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Echocardiographic characteristics of hypertensive patients affected by transient ischemic attack: a cross-sectional study. ACTA ACUST UNITED AC 2017; 11:213-219. [PMID: 28595718 DOI: 10.1016/j.jash.2017.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/07/2017] [Accepted: 02/12/2017] [Indexed: 01/19/2023]
Abstract
Atrial septal aneurysm (ASA), common finding in normal echocardiographies, has been described in association with transient ischemic attacks (TIAs)/strokes, as well as hypertensive end-organ damage such as left ventricular (LV) hypertrophy. Aim of this study was to assess if a cluster of echocardiographic aspects could characterize TIA hypertensive patients. A cross-sectional study on patients with history of TIA, referring to a Hypertension Center echolab, has been performed. A total of 5223 patients received transthoracic echocardiography. TIA patients were 292 (5.6%). A total of 102 age/sex-matched patients without TIA have been collected as controls. The main characteristic of TIA patients resulted ASA/bulging (B) (TIA 61%, controls 6%, P = .0001). Other aspect was LV concentric remodeling (TIA 32.3%, controls 20.8%, P = .029) and mitral flow aspects of diastolic dysfunction. After adjustment for age and hypertension, ASA/B (odds ratio [OR] = 62.4, 95% confidence interval [CI]: 13.6-73.9, P < .001), followed by LV concentric hypertrophy (OR = 2.1, 95% CI: 1.1-4.3, P = .043), was associated with a positive TIA history. A binary logistic regression performed in ASA/B patients, identified relative wall thickness as the strongest TIA-associated aspect (OR = 53.4, 95% CI: 11.9-74.18, P = .001). ASA/B, common finds in general population, could carry a significant incremental possibility of association with TIA when concentric geometry, frequent hypertensive aspect, is present as well.
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Layoun ME, Aboulhosn JA, Tobis JM. Potential Role of Patent Foramen Ovale in Exacerbating Hypoxemia in Chronic Pulmonary Disease. Tex Heart Inst J 2017; 44:189-197. [PMID: 28761399 DOI: 10.14503/thij-16-6027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Patent foramen ovale has been associated with multiple pulmonary diseases, such as pulmonary hypertension, platypnea-orthodeoxia syndrome, and chronic obstructive pulmonary disease. A connection between patent foramen ovale and chronic pulmonary disease was first described more than 2 decades ago in case reports associating patent foramen ovale with more severe hypoxemia than that expected based on the severity of the primary pulmonary disease. It has been suggested that patients with both chronic pulmonary disease and patent foramen ovale are subject to severe hypoxemia because of the right-to-left shunt. Furthermore, investigators have reported improved systemic oxygenation after patent foramen ovale closure in some patients with chronic pulmonary disease. This review focuses on the association between chronic pulmonary disease and patent foramen ovale and on the dynamics of a right-to-left shunt, and it considers the potential benefit of patent foramen ovale closure in patients who have hypoxemia that is excessive in relation to the degree of their pulmonary disease.
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MESH Headings
- Coronary Circulation
- Disease Progression
- Echocardiography, Doppler, Color
- Echocardiography, Three-Dimensional
- Foramen Ovale, Patent/complications
- Foramen Ovale, Patent/diagnostic imaging
- Foramen Ovale, Patent/physiopathology
- Foramen Ovale, Patent/therapy
- Hemodynamics
- Humans
- Hypoxia/diagnosis
- Hypoxia/etiology
- Hypoxia/physiopathology
- Hypoxia/therapy
- Male
- Middle Aged
- Pulmonary Circulation
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Risk Factors
- Severity of Illness Index
- Treatment Outcome
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Abstract
Cardiac embolism accounts for an increasing proportion of ischemic strokes and might multiply several-fold during the next decades. However, research points to several potential strategies to stem this expected rise in cardioembolic stroke. First, although one-third of strokes are of unclear cause, it is increasingly accepted that many of these cryptogenic strokes arise from a distant embolism rather than in situ cerebrovascular disease, leading to the recent formulation of embolic stroke of undetermined source as a distinct target for investigation. Second, recent clinical trials have indicated that embolic stroke of undetermined source may often stem from subclinical atrial fibrillation, which can be diagnosed with prolonged heart rhythm monitoring. Third, emerging evidence indicates that a thrombogenic atrial substrate can lead to atrial thromboembolism even in the absence of atrial fibrillation. Such an atrial cardiomyopathy may explain many cases of embolic stroke of undetermined source, and oral anticoagulant drugs may prove to reduce stroke risk from atrial cardiomyopathy given its parallels to atrial fibrillation. Non-vitamin K antagonist oral anticoagulant drugs have recently expanded therapeutic options for preventing cardioembolic stroke and are currently being tested for stroke prevention in patients with embolic stroke of undetermined source, including specifically those with atrial cardiomyopathy. Fourth, increasing appreciation of thrombogenic atrial substrate and the common coexistence of cardiac and extracardiac stroke risk factors suggest benefits from global vascular risk factor management in addition to anticoagulation. Finally, improved imaging of ventricular thrombus plus the availability of non-vitamin K antagonist oral anticoagulant drugs may lead to better prevention of stroke from acute myocardial infarction and heart failure.
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Affiliation(s)
- Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (H.K.) and Department of Neurology, Weill Cornell Medicine, New York, NY (H.K.); and Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.).
| | - Jeff S Healey
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (H.K.) and Department of Neurology, Weill Cornell Medicine, New York, NY (H.K.); and Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
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54
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Dalen JE, Alpert JS. Silent Atrial Fibrillation and Cryptogenic Strokes. Am J Med 2017; 130:264-267. [PMID: 27756556 DOI: 10.1016/j.amjmed.2016.09.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 09/19/2016] [Indexed: 01/26/2023]
Abstract
A new suspected cause of cryptic strokes is "silent atrial fibrillation." Pacemakers and other implanted devices allow continuous recording of cardiac rhythm for months or years. They have discovered that short periods of atrial fibrillation lasting minutes or hours are frequent and usually are asymptomatic. A meta-analysis of 50 studies involving more than 10,000 patients with a recent stroke found that 7.7% had new atrial fibrillation on their admitting electrocardiogram. In 3 weeks during and after hospitalization, another 16.9% were diagnosed. A total of 23.7% of these stroke patients had silent atrial fibrillation; that is, atrial fibrillation diagnosed after hospital admission. Silent atrial fibrillation is also frequent in patients with pacemakers who do not have a recent stroke. In a pooled analysis of 3 studies involving more than 10,000 patients monitored for 24 months, 43% had at least 1 day with atrial fibrillation lasting more than 5 minutes. Ten percent had atrial fibrillation lasting at least 12 hours. Despite the frequency of silent atrial fibrillation in these patients with multiple risk factors for stroke, the annual incidence of stroke was only 0.23%. When silent atrial fibrillation is detected in patients with recent cryptogenic stroke, anticoagulation is indicated. In patients without stroke, silent atrial fibrillation should lead to further monitoring for clinical atrial fibrillation rather than immediate anticoagulation, as some have advocated.
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Affiliation(s)
- James E Dalen
- Department of Medicine, University of Arizona, Tucson.
