1 | INTRODUCTION
Approximately 25% of all ischemic strokes are
cryptogenic.1 Of these, a clinical entity of embolic
stroke of undetermined source (ESUS) was recently established. ESUS is
defined as a non-lacunar brain infarction without a proximal arterial
steno-occlusive lesion or cardioembolic source. Thus, the pathogenesis
of ESUS is varied and includes covert paroxysmal atrial fibrillation
(CPAF), aorto/arteriogenic embolism, paradoxical embolism, and
cancer-related embolism. CPAF is a major cause of
ESUS.1 However, detecting CPAF during hospitalization
is often difficult, even with continuous electrocardiographic (ECG)
monitoring.
Insertable cardiac monitors (ICMs) combined with remote monitoring have
been used in ESUS patients with mild symptoms (modified Rankin scale
from 0 to 2) to detect CPAF and to prevent recurrent ischemic stroke.
ICMs are usually implanted into the left margin of the sternum, from the
3rd to the 6th intercostal space
parallel to the cardiac shadow, using the provided insertion
tools.2 Because
these tools are very simple and easy to use, complications of ICM (e.g.,
bleeding or infection) are very rare. However, to our knowledge there
are no reports of ICM implantation in patients with situs inversus
totalis (SIT). Herein, we describe ICM implantation for detection of
CPAF as an embolic source of ischemic stroke in a patient with SIT.