Patent foramen ovale and cryptogenic stroke in older patients

Medical prevention of stroke and stroke recurrence in patients with TIA and minor stroke

BACKGROUND

Secondary stroke prevention after transient ischemic stroke (TIA) or minor stroke is of major importance in order to avoid recurrent cerebrovascular events and decrease morbidity and mortality.

OBJECTIVE/METHODS

Systematically review of recently published, high-quality studies emphasizing the need for emergency assessment and treatment of patients with TIA and minor stroke and to give a comprehensive and distinct overview over medical secondary stroke prevention trials performed in these patients.

RESULTS/CONCLUSIONS

Evaluation and implementation of preventive stroke therapy has to be immediate in patients with TIA and stroke. For patients with non-cardioembolic stroke, antiplatelet agents are the treatment of choice. Aspirin plus extended-release dipyridamole and clopidogrel are more effective than aspirin and should be used in patients with a high risk of recurrent stroke. Oral anticoagulation is highly effective in patients with a cardiac source of embolism. Treatment of risk factors such as arterial hypertension and high cholesterol is even more important in secondary stroke prevention than in primary prevention. Vitamin supplementation and lowering of elevated levels of homocysteine are not effective in stroke prevention.

Multiorgan paradoxical embolism consequent to acute pulmonary thromboembolism with patent foramen ovale: a case report

Paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt. It is a relatively rare phenomenon, representing about 2% of all cases of arterial embolism. We report a case of a 79-years-old woman admitted to hospital because of dyspnea and lower left limb pain. CT scan revealed multiple thrombi to kidney, lower limb and superior mesenteric artery during acute pulmonary embolism. Echocardiogram documented a patent foramen ovale with a right-to-left shunt. The patient was treated with thrombolytic therapy and heparin with progressive improvement of symptoms and resolution of pulmonary embolism and peripheral thrombosis. Patent foramen ovale closure was not performed because a life-long anticoagulation therapy was necessary, a tunnel-type patent foramen ovale may increases difficulty in realizing device implantation and there are no clear evidence-based guidelines to date addressing treatment in presence of a patent foramen ovale.

Transvenous closure of patent foramen ovale: preliminary results with a new self-expanding nitinol wire mesh in a Swine model

Objectives. The transvascular closure of patent foramen ovale (PFO) with self-expanding devices carries the risk of left atrial thrombus formation related to material protruding into the left atrium. Thus, we developed a novel device with flat left atrial disc geometry. We evaluated feasibility, handling, and biocompatibility in a porcine animal model. Methods. Implantation of an Occlutech Figulla PFO device was performed in 10 mini pigs using fluoroscopy and intra-cardiac ultrasound after transseptal puncture of the interatrial septum. Angiographic follow-up was performed after six and twelve weeks. Results. Implantation was successful in 100%. There were no further implant related complications. One procedure related death occurred, as one animal died of ventricular tachycardia due to mispunture of the interatrial septum. Angiographic studies showed no residual shunt during follow-up. Histopathological evaluation could demonstrate partial neoendothelialization after 6 weeks with completion after 12 weeks. The devices were incorporated into connective tissue containing fibro muscular cells. An only mild inflammatory reaction was detected locally related to the polyester fibers. Conclusion. In terms of feasibility and handling, the new device does not seem to be inferior to other presently used implantation systems. Good biocompatibility was demonstrated with rapid and complete neoendothelialization.

Patent foramen ovale in cryptogenic stroke: incidental or pathogenic?

BACKGROUND AND PURPOSE

Patent foramen ovale (PFO) is significantly associated with cryptogenic stroke (CS). However, even in patients with CS, a PFO can be an incidental finding. We sought to estimate the probability that a PFO in a patient with CS is incidental.

METHODS

A systematic search identified 23 case-control studies examining the prevalence of PFO in patients with CS versus control subjects with stroke of known cause. Using simple assumptions and Bayes' theorem, we calculated the probability a PFO is incidental in patients with CS. Random effects meta-analyses estimated the odds ratio (OR) of a PFO in CS versus control subjects in different age populations, with or without atrial septal aneurysms, and were used to summarize across studies the probability that a PFO in CS is incidental.