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55
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Ponamgi SP, Vaidya VR, DeSimone CV, Noheria A, Hodge DO, Slusser JP, Ammash NM, Bruce CJ, Rabinstein AA, Friedman PA, Asirvatham SJ. Endocardial Device Leads in Patients with Patent Foramen Ovale: Echocardiographic Correlates of Stroke/TIA and Mortality. Pacing Clin Electrophysiol 2017; 40:310-322. [PMID: 27943333 PMCID: PMC5352469 DOI: 10.1111/pace.12985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/24/2016] [Accepted: 11/02/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Echocardiographically detected patent foramen ovale (PFO) has been associated with stroke/transient ischemic attack (TIA) in patients with cardiac implantable electronic devices (CIEDs). We sought to evaluate the relationship between echocardiographic characteristics and risk of stroke/TIA and mortality in CIED patients with PFO. METHODS In 6,086 device patients, PFO was detected in 319 patients. A baseline echocardiogram was present in 250 patients, with 186 having a follow-up echocardiogram. RESULTS Of 250 patients with a baseline echocardiogram, 9.6% (n = 24) had a stroke/TIA during mean follow-up of 5.3 ± 3.1 years; and 42% (n = 105) died over 7.1 ± 3.7 years. Atrial septal aneurysm, prominent Eustachian valve, visible shunting across PFO, baseline or change in estimated right ventricular systolic pressure (RVSP)/tricuspid regurgitation (TR), or maximum RVSP were not associated with postimplant stroke/TIA (P > 0.05). An exploratory multivariate analysis using time-dependent Cox models showed increased hazard of death in patients with increase in TR ≥2 grades (hazard ratio [HR] 1.780, 95% confidence interval [CI] 1.447-2.189, P < 0.0001), or increase in RVSP by >10 mm Hg (HR 2.018, 95% CI 1.593-2.556, P < 0.0001), or maximum RVSP in follow-up (HR 1.432, 95% CI 1.351-1.516, P < 0.0001). A significant increase (P < 0.001) in TR was also noted during follow-up. CONCLUSIONS In patients with CIED and PFO, structural and hemodynamic echocardiographic markers did not predict future stroke/TIA. However, a significantly higher TR or RVSP was associated with higher mortality.
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Affiliation(s)
- Shiva P. Ponamgi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Austin, Minnesota, U.S.A
| | - Vaibhav R. Vaidya
- Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Amit Noheria
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - David O. Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Joshua P. Slusser
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Naser M. Ammash
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Charles J. Bruce
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Paul A. Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Samuel J. Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Timm FP, Houle TT, Grabitz SD, Lihn AL, Stokholm JB, Eikermann-Haerter K, Nozari A, Kurth T, Eikermann M. Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study. BMJ 2017; 356:i6635. [PMID: 28073753 PMCID: PMC5225233 DOI: 10.1136/bmj.i6635] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate. DESIGN Prospective hospital registry study. SETTING Massachusetts General Hospital and two satellite campuses between January 2007 and August 2014. PARTICIPANTS 124 558 surgical patients (mean age 52.6 years; 54.5% women). MAIN OUTCOME MEASURES The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location. RESULTS 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura. : Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41). CONCLUSIONS Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.
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Affiliation(s)
- Fanny P Timm
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Stephanie D Grabitz
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Anne-Louise Lihn
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- Department of Anesthesiology, University of Copenhagen, Herlev Hospital, Copenhagen, Denmark
| | - Janne B Stokholm
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- Department of Anesthesiology, University of Copenhagen, Herlev Hospital, Copenhagen, Denmark
| | | | - Ala Nozari
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Germany
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Celeste F, Muratori M, Mapelli M, Pepi M. The Evolving Role and Use of Echocardiography in the Evaluation of Cardiac Source of Embolism. J Cardiovasc Echogr 2017; 27:33-44. [PMID: 28465991 PMCID: PMC5412748 DOI: 10.4103/jcecho.jcecho_1_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This report will review the role of echocardiography in the diagnosis of cardiac sources of embolism. Embolism of cardiac origin accounts for around 15%–30% of ischemic strokes. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthonous cerebrovascular occlusive disease. Transthoracic and/or transesophageal echocardiography serves as a cornerstone in the evaluation, diagnosis, and management of these patients. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism.
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Affiliation(s)
- Fabrizio Celeste
- Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, 20138 Milan, Italy
| | - Manuela Muratori
- Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, 20138 Milan, Italy
| | - Massimo Mapelli
- Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, 20138 Milan, Italy
| | - Mauro Pepi
- Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, 20138 Milan, Italy
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58
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Snijder RJR, Luermans JGLM, de Heij AH, Thijs V, Schonewille WJ, Van De Bruaene A, Swaans MJ, Budts WIHL, Post MC. Patent Foramen Ovale With Atrial Septal Aneurysm Is Strongly Associated With Migraine With Aura: A Large Observational Study. J Am Heart Assoc 2016; 5:e003771. [PMID: 27930349 PMCID: PMC5210450 DOI: 10.1161/jaha.116.003771] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 10/26/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND A patent foramen ovale (PFO) with atrial septal aneurysm (ASA) has been identified as a risk factor for cryptogenic stroke. Patients with migraine with aura (MA) appear to be at risk for silent brain infarction, which might be related to the presence of a PFO. However, the association between MA and PFO with ASA has never been reported. We examined this association in a large observational study. METHODS AND RESULTS Patients (>18 years) who underwent an agitated saline transesophageal echocardiography (cTEE) at our outpatient clinics within a timeframe of 4 years were eligible to be included. Before cTEE they received a validated headache questionnaire. Two neurologists diagnosed migraine with or without aura according to the International Headache Criteria. A total of 889 patients (mean age 56.4±14.3 years, 41.7% women) were included. A PFO was present in 23.2%, an isolated ASA in 2.7%, and a PFO with ASA in 6.9%. The occurrence of migraine was 18.9%; the occurrence of MA was 8.1%. The prevalence of PFO with ASA was significantly higher in patients with MA compared to patients without migraine (18.1% vs 6.1%; OR 3.72, 95% CI 1.86-7.44, P<0.001). However, a PFO without ASA was not significantly associated with MA (OR 1.50, 95% CI 0.79-2.82, P=0.21). Interestingly, a PFO with ASA was strongly associated with MA (OR 2.71, 95% CI 1.23-5.95, P=0.01). CONCLUSION In this large observational study, PFO with ASA was significantly associated with MA only. PFO closure studies should focus on this specific intra-atrial anomaly.
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Affiliation(s)
- Roel J R Snijder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Albert H de Heij
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
- Department of Neurology, Austin Health, Victoria, Australia
| | | | | | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Werner I H L Budts
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Martijn C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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59
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Amin A. Role of hospitalists in the diagnosis of atrial fibrillation for the management of cryptogenic stroke patients. Hosp Pract (1995) 2016; 44:274-278. [PMID: 27817241 DOI: 10.1080/21548331.2016.1258292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Cryptogenic strokes are responsible for significant morbidity and mortality. Identifying the underlying cause of cryptogenic stroke is imperative for appropriate short and long-term management of these patients. In particular, detecting atrial fibrillation in cryptogenic stroke patients may shed insight into the cause of the index stroke, but is also important to identify an important cause of secondary stroke. There is accumulating evidence indicating that monitoring for durations beyond the guideline recommended 30 day-period results in greater atrial fibrillation yield. This article reviews current guidelines and practices for the diagnosis of cryptogenic stroke, as well as outpatient cardiac monitoring options available, and focuses on the role that hospitalists have to play in the care of these patients.
