Background and purpose: There are many cases of cerebral infarction of unknown etiology in which the embolic sources cannot be identified including atrial fibrillation despite achievement of complete revascularization after thrombectomy. Method: An analysis was conducted for 556 consecutive cases of patients who were hospitalized for cerebral infarction to determine the significance of accurate classification of disease type and investigation into causes of cerebral infarction of unknown cause. Result: According to the Trials of Org 10172 in Acute Stroke Treatment (TOAST) classification, cerebral infarction of other/unknown etiology was observed in 94 cases, of which 22 cases were found to have causes by additional workup. Implantable cardiac monitors were inserted in 15 of 76 cases of cryptogenic cerebral infarction, of which 4 cases (26%) showed detection of paroxysmal atrial fibrillation (PAF) during observation period (223–384 days). Conclusion: Brain natriuretic peptide (BNP) measurement, abdomen-pelvic computed tomography (CT), cardiac monitoring for 1 week, and implantable cardiac monitors (ICM) were useful for the classification of disease type and detection of cryptogenic atrial fibrillation.

The patient is a 41-year-old man, who underwent emergency surgery for Stanford type A AAD. Immediately after CPB was commenced via the right subclavian artery, NIRO dropped and blood flow in the left common carotid artery disappeared. Switching to the left femoral artery cannulation resulted in improvement in left common carotid artery blood flow and NIRO. The patient underwent total arch replacement surgery and was discharged on postoperative day 20 with no neurological sequelae. We report this case as an example of trouble-shooting for malperfusion syndrome during acute aortic dissection surgery.