2 | CASE REPORT
A 74-year-old woman with sudden right hemiparesis was admitted to our hospital with a diagnosis of acute ischemic stroke. She was treated with intravenous tissue plasminogen activator and thrombectomy in the left M2 segment of the middle cerebral artery, after which her symptoms improved remarkably (modified Rankin scale 0). The patient met the criteria of ESUS and a thorough examination was performed to determine the cause. Transesophageal echocardiography showed minor plaque formation in the aortic arch (a potential cause of aortogenic embolism) and absence of a patent foramen ovale (a potential cause of paradoxical embolism). Although CPAF was not identified by telemetry at admission, it was suspected and we decided to implant an ICM device. However, SIT was observed by chest X-ray. Thus, the ICM device was implanted into the right chest in a symmetrical position (Figure 1).
We used fluoroscopy to locate the heart. An ICM (BIOMONITOR IIITM; Biotronik, Berlin, Germany) was then inserted into the right margin of the 3rd to 6th intercostal sternum along the long axis shadow of the heart using the provided tools. The procedure duration was 5 min and the fluoroscopy time was 15 s. There were no complications during the procedure.
AF was successfully detected at 28 days after ICM insertion (Figure 2A). Figure 2B shows the sudden drop rate alarm, the feature unique to the BIOMONITOR IIIā„¢ device. It shows the moment when rhythm changed from AF to sinus rhythm. P wave can be clearly seen during the sinus rhythm. AF was then detected on a number of occasions.
Aspirin was used initially for prevention of recurrent ischemic stroke. However, we changed to edoxaban after CPAF was detected.