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Affiliation(s)
- Alpesh Amin
- a Department of Medicine , University of California Irvine , Orange , CA , USA
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60
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Huber R, Grittner U, Weidemann F, Thijs V, Tanislav C, Enzinger C, Fazekas F, Wolf M, Hennerici MG, McCabe DJH, Putaala J, Tatlisumak T, Kessler C, von Sarnowski B, Martus P, Kolodny E, Norrving B, Rolfs A. Patent Foramen Ovale and Cryptogenic Strokes in the Stroke in Young Fabry Patients Study. Stroke 2016; 48:30-35. [PMID: 27899752 DOI: 10.1161/strokeaha.116.013620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 09/05/2016] [Accepted: 10/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A patent foramen ovale (PFO) is disproportionately prevalent in patients with cryptogenic stroke. Without alternative explanations, it is frequently considered to be causative. A detailed stratification of these patients may improve the identification of incidental PFO. METHODS We investigated the PFO prevalence in 3497 transient ischemic attack and ischemic stroke patients aged 18 to 55 years in the prospective multicenter SIFAP1 study (Stroke in Young Fabry Patients 1) using the ASCO classification. Patients without an obvious cause for transient ischemic attack/stroke (ASCO 0) were divided into subgroups with and without vascular risk factors (ASCO 0+ and 0-). In addition, we looked for PFO-related magnetic resonance imaging lesion patterns. RESULTS PFO was identified in 25% of patients. Twenty percent of patients with a definite or probable cause of transient ischemic attack/stroke (≥1 grade 1 or 2 ASCO criterion; n=1769) had a PFO compared with 29% of cryptogenic stroke patients (ASCO 0 and 3; n=1728; P<0,001); subdivision of cryptogenic strokes revealed a PFO in 24% of 978 ASCO 3 patients (n.s. versus ASCO 1 and 2) and a higher prevalence of 36% in 750 ASCO 0 cases (P<0.001 versus ASCO 3 and versus ASCO 1 and 2). PFO was more commonly observed in ASCO 0- (n=271) than in ASCO 0+ patients (n=479; 48 versus 29%; P<0.001). There was no PFO-associated magnetic resonance imaging lesion pattern. CONCLUSIONS Cryptogenic stroke patients demonstrate a heterogeneous PFO prevalence. Even in case of less conclusive diseases like nonstenotic arteriosclerosis, patients should preferentially be considered to have a non-PFO-mediated stroke. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583.
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Affiliation(s)
- Roman Huber
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.).
| | - Ulrike Grittner
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Frank Weidemann
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Vincent Thijs
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Christian Tanislav
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Christian Enzinger
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Franz Fazekas
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Markus Wolf
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Michael G Hennerici
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Dominick J H McCabe
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Jukaa Putaala
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Turgut Tatlisumak
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Christoph Kessler
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Bettina von Sarnowski
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Peter Martus
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Edwin Kolodny
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Bo Norrving
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
| | - Arndt Rolfs
- From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.)
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Love B. Cryptogenic Stroke, Patent Foramen Ovale, and ASD Closure. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Barry Love
- Mount Sinai Medical Center; New York NY USA
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Bugnitz CJ, Cripe LH, Lo WD, Flanigan KM. Recurrent Fat Embolic Strokes in a Patient With Duchenne Muscular Dystrophy With Long Bone Fractures and a Patent Foramen Ovale. Pediatr Neurol 2016; 63:76-79. [PMID: 27595520 DOI: 10.1016/j.pediatrneurol.2016.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 05/21/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Individuals with Duchenne muscular dystrophy have an increased risk of long bone fractures. Such fractures are sometimes associated with brain dysfunction due to fat embolism syndrome, although this syndrome has seldom been documented in muscular dystrophy patients. PATIENT DESCRIPTION We describe a child with Duchenne muscular dystrophy who developed fat embolism syndrome with neurological dysfunction following multiple long bone fractures. He experienced recurrent cerebral infarctions that probably resulted from embolization through a patent foramen ovale. The patent foramen ovale was closed by an occluder device in the cardiac catheterization laboratory, and he did not experience further infarctions. CONCLUSIONS Fat embolism with ischemic cerebral infarction can occur in individuals with Duchenne muscular dystrophy following long bone fractures. In this setting it is important to identify and close atrial level shunts in order to prevent additional infarctions.
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Affiliation(s)
| | - Linda H Cripe
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Warren D Lo
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Kevin M Flanigan
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
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63
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Tan S, Zhang L, Chen X, Wang Y, Lin Y, Cai W, Shan Y, Qiu W, Hu X, Lu Z. Comparison of the Chinese ischemic stroke subclassification and Trial of Org 10172 in acute stroke treatment systems in minor stroke. BMC Neurol 2016; 16:162. [PMID: 27601009 PMCID: PMC5011990 DOI: 10.1186/s12883-016-0688-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/29/2016] [Indexed: 11/25/2022] Open
Abstract
Background The underlying causes of minor stroke are difficult to assess. Here, we evaluate the reliability of the Chinese Ischemic Stroke Subclassification (CISS) system in patients with minor stroke, and compare it to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) system. Methods A total of 320 patients with minor stroke were retrospectively registered and categorized into different subgroups of the CISS and TOAST by two neurologists. Inter- and intra-rater agreement with the two systems were assessed with kappa statistics. Results The percentage of undetermined etiology (UE) cases in the CISS system was 77.3 % less than that in the TOAST system, which was statistically significant (P < 0.001). The percentage of large artery atherosclerosis (LAA) in the CISS system was 79.7 % more than that in the TOAST system, which was also statistically significant (P < 0.001). The kappa values for inter-examiner agreement were 0.898 (P = 0.031) and 0.732 (P = 0.022) for the CISS and TOAST systems, respectively. The intra-observer reliability indexes were moderate (0.569 for neurologist A, and 0.487 for neurologist B). Conclusions The CISS and TOAST systems are both reliable in classifying patients with minor stroke. CISS classified more patients into known etiologic categories without sacrificing reliability.
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Affiliation(s)
- Sha Tan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China
| | - Lei Zhang
- Department of Neurology, The Fifth Affiliated Hospital of Sun Yat-sen University, No 52 Meihuadong Road, Zhuhai City, China
| | - Xiaoyu Chen
- Department of Neurology, People's Hospital of Zhongshan City, No 2 Sun Yat-sen East Road, Zhongshan City, China
| | - Yanqiang Wang
- Department of Neurology, Affiliated Hospital of Weifang Medical University, No 465 Yuhe Road, Weifang City, China
| | - Yinyao Lin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China
| | - Wei Cai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China
| | - Yilong Shan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China
| | - Zhengqi Lu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou City, Guangdong, China.
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Savino K, Maiello M, Pelliccia F, Ambrosio G, Palmiero P. Patent foramen ovale and cryptogenic stroke: from studies to clinical practice: Position paper of the Italian Chapter, International Society Cardiovascular Ultrasound. Int J Clin Pract 2016; 70:641-8. [PMID: 27384340 DOI: 10.1111/ijcp.12842] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Over the last two decades the interest on patent foramen ovale (PFO) as a cause of cardioembolism in cryptogenic stroke has tremendously increased, thanks to the availability of better techniques to diagnose cardiac right-to-left shunt by ultrasounds and of percutaneous means of PFO treatment with interventional techniques. Many studies have been published that have attempted to define diagnostic methodology, prognosis, and optimal treatment (pharmacological or percutaneous closure) of PFO patients with cryptogenic stroke. Unfortunately, even today, definitive evidence is still lacking, and clinical management is not consistent among cardiologists. AIMS This review aims to evaluate the role of PFO in cryptogenic stroke, the diagnostic accuracy of transcranial Doppler, contrast transthoracic and transesophageal echocardiography in the diagnosis of left-fright shunt and PFO; and discuss the indications to medical treatment and percutaneous closure of PFO. METHODS All studies published in the literature on PFO and cryptogenic stroke are considered and discussed. RESULTS We define an appropriate diagnostic and clinical management of PFO patients with cryptogenic stroke. CONCLUSION After many years of interest on PFO and many concluded studies, there are still no definitive data. However, we are on good track for an appropriate management of PFO patients and cryptogenic stroke.
