Response to Letter by D’Anna et al Regarding Article, “Long-Term Mortality in Patients With Stroke of Undetermined Etiology”

We appreciate the interest of Dr D’Anna and colleagues in our recently published article.1 Dr D’Anna and colleagues raised a question about the definition of incomplete evaluation. They argued that echocardiography should be a routine and essential evaluation for stroke patients. Dr D’Anna and colleagues mentioned that Adams et al2 recommended not to classify study patients in a defined category (the cardioembolic one in this case) without performing essential diagnostic tests. However, we cannot find any description that a patient should not be classified in a defined category without echocardiography. Dr Adams stated that, “Diagnoses are based on clinical features and on data collected by tests such as brain imaging (CT/MRI), cardiac imaging (echocardiography, etc.), duplex imaging of extracranial arteries, arteriography, and laboratory assessments for a prothrombotic state. we cannot require that all patients have all diagnostic tests To compensate for this situation, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) system allows for a ‘possible’ stroke subtype diagnosis.” Although we agree with Dr D’Anna and colleagues that physicians should make every effort to find potential causes of stroke, cardiac imagings may not be performed because of several …