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.