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Affiliation(s)
- K Savino
- Division of Cardiology - S. Maria della Misericordia Hospital, University of Perugia School of Medicine, Perugia, Italy
| | - M Maiello
- ASL Brindisi, District Cardiology Equipe, Brindisi, Italy
| | - F Pelliccia
- Department Heart and Great Vessels "Attilio Reale", University "La Sapienza" Rome, Rome, Italy
| | - G Ambrosio
- Division of Cardiology - S. Maria della Misericordia Hospital, University of Perugia School of Medicine, Perugia, Italy
| | - P Palmiero
- ASL Brindisi, District Cardiology Equipe, Brindisi, Italy
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Khan R, Chan AK, Mondal TK, Paes BA. Patent foramen ovale and stroke in childhood: A systematic review of the literature. Eur J Paediatr Neurol 2016; 20:500-11. [PMID: 27169856 DOI: 10.1016/j.ejpn.2016.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/14/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke in association with a patent foramen ovale (PFO) may be due to paradoxical embolization via a right to left intracardiac shunt but the exact contribution of PFO to stroke or stroke recurrence in childhood remains unclear. METHODS To review the relationship of a PFO with stroke, and evaluate associated co-morbidities. An electronic database literature search of Pubmed, Cochrane and EMBASE was performed from January 2000-December 2014. RESULTS 149 articles were retrieved, with overlap for diagnosis, management, treatment and outcome. 65 reports were utilized for the comprehensive review. Majority of childhood arterial ischemic stroke and transient ischemic attacks are associated with prothrombotic disorders or arteriopathy. Transthoracic echocardiography with a Valsalva maneuver is highly sensitive as a screening tool but may be falsely positive. Transthoracic echocardiography with color Doppler and a concurrent bubble contrast study are excellent for visualizing the atrial septum and PFO and identifying a right to left shunt. Current literature does not support PFO closure for cryptogenic stroke in young adults without an associated risk of thromboembolism. CONCLUSIONS High quality research in the pediatric population is lacking and most of the data is extrapolated from adults. Paradoxical embolism from a PFO as a cause of transient ischemic attack or stroke is a diagnosis of exclusion. PFO closure should be individualized based on significant shunting and risk factors such that maximum benefit is derived from the procedure. A young person with a PFO and stroke should be thoroughly investigated to rule out other etiologies.
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Affiliation(s)
- Rubeena Khan
- Division of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| | - Anthony K Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| | - Tapas K Mondal
- Division of Cardiology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| | - Bosco A Paes
- Division of Neonatology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
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Abstract
A patent foramen ovale (PFO) is common and found in nearly 25% of healthy individuals. The majority of patients with PFO remain asymptomatic and they are not at increased risk for developing a stroke. The presence of PFO, however, has been found to be higher in patients with cryptogenic stroke, suggesting there may be a subset of patients with PFO who are indeed at risk for stroke. Paradoxical embolization of venous thrombi through the PFO, which then enter the arterial circulation, is hypothesized to account for this relationship. Although aerated-saline transesophageal echocardiography is the gold standard for diagnosis, aerated-saline transthoracic echocardiography and transcranial Doppler are often used as the initial diagnostic tests for detecting PFO. Patients with cryptogenic stroke and PFO are generally treated with antiplatelet therapy in the absence of another condition for which anticoagulation is necessary. Based on the findings of 3 large randomized clinical trials, current consensus guidelines do not recommend percutaneous closure, though this is an area of controversy. The following review discusses the relationship of PFO and cryptogenic stroke, focusing on the epidemiology, pathophysiological mechanisms, diagnostic tools, associated clinical/anatomic factors and treatment. (Circ J 2016; 80: 1665-1673).
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Taggart NW, Reeder GS, Lennon RJ, Slusser JP, Freund MA, Cabalka AK, Cetta F, Hagler DJ. Long-term follow-up after PFO device closure. Catheter Cardiovasc Interv 2016; 89:124-133. [DOI: 10.1002/ccd.26518] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/26/2016] [Accepted: 02/27/2016] [Indexed: 11/08/2022]
Affiliation(s)
| | - Guy S. Reeder
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota
| | - Ryan J. Lennon
- Division of Biostatistics; Mayo Clinic; Rochester Minnesota
| | | | - Monique A. Freund
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota
| | | | - Frank Cetta
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota
| | - Donald J. Hagler
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota
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Abstract
Patent foramen ovale (PFO) is a common finding in healthy adults and has long been implicated in cryptogenic stroke. The pathogenesis is hypothesized to be caused by microemboli gaining access into the systemic circulation via a PFO. Proposed treatment options include medical therapy and/or PFO closure. Despite numerous studies and several randomized trials, much debate persists regarding the efficacy of this approach in reducing the risk of recurrent stroke in cryptogenic stroke patients. This article reviews the association between PFO and cryptogenic stroke, as well as current evidence for PFO device closure.
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Affiliation(s)
- Hussam S Suradi
- Interventional Cardiology, Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612, USA; Department of Cardiology, St Mary Medical Center, Community HealthCare Network, Community Healthcare System, 1500 South Lake Park Avenue, Suite 110, Hobart, IN 46342, USA.
| | - Ziyad M Hijazi
- Sidra Cardiovascular Center of Excellence, Sidra Medical & Research Center, Al Corniche street, P.O. Box 26999, Doha, Qatar
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Şenadim S, Bozkurt D, Çabalar M, Bajrami A, Yayla V. The Role of Patent Foramen Ovale in Cryptogenic Stroke. Noro Psikiyatr Ars 2016; 53:63-66. [PMID: 28360768 DOI: 10.5152/npa.2015.10034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/11/2014] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Almost one-third of ischemic strokes has an unknown etiology and are classified as cryptogenic stroke. Paradoxical embolism because of a patent foramen ovale (PFO) is detected in 40%-50% of these patients. Recently, PFO has been reported as a risk factor for patients of all age groups. METHODS In this study, 1080 ischemic stroke patients admitted to our clinic (2011-2013) were retrospectively evaluated. Age, sex, risk factors, complete blood count, vasculitis, biochemical and hypercoagulability tests, magnetic resonance imaging, magnetic resonance angiography, transthoracic echocardiography, transeosophageal echocardiography (TEE) findings, and therapeutic approaches were evaluated. RESULTS The age range of the participants (seven male and four female patients) was 20-60 years (mean=43.09±11.13 years). Hemiparesis (n=10), diplopia (n=2), hemianopsia (n=2), and dysarthria (n=2) were the main findings of the neurological examinations. Patient medical history revealed hypertension (n=3), asthma (n=1), deep venous thrombosis (n=1), and smoking (n=4). Diffusion-weighted imaging showed middle cerebral artery (n=8) and posterior cerebral artery (n=3) infarctions. In one case, symptomatic severe carotid stenosis was detected. In eight cases, TEE showed PFO without any other abnormalities, but PFO was associated with atrial septal aneurysm in two cases, and in one case it was associated with ventricular hypokinesia and pulmonary arterial hypertension. Antiplatelet therapy was applied to nine patients and percutaneous PFO closure operation to two patients. In a 2-year follow-up, no recurrent ischemic stroke was recorded. CONCLUSION PFO, especially in terms of the etiology of cryptogenic stroke in young patients, should not be underestimated. We want to emphasize the importance of TEE in identifying potential cardioembolic sources not only in young but also in all ischemic stroke patients with unknown etiology; we also discuss the controversial management options of PFO.
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Affiliation(s)
- Songül Şenadim
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Dilek Bozkurt
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Murat Çabalar
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Arsida Bajrami
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Vildan Yayla
- Clinic of Neurology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
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Homma S, Messé SR, Rundek T, Sun YP, Franke J, Davidson K, Sievert H, Sacco RL, Di Tullio MR. Patent foramen ovale. Nat Rev Dis Primers 2016; 2:15086. [PMID: 27188965 DOI: 10.1038/nrdp.2015.86] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.