RESULTS

The summary OR (95% CIs) for PFO in CS versus control subjects was 2.9 (CI, 2.1 to 4.0). The corresponding ORs for young and old patients (< or >or=55 years) were 5.1 (3.3 to 7.8) and 2.0 (>1.0 to 3.7), respectively. The corresponding probabilities that a PFO in patients with CS is incidental were 33% (28% to 39%) in age-inclusive studies, 20% (16% to 25%) in younger patients, and 48% (34% to 66%) in older patients. These probabilities were much lower when an atrial septal aneurysm was present.

CONCLUSIONS

In patients with otherwise CS, approximately one third of discovered PFOs are likely to be incidental and hence not benefit from closure. This probability is sensitive to patient characteristics such as age and the presence of an atrial septal aneurysm, suggesting the importance of patient selection in therapeutic decision-making.

Percutaneous device closure of patent foramen ovale for secondary stroke prevention: a call for completion of randomized clinical trials. A science advisory from the American Heart Association/American Stroke Association and the American College of Cardiology Foundation

The optimal therapy for prevention of recurrent stroke or transient ischemic attack in patients with cryptogenic stroke and patent foramen ovale has not been defined. Although numerous observational studies have suggested a strong association between patent foramen ovale and cryptogenic stroke, a causal relationship has not been convincingly established for the majority of affected patients. Treatment choices include medical therapy with antiplatelet agents or vitamin K antagonists, percutaneous device closure, or open surgical repair. Whereas suture closure of an incidental patent foramen ovale is performed routinely during the course of an operation undertaken for another indication, primary surgical repair is rarely advocated in the current era. The choice between medical therapy and percutaneous device closure has been the subject of intense debate over the past several years, albeit one that has not been adequately informed by randomized, prospective clinical trial data to permit an objective comparison of the relative safety and efficacy of these respective approaches. Enrollment in clinical trials has lagged considerably despite frequent calls for participation from the US Food and Drug Administration and major professional societies. Completion and peer review of ongoing trials are critical steps to establish an evidence base from which clinicians can make informed decisions regarding the best therapy for individual patients. The present advisory strongly encourages all clinicians involved in the care of appropriate patients with cryptogenic stroke and patent foramen ovale--cardiologists, neurologists, internists, radiologists, and surgeons--to consider referral for enrollment in these landmark trials to expedite their completion and help resolve the uncertainty regarding optimal care for this condition.

[Cryptogenic cerebral infarction: from classification to concept]

Since the foundations laid by Sacco and Mohr in 1989, from the Stroke data bank, cryptogenic infarctions have had a predominant place among the causes of ischemic strokes. In that study, they accounted for approximately 40% of the stroke causes. Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up; they differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. The size of this group will probably shrink as knowledge advances. Patent foramen ovale (PFO), with or without a septal aneurysm, is more frequent in patients with a cryptogenic infarction. Transesophageal echocardiography is the reference examination for screening for these abnormalities. A meta-analysis of several case-control studies showed a significant association between PFO and stroke in subjects younger than 55 years. For now, these septal abnormalities constitute a risk factor but not a cause. Complex aortic atheroma affecting area upstream of the left subclavian artery may be a source of cerebral embolisms in some conditions. The prevalence of this disease increases with age. It is identified most frequently in patients older than 60 years with a cryptogenic infarction. The thickness of the atheromatous plaque determines whether it is a risk factor or a cause. Recent stroke classifications do not consider carotid atheromatous lesions less than 50% to be a source of ischemic stroke. Nonetheless some studies identify moderate stenosis of the carotid artery more frequently in infarctions of unknown causes than in other categories. The increased risk of cerebral infarction when parents and homozygous twins have a history of stroke suggests that there may be genetic causes that have not yet been detected. An unknown genetic cause would thus be included in the infarctions of unknown causes. A recent study tested for Fabry disease in young patients with a cryptogenic infarction: 4.9% of the men and 2.4% of the women had a functional mutation of the alpha-galactosidase gene. These findings must be confirmed. Some studies suggest an association between cryptogenic infarction and hereditary thrombophilias. Nonetheless the risk attributable to these thrombophilic disorders is slight and the discovery may be only a coincidence. The work described above shows the importance of stratification in the identification of stroke causes: age older or younger than 55/60 years, type of interatrial abnormality (PFO and aneurysms of the interatrial septum), type of atheroma of the aortic arch (more or less than 4mm). They also show the difficulty involved in attributing cause to an identified abnormality: is carotid stenosis of less than 50% a marker of atherosclerosis or also a cause of stroke? To continue improving our understanding of the mechanisms of strokes, new investigational techniques are under evaluation. They include magnetic resonance imaging (MRI), computed tomographic angiography (CT), positron emission tomography (PET) of carotid plaque and of the aortic arch, transcranial Doppler, cardiac recording by telemetry, and even new biological assays.

