Journal of Clinical and Scientific Research

: 2019  |  Volume : 8  |  Issue : 4  |  Page : 215-

Authors' response

Deshmukh Dnyaneswar Shivajirao, K Josehva Caleb, Bimal Prasad Padhy, H Radhakrishna, Vishanji Karani 
 Department of Neurology, CARE Hospitals, Hyderabad, Telangana, India

Correspondence Address:
H Radhakrishna
Consultant, 8-3-224, Vora Towers, Yousufguda Road, Madhura Nagar, Hyderabad - 500 038, Telangana

How to cite this article:
Shivajirao DD, Caleb K J, Padhy BP, Radhakrishna H, Karani V. Authors' response.J Clin Sci Res 2019;8:215-215

How to cite this URL:
Shivajirao DD, Caleb K J, Padhy BP, Radhakrishna H, Karani V. Authors' response. J Clin Sci Res [serial online] 2019 [cited 2020 Nov 28 ];8:215-215
Available from:

Full Text

We thank the authors of the Correspondence[1] for their interest in the subject. I must also thank them for providing the useful mnemonic “TRANESOPGAGEAL” and for remembering the facts related to transoesophageal echocardiography (TEE). However, I would like to highlight a few points of interest.

Cardioembolic source does not have a high association with posterior fossa infarcts. In fact, involvement of multiple vascular territories is more common with embolic mechanism. Large infarcts in the supratentorial compartment especially anterior temporal and occipital areas are commonly cardioembolic. When compared to a cardiac source, the emboli from atheromatous aorta are much smaller and affect one hemisphere only.

A patent foramen (PFO) ovale alone may not be an important embolic source compared to the one associated with atrial septal aneurysm, has vegetations along the edge of PFO or has right-to-left shunt. In our series,[2] no single case satisfied these criteria, even though there were 7 (1.2%) patients with PFO.

TEE was useful in identifying an embolic source in 10% of our patients and in initiating treatment with anticoagulants.[2] It was also useful in identifying complex plaques in the aortic arch which required dual antiplatelet therapy. Hence, it was worthwhile doing this test among stroke patients, particularly where the pathogenetic mechanism is not clear.

TEE is definitely useful in evaluating the mechanism in a cryptogenic stroke or embolic stroke of undetermined source.

Aortic atheromatous disease does not correlate directly with the severity of carotid atheromatous process. A severe disease (Grade IV) of aortic arch atheroma may not be associated with severe carotid artery disease.

Brain natriuretic peptide (BNP) estimation is not much useful in identifying stroke mechanism. Moreover, in the elderly patient with ischaemic stroke, BNP can be falsely elevated due to coexistent renal or cardiac disease or due to high blood pressure itself.[3] Plasma BNP level can be a short term marker of severity in a haemorrhagic stroke to predict mortality.[4]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Rissardo JP, Fornari Caprara AL. Transoesophageal echocardiography and stroke: An overview. J Clin Sci Res 2019;8:45-6.
2Shivaji Rao DD, Cabel KJ, Padhy BP, Radhakrishana H, Karani V. Usefulness of transoesophageal echocardiography in ischaemic stroke. J Clin Sci Res 2019;8:47.
3Nakagawa K, Yamaguchi T, Seida M, Yamada S, Imae S, Tanaka Y, et al. Plasma concentrations of brain natriuretic peptide in patients with acute ischemic stroke. Cerebrovasc Dis 2005;19:157-64.
4Goya Y, Shibazaki K, Sakai K, Aoki J, Uemura J, Saji N, et al. Brain natriuretic peptide upon admission as a biological marker of short-term mortality after intracerebral hemorrhage. Eur Neurol 2014;71:203-7.