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Affiliation(s)
- Shunichi Homma
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Yee-Ping Sun
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Karina Davidson
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
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Li L, Schulz UG, Kuker W, Rothwell PM. Age-specific association of migraine with cryptogenic TIA and stroke: Population-based study. Neurology 2015; 85:1444-51. [PMID: 26423431 DOI: 10.1212/wnl.0000000000002059] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 04/24/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether there is an association between previous migraine and cryptogenic TIA or ischemic stroke at older ages. METHODS We determined the age-specific associations of history of migraine and Trial of Org 10172 in Acute Stroke Treatment (TOAST) subtype of TIA and ischemic stroke in a population-based cohort study (Oxford Vascular Study; 2002-2012). RESULTS Among 1,810 eligible patients with TIA or ischemic stroke, 668 (36.9%) had cryptogenic events, of whom 187 (28.0%) had previous migraine. Migraine was more commonly associated with cryptogenic events than with those of known etiology (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.38-2.16, p < 0.0001; cardioembolic 2.00, 1.50-2.66, p < 0.0001; large artery 1.75, 1.20-2.53, p = 0.003; small vessel 1.32, 0.95-1.83, p = 0.096). The association of migraine with cryptogenic events was independent of age, sex, and all measured vascular risk factors (RFs) (adjusted OR 1.68, 1.33-2.13, p < 0.0001) and was strongest at older ages (<55 years, OR 1.11, 0.55-2.23; 55-64 years, 1.48, 0.83-2.63; ≥65 years, 1.81, 1.39-2.36) and in patients without vascular RFs (0 RFs OR 2.62, 1.33-5.15; 1 RF 2.01, 1.35-3.01; 2 RFs 1.80, 1.21-2.68; 3 RFs 1.21, 0.71-2.07; 4 RFs 0.92, 0.28-2.99). Results were consistent for migraine with or without aura and for analyses excluding TIA or stratified by sex or vascular territory of event. CONCLUSIONS In this population-based study of stroke etiology stratified by age, migraine was most strongly associated with cryptogenic TIA and ischemic stroke, particularly at older ages, suggesting a causal role or a shared etiology.
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Affiliation(s)
- Linxin Li
- From the Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Ursula G Schulz
- From the Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Wilhelm Kuker
- From the Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Peter M Rothwell
- From the Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK.
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Li J, Liu J, Liu M, Zhang S, Hao Z, Zhang J, Zhang C. Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack. Cochrane Database Syst Rev 2015; 2015:CD009938. [PMID: 26346232 PMCID: PMC7389291 DOI: 10.1002/14651858.cd009938.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The optimal therapy for preventing recurrent stroke in people with cryptogenic stroke and patent foramen ovale (PFO) has not been defined. The choice between medical therapy (antithrombotic treatment with antiplatelet agents or anticoagulants) and transcatheter device closure has been the subject of intense debate over the past several years. Despite the lack of scientific evidence, a substantial number of people undergo transcatheter device closure (TDC) for secondary stroke prevention. OBJECTIVES To: 1) compare the safety and efficacy of TDC with best medical therapy alone for preventing recurrent stroke (fatal or non-fatal) or transient ischemic attacks (TIAs) in people with PFO and a history of cryptogenic stroke or TIA; 2) identify specific subgroups of people most likely to benefit from closure for secondary prevention; and 3) assess the cost-effectiveness of this strategy, if possible. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (July 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2014), MEDLINE (1950 to July 2014) and EMBASE (1980 to July 2014). In an effort to identify unpublished and ongoing trials we searched seven trials registers and checked reference lists. SELECTION CRITERIA We included randomized controlled trials (RCTs), irrespective of blinding, publication status, and language, comparing the safety and efficacy of device closure with medical therapy for preventing recurrent stroke or TIA in people with PFO and a history of cryptogenic stroke or TIA. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed quality and risk of bias, and extracted data. The primary outcome measures of this analysis were the composite endpoint of ischemic stroke or TIA events as well as recurrent fatal or non-fatal ischemic stroke. Secondary endpoints included all-cause mortality, serious adverse events (atrial fibrillation, myocardial infarction, bleeding) and procedural success and effective closure. We used the Mantel-Haenszel method to obtain pooled risk ratios (RRs) using the random-effects model regardless of the level of heterogeneity. We pooled data for the primary outcome measure with the generic inverse variance method using the random-effects model, yielding risk estimates as pooled hazard ratio (HR), which accounts for time-to-event outcomes. MAIN RESULTS We included three RCTs involving a total of 2303 participants: 1150 participants were randomized to receive TDC and 1153 participants were randomized to receive medical therapy. Overall, the risk of bias was regarded as high. The mean follow-up period of all three included trials was less than five years. Baseline characteristics (age, sex, and vascular risk factors) were similar across trials. Intention-to-treat analyses did not show a statistically significant risk reduction in the composite endpoint of recurrent stroke or TIA in the TDC group when compared with medical therapy (RR 0.73, 95% CI 0.45 to 1.17). A time-to-event analysis combining the results of two RCTs also failed to show a significant risk reduction with TDC (HR 0.69, 95% CI 0.43 to 1.13). When assessing stroke prevention alone, TDC still did not show a statistically significant benefit (RR 0.61, 95% CI 0.29 to 1.27) (HR 0.55, 95% CI 0.26 to 1.18). In a sensitivity analysis including the two studies using the Amplatzer PFO occluder, TDC showed a possible protective effect on recurrent stroke compared with medical therapy (HR 0.38, 95% CI 0.14 to 1.02); however, it did not reach statistical significance. Safety analysis found that the overall risks for all-cause mortality and adverse events were similar in both the TDC and medical therapy groups. However, TDC increased the risk of new-onset atrial fibrillation (RR 3.50, 95% CI 1.47 to 8.35) and may be associated with the type of device used. AUTHORS' CONCLUSIONS The combined data from recent RCTs have shown no statistically significant differences between TDC and medical therapy in the prevention of recurrent ischemic stroke. TDC closure was associated with an increased risk of atrial fibrillation but not with serious adverse events.
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Affiliation(s)
- Jie Li
- People's Hospital of Deyang CityDepartment of NeurologyNo.173, Taishan North RoadDeyangSichuanChina618000
- West China Hospital, Sichuan UniversityDepartment of NeurologyNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Junfeng Liu
- West China Hospital, Sichuan UniversityDepartment of NeurologyNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Ming Liu
- West China Hospital, Sichuan UniversityDepartment of NeurologyNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Shihong Zhang
- West China Hospital, Sichuan UniversityDepartment of NeurologyNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Zilong Hao
- West China Hospital, Sichuan UniversityDepartment of NeurologyNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jing Zhang
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyNo. 45, Changchun StreetBeijingBeijingChina100053
| | - Canfei Zhang
- The First Affiliated Hospital of Henan University of Science and TechnologyDepartment of NeurologyNo. 24, Jinghua RoadLuoyangHenan ProvinceChina471003
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Abstract
Strokes are the second leading cause of death and the third leading cause of disability worldwide. Thanks in part to better and more available diagnosis, treatment, and rehabilitation, the vast majority of stroke patients tend to survive strokes, particularly in the industrialized world. Motor disability and cognitive changes such as aphasia and visuospatial disorders are most often considered among the major contributors to stroke burden. This chapter discusses disorders of sexual functions as another frequent sequel of strokes. Strokes generally induce hyposexuality, but in some instances they may be followed by hypersexuality. There is some evidence suggesting that lesions of either hemisphere affect sexual activities, but for different reasons: aphasia and depression after left-hemisphere lesions, a deficit in arousal and perhaps visuospatial disorders after right-hemisphere lesions. Psychologic, psychosocial, and physical factors, as well as medications, play an important role. A better understanding of the psychosocial and physiologic mechanisms underlying sexual functioning can provide insight into improving sexual activity and therefore quality of life in patients affected by strokes and other brain lesions.