Stroke prevention in atrial fibrillation and other major cardiac sources of embolism

The frequency of cardioembolic stroke is expected to rise as the general population ages. Much of the increase may be attributed to atrial fibrillation, the most common cause of cardioembolic stroke and one that plays a substantial role in aging adults. Other sources of cardioembolic stroke may include ventricular thrombus from myocardial infarction, heart failure, structural heart defects such as patent foramen ovale (PFO), atrial septal aneurysm, proximal aortic atheroma, valvular heart disease, and endocarditis. Diagnostic studies, such as neuroimaging, ECG, and echocardiography, are helpful in uncovering cardioembolic sources of stroke. Medical therapy is predicated on the underlying mechanism. For example, warfarin may be indicated in certain patients who have atrial fibrillation, atrial, or ventricular thrombi, and PFO with atrial septal aneurysm and cryptogenic stroke in select young patients to prevent stroke. Newer diagnostic technologies, including multidetector CT and cardiac MRI, may be useful to diagnose cardiac causes of stroke when transesophageal echocardiography is indeterminate or cryptogenic stroke is present.

Transesophageal echocardiography in patients with cryptogenic cerebral ischemia

BACKGROUND

In about one third of all patients with cerebral ischemia, no definite cause can be identified (cryptogenic stroke). In many patients with initially suspected cryptogenic stroke, however, a cardiogenic etiology can eventually be determined. Hence, the aim of this study was to describe the prevalence of abnormal echocardiographic findings in a large number of these patients.

METHOD

Patients with cryptogenic cerebral ischemia (ischemic stroke, IS, and transient ischemic attack, TIA) were included. The initial work-up included a neurological examination, EEG, cCT, cMRT, 12-lead ECG, Holter-ECG, Doppler ultrasound of the extracranial arteries, and transthoracic echocardiography. A multiplane transeophageal echocardiography (TEE, including i.v. contrast medium application [Echovist], Valsalva maneuver) was performed in all patients

RESULTS

702 consecutive patients (380 male, 383 IS, 319 TIA, age 18-90 years) were included. In 52.6% of all patients, TEE examination revealed relevant findings. Overall, the most common findings in all patients were: patent foramen ovale (21.7%), previously undiagnosed valvular disease (15.8%), aortic plaques, aortic valve sclerosis, atrial septal aneurysms, regional myocardial dyskinesia, dilated left atrium and atrial septal defects. Older patients (> 55 years, n = 291) and patients with IS had more relevant echocardiographic findings than younger patients or patients with TIA, respectively (p = 0.002, p = 0.003). The prevalence rates of PFO or ASD were higher in younger patients (PFO: 26.8% vs. 18.0%, p = 0.005, ASD: 9.6% vs. 4.9%, p = 0.014).

CONCLUSION

A TEE examination in cryptogenic stroke reveals contributing cardiogenic factors in about half of all patients. Younger patients had a higher prevalence of PFO, whereas older patients had more frequently atherosclerotic findings. Therefore, TEE examinations seem indicated in all patients with cryptogenic stroke - irrespective of age - because of specific therapeutic consequences.

[Update on interventional cardiology]

