CTP to recanalization time (odds ratio 1.035 [1.004-1.067], P = .025) was an independent predictor of good clinical outcome only in the low rCBV group. CONCLUSIONS: The association between time to recanalization and clinical outcomes depends on rCBV obtained from pretreatment CTP. Time to recanalization is more important for good clinical outcomes in patients with low rCBV than in patients with normal rCBV.

A case in which contrast-enhanced transoral carotid ultrasonography was useful for pre- and post-procedural evaluation in carotid artery stenting.

Contrast-enhanced transoral carotid ultrasonography (CETOCU) is a novel examination modality that is superior to other modalities in the cases of pseudo-occlusion with severe arteriosclerotic stenosis of the distal internal carotid artery (ICA), and is also useful for noninvasively evaluating changes over time in the vessel distal to the stent following carotid artery stenting (CAS). We report a case of a patient who we evaluated with CETOCU for a pseudo-occlusive ICA before and after CAS.

Contrast-enhanced transoral carotid ultrasonography for the evaluation of a long stenotic lesion in the internal carotid artery.

Contrast-enhanced transoral carotid ultrasonography (CETOCU) is a novel modality for imaging the distal extracranial internal carotid artery, which is not possible with conventional carotid ultrasonography. We present a representative case that demonstrates the usefulness of CETOCU.

Prediction of cerebral hyperperfusion syndrome after carotid artery stenting by CT perfusion imaging with acetazolamide challenge.

INTRODUCTION: Cerebral hyperperfusion syndrome (HPS) is an uncommon but serious complication of carotid artery stenting (CAS). The purpose of this study was to investigate the efficacy of CT perfusion imaging (CTP) with acetazolamide challenge to identify patients at risk for HPS after CAS. METHODS: We retrospectively analyzed 113 patients who underwent CTP with rest and acetazolamide challenge before CAS. CTP maps were assessed for absolute and relative cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and change of each parameter before and after acetazolamide challenge. Patients were divided into two groups according to the HPS after the CAS. Receiver-operating characteristic (ROC) curve analysis was performed to determine the most accurate CTP parameter for the prediction of HPS. RESULTS: Nine of 113 patients had HPS. There were significant differences for absolute and relative values of resting CBF (p = 0.001 and p = 0.026), resting MTT (p < 0.001 and p = 0.004), post-acetazolamide CBF (p < 0.001 and p = 0.001), post-acetazolamide MTT (p < 0.001 and p = 0.002), and % changes of CBF (p = 0.009) between the HPS and non-HPS groups. ROC curve analysis showed that the CTP parameters with the maximal area under the receiver-operating characteristic curve (AUC) for HPS was the absolute value of post-acetazolamide MTT (AUC 0.909) and the absolute value of resting MTT (AUC 0.896). CONCLUSION: Pretreatment CTP with acetazolamide challenge could identify patients at risk for HPS after CAS. Although the CTP parameter that most accurately identified patients at risk for HPS was the absolute value of post-acetazolamide MTT, resting MTT was sufficiently accurate.

Assessment of factors associated with prominent changes in blood pressure during an early mobilization protocol for patients with acute ischemic stroke after mechanical thrombectomy.

OBJECTIVE: To assess factors associated with changes in blood pressure during early mobilization protocol for patients with acute ischemic stroke who were treated with mechanical thrombectomy. DESIGN: Retrospective observational study. METHOD: We analyzed patients with acute ischemic stroke who were treated with mechanical thrombectomy (MT group, n=60) and patients who received conservative medical management (control group, n=60) matched by age and National Institute Health of Stroke Score at admission from April 2009 to July 2014. The proportion of patients with prominent blood pressure change during an early mobilization protocol was compared between the MT group and control group. Factors associated with prominent blood pressure change were also analyzed using multivariable logistic regression analysis. RESULT: The deviation in blood pressure response was much more significant in the MT than control group (13.3 vs. 1.7%, p<0.016). Logistic regression analysis showed the interval from admission to being able to sit in a wheelchair associated with prominent changes in blood pressure (odds ratio, 1.604; 95% confidence interval, 1.196-2.150; p<0.002). CONCLUSION: Our results showed that prominent changes in blood pressure during an early mobilization protocol can occur easily in patients with acute ischemic stroke after mechanical thrombectomy.

[Education for stroke neurologists in neuroendovascular revascularization therapy of acute ischemic stroke].

Outcome of large cerebral artery occlusions in intravenous recombinant tissue plasminogen activator failed and ineligible patients has been improved by Mechanical clot retrievers. The key words of revascularization therapies are improvement of reperfusion rate and shortening of reperfusion time. Stroke neurologists have to acquire skill of neuroendovascular therapy technique, because acute stroke patients are examined first by stroke neurologists. However acquisition of neuroendovascular skills are not easy for stroke neurologists. It is important that we establish the educational systems of neuroendovascular therapy for stroke neurologists.

Association between paroxysmal atrial fibrillation and the left atrial appendage ejection fraction during sinus rhythm in the acute stage of stroke: a transesophageal echocardiographic study.

BACKGROUND: This study aimed to investigate whether left atrial appendage (LAA) dysfunction evaluated by transesophageal echocardiography (TEE) during sinus rhythm is predictable of paroxysmal atrial fibrillation (PAF) as an embolic source in the acute stage of stroke. METHODS AND RESULTS: We measured and analyzed LAA flow velocity (LAA-FV) and LAA ejection fraction (LAA-EF) in 300 acute ischemic stroke patients by TEE. We divided the acute ischemic stroke patients into 3 groups. The atrial fibrillation (AF) group (n=58) comprised patients whose TEE was performed during AF rhythm. The PAF group (n=42) comprised patients with a history of AF but with normal sinus rhythm when TEE was performed. The normal sinus (sinus) group (n=200) did not have any history of AF. We found that mean LAA-FV and LAA-EF values in the PAF group were significantly lower than those in the sinus group (P<.001). The diagnostic accuracy of LAA-FV for the diagnosis of PAF calculated as the area under receiver operating characteristic curves was low (.582, 95% confidence interval [CI]=.498-.665) but that of LAA-EF was modest (.721, 95% CI=.653-.789), with an optimal cutoff point of 49.1%. CONCLUSIONS: LAA dysfunction as determined by TEE (LAA-EF<49.1%) in the acute stage of stroke is predictive of PAF with moderate accuracy. Long-term electrocardiographic monitoring is recommended for cryptogenic stroke patients with LAA dysfunction.