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75
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Seiler C. Patent foramen ovale (PFO): is there life before death in the presence of PFO? Eur J Clin Invest 2015; 45:875-82. [PMID: 26017145 DOI: 10.1111/eci.12469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/23/2015] [Indexed: 11/30/2022]
Abstract
Patent foramen ovale (PFO) is an embryologic remnant with incomplete postnatal adhesion of the cardiac atrial septum primum and secundum. After birth, the prevalence of PFO decreases from about 35% at young to approximately 20% at old age. PFO has been associated with numerous conditions such as decompression illness in divers, migraine, high-altitude pulmonary oedema, cerebrovascular and coronary ischaemia, and obstructive sleep apnoea syndrome. PFO is the cause of intermittent atrial right-to-left shunt, and it can be the source of cardiac paradoxical embolism. So far, randomized controlled trials have not documented a reduced rate of cerebrovascular recurrent events in patients receiving PFO device closure as compared to those on medical treatment. The purpose of this article was to critically evaluate evidence on the pathophysiologic, clinical as well as prognostic relevance of PFO.
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Affiliation(s)
- Christian Seiler
- Department of Cardiology, University Hospital, Bern, Switzerland
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76
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Sinha RS, Hussain Z, Bhatia N, Stoddard MF. Risk of Recurrent Neurologic Stroke or Transient Ischemic Attack in Patients with Cryptogenic Stroke and Intrapulmonary Shunt. Echocardiography 2015. [PMID: 26197703 DOI: 10.1111/echo.13017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Cardio-embolic phenomenon is believed to underlie a significant proportion of cryptogenic strokes. We recently showed that intrapulmonary shunt (IPS) was associated with cryptogenic stroke and transient ischemic attack (TIA). We hypothesized that patients with prior cryptogenic stroke or TIA that had an IPS were at a higher risk for recurrent ischemic events. METHODS The population included subjects with cryptogenic cerebrovascular accident (CVA) or TIA. Inclusion criteria were age ≥18 years, sinus rhythm, and clinically indicated transesophageal echocardiography (TEE). Exclusion criteria were hemorrhagic CVA, septal defect, and patent foramen. Patients were followed from index TEE. RESULTS Of 71 patients, 8 were lost to follow-up. A total of 23 patients had and 40 were without IPS. Average follow-up duration was 38.3 ± 19.2 months. Groups were similar at baseline. There was no significant difference in the recurrence of ischemic CVA or TIA in the IPS versus non-IPS groups (0% vs. 7.5%; P = NS). There was no difference between the incidence of hemorrhagic CVA in the IPS and non-IPS groups (4.3% vs. 5.0%; P = NS). The proportion of patients on warfarin in the IPS group was significantly higher compared to the non-IPS group (17.4% vs. 0%; P < 0.05). CONCLUSIONS Patients with IPS and cryptogenic stroke or TIA did not have a higher recurrence of ischemic cerebral events. Warfarin was significantly higher at follow-up in the IPS compared to the non-IPS group, which may explain these findings. A study randomizing patients with IPS and cryptogenic stroke or TIA to warfarin or no warfarin would be of great interest.
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Affiliation(s)
- Rahul S Sinha
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Zeeshan Hussain
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Nirmanmoh Bhatia
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Marcus F Stoddard
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, Kentucky
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77
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Affiliation(s)
- Arjun K Ghosh
- Specialty Registrar in Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
| | - Ajay Jain
- Consultant Cardiologist at Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London
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78
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Propensity Score–matched Comparison of Postoperative Adverse Outcomes between Geriatric Patients Given a General or a Neuraxial Anesthetic for Hip Surgery. Anesthesiology 2015; 123:136-47. [DOI: 10.1097/aln.0000000000000695] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
The effects of the mode of anesthesia on major adverse postoperative outcomes in geriatric patients are still inconclusive. The authors hypothesized that a neuraxial anesthetic (NA) rather than a general anesthetic (GA) would yield better in-hospital postoperative outcomes for geriatric patients undergoing hip surgery.
Methods:
The authors used data from Taiwan’s 1997–2011 in-patient claims database to evaluate the effect of anesthesia on in-hospital outcomes. The endpoints were mortality, stroke, transient ischemic stroke, myocardial infarction, respiratory failure, and renal failure. Of the 182,307 geriatric patients who had hip surgery, a GA was given to 53,425 (29.30%) and an NA to 128,882 (70.70%). To adjust for baseline differences and selection bias, patients were matched on propensity scores, which left 52,044 GA and 52,044 NA patients.
Results:
GA-group patients had a greater percentage and higher odds of adverse in-hospital outcomes than did NA-group patients: death (2.62 vs. 2.13%; odds ratio [OR], 1.24; 95% CI, 1.15 to 1.35; P < 0.001), stroke (1.61 vs. 1.38%; OR, 1.18, 95% CI, 1.07 to 1.31; P = 0.001), respiratory failure (1.67 vs. 0.63%; OR, 2.71; 95% CI, 2.38 to 3.01; P < 0.001), and intensive care unit admission (11.03 vs. 6.16%; OR, 1.95; 95% CI, 1.87 to 2.05; P < 0.001), analyzed using conditional logistic regression. Moreover, patients given a GA had longer hospital stays (10.77 ± 8.23 vs. 10.44 ± 6.67 days; 95% CI, 0.22 to 0.40; P < 0.001) and higher costs (New Taiwan Dollars [NT$] 86,606 ± NT$74,162 vs. NT$74,494 ± NT$45,264; 95% CI, 11,366 to 12,859; P < 0.001).
Conclusion:
For geriatric patients undergoing hip surgery, NA was associated with fewer odds of adverse outcomes than GA.
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79
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Abstract
A patent foramen ovale (PFO) is a common finding in the general population and has been theorized to be a mechanism for ischemic stroke primarily due to a deep venous thrombus embolizing through the shunt into the arterial circulation. There has been much debate regarding the association between PFO and stroke, especially in the case of a cryptogenic stroke (i.e., stroke of unknown etiology) in a younger patient without other risk factors. Traditionally, when a PFO is detected, antithrombotic therapy to mitigate risk of a future ischemic event has been the mainstay of treatment. More recently, both surgical and transcatheter closure of a PFO have been widely utilized. However, there are only few randomized controlled trials assessing the efficacy of PFO closure for stroke prevention.
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Affiliation(s)
- Sabreena J Gillow
- Department of Neurological Sciences, Section of Cerebrovascular Disease, Rush University Medical Center, 1725 W. Harrison St #1121, Chicago, IL, 60612, USA,
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80
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Abstract
Patent foramen ovale (PFO) is common and only rarely related to stroke. The high PFO prevalence in healthy individuals makes for difficult decision making when a PFO is found in the setting of a cryptogenic stroke, because the PFO may be an incidental finding. Recent clinical trials of device-based PFO closure have had negative overall summary results; these trials have been limited by low recurrence rates. The optimal antithrombotic strategy for these patients is also unknown. Recent work has identified a risk score that estimates PFO-attributable fractions based on individual patient characteristics, although whether this score can help direct therapy is unclear.
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Affiliation(s)
- Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Box 63, Boston, MA 02111, USA; Division of Cardiology, Tufts Medical Center, 800 Washington Street, Box 63, Boston, MA 02111, USA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Box 63, Boston, MA 02111, USA.
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81
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Steinberg DH, Bertog SC, Momberger J, Franke J, Hofmann I, Renkhoff K, Joy S, Vaskelyte L, Sievert H. Initial experience with the novel patent foramen ovale occlusion device Nit-Occlud® in patients with stroke or transient ischemic attack. Catheter Cardiovasc Interv 2015; 85:1262-7. [DOI: 10.1002/ccd.25580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 06/14/2014] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | | | | | | | - Sonya Joy
- CardioVascular Center Frankfurt; Frankfurt Germany
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82
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Amin H, Nowak RJ, Schindler JL. Cardioembolic Stroke: Practical Considerations for Patient Risk Management and Secondary Prevention. Postgrad Med 2015; 126:55-65. [DOI: 10.3810/pgm.2014.01.2725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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83
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Carnahan L, Steven Block H, Biller J. Eleven Commonly Asked Questions About Ischemic Stroke. Top Stroke Rehabil 2015; 20:93-100. [DOI: 10.1310/tsr2002-93] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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84
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Yen P. ASD and VSD Flow Dynamics and Anesthetic Management. Anesth Prog 2015; 62:125-30. [PMID: 26398131 PMCID: PMC4581019 DOI: 10.2344/0003-3006-62.3.125] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/22/2015] [Indexed: 11/11/2022] Open
Abstract
Atrial septal defects and ventricular septal defects are often encountered in patients presenting for treatment under anesthesia. The flow mechanisms for both defects are predominantly left to right shunting prior to long-term maladaptive changes that may occur. Close examination of the shunt dynamics demonstrates a minor right to left shunt that occurs as well. The article discusses these dynamics and the impact on an anesthetic plan.
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Affiliation(s)
- Philip Yen
- Dentist Anesthesiologist, CarePoint Anesthesia Group, LLC, Highlands Ranch, Colorado, and Assistant Professor, University of Colorado School of Dental Medicine, Aurora, Colorado
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85
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Yevtushenko SK, Filimonov DA, Yevtushenko IS. New risk factors of stroke in young adults. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-12. [DOI: 10.17116/jnevro20151151223-12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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86
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Abstract
The clinical significance of persistent patent foramen ovale (PFO) is not well defined. Empirically, PFO has been associated with many clinical conditions. In cryptogenic stroke, migraine, and orthodeoxia/platypnea, a plausible biologic mechanism exists to support PFO closure as a possible treatment. Although transcatheter closure of PFO has been available for over 2 decades, it has remained controversial due to a paucity of evidence to guide patient and device selection. Contemporary studies investigating PFO closure as treatment for patients with these conditions have been published recently and longitudinal data regarding the safety and efficacy of the devices is now available. In this review, we aim to describe the potential clinical significance of a patent foramen in the adult, appraise the newest additions to the body of evidence, and discuss the safety, benefit, patient selection, and future of transcatheter treatment of PFO.
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Affiliation(s)
- N Rohrhoff
- Duke University Medical Center, 3331 DUMC, Durham, NC, 27710, USA
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87
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Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 989] [Impact Index Per Article: 98.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
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88
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Katsanos AH, Spence JD, Bogiatzi C, Parissis J, Giannopoulos S, Frogoudaki A, Safouris A, Voumvourakis K, Tsivgoulis G. Recurrent Stroke and Patent Foramen Ovale. Stroke 2014; 45:3352-9. [DOI: 10.1161/strokeaha.114.007109] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Aristeidis H. Katsanos
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - J. David Spence
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - Chrysi Bogiatzi
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - John Parissis
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - Sotirios Giannopoulos
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - Alexandra Frogoudaki
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - Apostolos Safouris
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - Konstantinos Voumvourakis
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
| | - Georgios Tsivgoulis
- From the Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece (A.H.K., S.G.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada (J.D.S., C.B.); Second Department of Cardiology (J.P., A.F.) and Second Department of Neurology (K.V., G.T.), Attikon Hospital, School of Medicine, University of Athens, Athens, Greece; Stroke Unit, Department of Neurology, Brugmann University Hospital,
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89
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Hari P, Pai RG, Varadarajan P. Echocardiographic Evaluation of Patent Foramen Ovale and Atrial Septal Defect. Echocardiography 2014; 32 Suppl 2:S110-24. [DOI: 10.1111/echo.12625] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Pawan Hari
- Division of Cardiology; Loma Linda University Medical Center; Loma Linda California
| | - Ramdas G. Pai
- Division of Cardiology; Loma Linda University Medical Center; Loma Linda California
| | - Padmini Varadarajan
- Division of Cardiology; Loma Linda University Medical Center; Loma Linda California
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90
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Komar M, Olszowska M, Przewłocki T, Podolec J, Stępniewski J, Sobień B, Badacz R, Kabłak-Ziembicka A, Tomkiewicz-Pająk L, Podolec P. Transcranial Doppler ultrasonography should it be the first choice for persistent foramen ovale screening? Cardiovasc Ultrasound 2014; 12:16. [PMID: 24884981 PMCID: PMC4046065 DOI: 10.1186/1476-7120-12-16] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/02/2014] [Indexed: 02/06/2023] Open
Abstract
Background Persistent foramen ovale (PFO) is considered a cause of cryptogenic stroke and a risk factor for neurological events in young patients. The reference standard for identifying a PFO is contrast-enhanced transesophageal echocardiography (TEE). The goal of this study was to evaluate the feasibility of transcranial color Doppler (TCD) and its diagnostic sensitivity compared with TEE. Methods We investigated 420 patients admitted to our department with cryptogenic stroke, transient ischemic attacks or other neurological symptoms. All patients underwent TCD and TEE evaluation. TCD and TEE examinations were performed according to a standardized procedure: air-mixed saline was injected into the right antecubital vein three times, while the Doppler signal was recorded during the Valsalva maneuver. During TCD the passage of contrast into the right-middle cerebral artery was recorded 25 seconds following the Valsalva maneuver. Results We detected a right-to-left shunt in 220 patients (52.3%) and no-shunts in 159 patients (37.9%) with both TCD and TEE. In 20 (4.8%) patients TEE did not reveal contrast passage which was then detected by TCD. In 21 (5.0%) patients only TEE revealed a PFO. The feasibility of both methods was 100%. TCD had a sensitivity of 95% and a specificity of 92% in the diagnosis of PFO. Conclusions TCD has a relatively good sensitivity and specificity. TCD and TEE are complementary diagnostic tests for PFO, but TCD should be recommended as the first choice for screening because of its simplicity, non-invasive character, low cost and high feasibility.
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Affiliation(s)
- Monika Komar
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Institute of Cardiology, Collegium Medicum, Jagiellonian University, Krakow, Poland.
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91
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Mean platelet volume, an indicator of platelet reactivity, is increased in patients with patent foramen ovale. Blood Coagul Fibrinolysis 2014; 24:605-7. [PMID: 23511902 DOI: 10.1097/mbc.0b013e32836029ee] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Numerous studies have shown an association between patent foramen ovale (PFO) and cryptogenic stroke suggesting that paradoxical emboli may be an important cause of stroke. In addition, some authors have proposed that platelet activation is present in PFO patients and this might be the cause of the stroke. The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation and/or reactivity in patients with PFO. The study group consisted of 77 patients with PFO. An age, sex, BMI-matched control group was composed of 43 healthy volunteers. We measured serum MPV values in patients and controls. MPV was significantly higher among PFO patients when compared with control group (9.0±0.8 vs. 8.3±0.9 fl, respectively; P<0.001). We have shown that MPV was significantly elevated in patients with PFO compared with controls.
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92
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Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SCC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160-236. [PMID: 24788967 DOI: 10.1161/str.0000000000000024] [Citation(s) in RCA: 2853] [Impact Index Per Article: 285.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
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93
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Maaijwee NAMM, Rutten-Jacobs LCA, Schaapsmeerders P, van Dijk EJ, de Leeuw FE. Ischaemic stroke in young adults: risk factors and long-term consequences. Nat Rev Neurol 2014; 10:315-25. [PMID: 24776923 DOI: 10.1038/nrneurol.2014.72] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Contrary to trends in most other diseases, the average age of ischaemic stroke onset is decreasing, owing to a rise in the incidence of stroke among 'young' individuals (under 50 years of age). This Review provides a critical overview of the risk factors and aetiology of young ischaemic stroke and addresses its long-term prognosis, including cardiovascular risk, functional outcome and psychosocial consequences. We highlight the diminishing role of 'rare' risk factors in the pathophysiology of young stroke in light of the rising prevalence of 'traditional' vascular risk factors in younger age groups. Long-term prognosis is of particular interest to young patients, because of their long life expectancy and major responsibilities during a demanding phase of life. The prognosis of young stroke is not as favourable as previously thought, with respect either to mortality or cardiovascular disease or to psychosocial consequences. Therefore, secondary stroke prevention is probably a life-long endeavour in most young stroke survivors. Due to under-representation of young patients in past trials, new randomized trials focusing on this age group are needed to confirm the benefits of long-term secondary preventive medication. The high prevalence of poor functional outcome and psychosocial problems warrants further study to optimize treatment and rehabilitation for these young patients.
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Affiliation(s)
- Noortje A M M Maaijwee
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Loes C A Rutten-Jacobs
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Pauline Schaapsmeerders
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Ewoud J van Dijk
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
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94
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Fuentes B, Gállego J, Gil-Nuñez A, Morales A, Purroy F, Roquer J, Segura T, Tejada J, Lago A, Díez-Tejedor E, Alonso de Leciñana M, Álvarez-Sabin J, Arenillas J, Calleja S, Casado I, Castellanos M, Castillo J, Dávalos A, Díaz-Otero F, Egido J, López-Fernández J, Freijo M, García Pastor A, Gilo F, Irimia P, Maestre J, Masjuan J, Martí-Fábregas J, Martínez-Sánchez P, Martínez-Vila E, Molina C, Nombela F, Ribó M, Rodríguez-Yañez M, Rubio F, Serena J, Simal P, Vivancos J. Guía para el tratamiento preventivo del ictus isquémico y AIT (II). Recomendaciones según subtipo etiológico. Neurologia 2014; 29:168-83. [DOI: 10.1016/j.nrl.2011.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 06/29/2011] [Indexed: 11/28/2022] Open
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95
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Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2011.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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96
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Ishida K, Brown MG, Weiner M, Kobrin S, Kasner SE, Messé SR. Endocarditis Is a Common Stroke Mechanism in Hemodialysis Patients. Stroke 2014; 45:1164-6. [DOI: 10.1161/strokeaha.113.003913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Hemodialysis patients are at high risk for ischemic stroke, and previous studies have noted a high rate of cardioembolism in this population. The aim of this study was to determine ischemic stroke causes among hemodialysis patients and elucidate specific cardioembolic stroke mechanisms.
Methods—
This study is a retrospective cross-sectional study of hemodialysis patients admitted with acute stroke to the University of Pennsylvania Health System between 2003 and 2010. Strokes were classified using modified Trial of Org 10 172 in Acute Stroke Treatment (TOAST) criteria as large vessel, cardioembolism, small vessel, atypical, multiple causes, or cryptogenic. Cardioembolic strokes were further characterized for specific mechanism.
Results—
We identified 52 patients hospitalized with acute stroke while receiving hemodialysis. Mean age was 64±13 years, 56% were female, and 67% were black. Stroke subtypes included 3 (6%) large vessel, 20 (38%) cardioembolism, 6 (11%) small vessel, 3 (6%) other, 4 (8%) with multiple causes, and 16 (31%) were unknown. Among patients who had an echocardiogram performed, 5 of 52 (10%; 95% confidence interval, 1%–18%) had a patent foramen ovale. Cardioembolic stroke mechanisms included 6 with infective endocarditis (accounting for 12% of all strokes).
Conclusions—
Cardioembolism and cryptogenic stroke are the predominant stroke mechanisms among hemodialysis patients. Infective endocarditis was identified frequently relative to other stroke cohorts, and a raised index of suspicion is warranted in the hemodialysis population.
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Affiliation(s)
- Koto Ishida
- From the Department of Neurology, New York University (K.I.); Departments of Neurology (M.G.B., S.E.K., S.R.M.) and Internal Medicine, Renal, Electrolyte and Hypertension Division (S.K.), Hospital of the University of Pennsylvania, Philadelphia; and Department of Internal Medicine, Temple University School of Medicine, Philadelphia, PA (M.W.)
| | - Mesha Gay Brown
- From the Department of Neurology, New York University (K.I.); Departments of Neurology (M.G.B., S.E.K., S.R.M.) and Internal Medicine, Renal, Electrolyte and Hypertension Division (S.K.), Hospital of the University of Pennsylvania, Philadelphia; and Department of Internal Medicine, Temple University School of Medicine, Philadelphia, PA (M.W.)
| | - Mark Weiner
- From the Department of Neurology, New York University (K.I.); Departments of Neurology (M.G.B., S.E.K., S.R.M.) and Internal Medicine, Renal, Electrolyte and Hypertension Division (S.K.), Hospital of the University of Pennsylvania, Philadelphia; and Department of Internal Medicine, Temple University School of Medicine, Philadelphia, PA (M.W.)
| | - Sidney Kobrin
- From the Department of Neurology, New York University (K.I.); Departments of Neurology (M.G.B., S.E.K., S.R.M.) and Internal Medicine, Renal, Electrolyte and Hypertension Division (S.K.), Hospital of the University of Pennsylvania, Philadelphia; and Department of Internal Medicine, Temple University School of Medicine, Philadelphia, PA (M.W.)
| | - Scott E. Kasner
- From the Department of Neurology, New York University (K.I.); Departments of Neurology (M.G.B., S.E.K., S.R.M.) and Internal Medicine, Renal, Electrolyte and Hypertension Division (S.K.), Hospital of the University of Pennsylvania, Philadelphia; and Department of Internal Medicine, Temple University School of Medicine, Philadelphia, PA (M.W.)
| | - Steven R. Messé
- From the Department of Neurology, New York University (K.I.); Departments of Neurology (M.G.B., S.E.K., S.R.M.) and Internal Medicine, Renal, Electrolyte and Hypertension Division (S.K.), Hospital of the University of Pennsylvania, Philadelphia; and Department of Internal Medicine, Temple University School of Medicine, Philadelphia, PA (M.W.)
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97
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Cruz-González I, Solis J, Kiernan TJ, Yan BP, Lam YY, Palacios IF. Clinical manifestation and current management of patent foramen ovale. Expert Rev Cardiovasc Ther 2014; 7:1011-22. [DOI: 10.1586/erc.09.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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98
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Eleftheriou D, Ganesan V. Controversies in childhood arterial ischemic stroke and cerebral venous sinus thrombosis. Expert Rev Cardiovasc Ther 2014; 7:853-61. [DOI: 10.1586/erc.09.41] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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99
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Gupta VK. Patent foramen ovale closure and migraine: science and sensibility. Expert Rev Neurother 2014; 10:1409-22. [DOI: 10.1586/ern.10.125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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100
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Reiffenstein I, Majunke N, Wunderlich N, Carter P, Jones R, Sievert H. Percutaneous closure of patent foramen ovale with a novel FlatStent™. Expert Rev Med Devices 2014; 5:419-25. [DOI: 10.1586/17434440.5.4.419] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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