Percutaneous intervention, whether coronary or noncoronary, continues to be a highly active area of medicine. This article contains an overview of the most notable developments reported in recent months. Drug-eluting stents (DESs) have provided one of the major advances in interventional cardiology as they have very effectively reduced the restenosis rate. Both randomized clinical trials and large observational studies have confirmed their safety, and their use has been extended to include highly complex conditions. Although thrombosis is one complication that can affect both conventional stents and DESs, the rate of late stent thrombosis is slightly, though significantly, higher with DESs. Primary angioplasty is the treatment of choice for patients with acute myocardial infarction if carried out under appropriate conditions, within a reasonable time period in a specialized center by experienced personnel. Use of thrombectomy devices can improve procedural outcomes and it appears that DES implantation is safe and effective, though more data are still needed. In patients with non-ST-elevation acute coronary syndrome, early treatment using an invasive approach coupled to the administration of various combinations of antiplatelet and antithrombotic drugs continues to be fundamental. Although left main coronary artery lesions are generally treated surgically, advances in percutaneous techniques and the use of DESs mean that an increasing number of patients are being treated using percutaneous coronary interventions. A number of studies have shown good results in other lesions and in high-risk patients with, for example, bifurcation lesions, chronic occlusions or diabetes. Intracoronary ultrasound is the predominant intracoronary diagnostic technique and it can be used to assist in optimizing DES implantation. In addition, measurement of the fractional flow reserve is helpful in evaluating the severity of moderate lesions whereas the high-resolution images provided by optical coherence tomography are particularly informative. Multislice computed tomography enables the presence of coronary artery disease to be ruled out and the technique is also useful as a complementary tool for interventional cardiologists. Research into regenerative techniques is promising but remains experimental at present. With regard to noncoronary interventions, new data have become available that support the use of a percutaneous approach in patients with patent foramen ovale. In addition, clinical experience with percutaneous aortic valve replacement, via either the transfemoral or transapical route, is increasing.

Atherosclerotic Burden Findings in Young Cryptogenic Stroke Patients With and Without a Patent Foramen Ovale

Background and Purpose— To further determine the mechanisms of cryptogenic stroke or transient ischemic attack in young patients, we evaluated indices of atherosclerosis in patients ≤55 years old diagnosed with cryptogenic cerebrovascular event comparing those with patent foramen ovale (PFO) with those without PFO.

Methods— This was a prospective study including 100 consecutive patients ≤55 years old (mean age, 45±8 years; 56 males) diagnosed with cryptogenic stroke/transient ischemic attack. PFO was identified in 59 of these patients with the use of transesophageal echocardiography with contrast study. The following surrogate markers of atherosclerosis were evaluated in all patients: carotid intima media thickness as measured by carotid ultrasonography and endothelial function as determined by brachial flow-mediated vasodilation. The same measurements were obtained in a control group of 50 age- and sex-matched control subjects.

Results— Patients without PFO were more likely to be current smokers and obese and more frequently had a history of hypertension and dyslipidemia. Carotid intima media thickness measurements were higher ( P <0.0001) in patients without PFO (1.03±0.31 mm) compared with those with PFO (0.75±0.20 mm) and control subjects (0.79±0.17 mm). The absence of PFO was also associated with lower brachial flow-mediated vasodilation (without PFO: 5.04±3.39%; with PFO: 7.16±4.09%; control subjects: 7.33±4.07%; P =0.02). There were no differences in carotid intima media thickness and flow-mediated vasodilation between patients with stroke/transient ischemic attack with PFO and control subjects. The presence of PFO was independently associated with reduced carotid intima media thickness ( P <0.0001) and increased flow-mediated vasodilation ( P =0.019).

Conclusions— In patients ≤55 years old diagnosed with cryptogenic stroke/transient ischemic attack, the presence of PFO was associated with a lower atherosclerotic burden as measured by carotid intima media thickness and endothelial function with no differences compared with a control group without cerebrovascular event. These results suggest that an atherosclerotic-mediated mechanism may be involved in cryptogenic stroke/transient ischemic attack in patients without PFO, whereas a nonatherosclerotic mechanism may mediate the cerebrovascular event in the presence of PFO.

May-Thurner syndrome in patients with cryptogenic stroke and patent foramen ovale: an important clinical association

BACKGROUND AND PURPOSE

We aimed to investigate the incidence of May-Thurner syndrome in patients with cryptogenic stroke with patent foramen ovale.

METHODS

This was a retrospective study. All consecutive patients with cryptogenic stroke having undergone patent foramen ovale closure from January 1, 2002, to December 31, 2007, at our institute were included in this study. Pelvic magnetic resonance venography studies of all patients were reviewed to determine if features of May-Thurner syndrome were present. Medical records and invasive venography studies of all patients were reviewed when available. All patients with May-Thurner syndrome features on magnetic resonance venography were reviewed by a vascular medicine specialist to define any previous incidence of deep vein thrombosis or any signs of chronic venous insufficiency. All patients also had lower limb venous duplex performed to rule out lower limb venous thrombosis.

RESULTS

A total of 470 patients from January 1, 2002, until December 31, 2007, with cryptogenic stroke underwent patent foramen ovale closure at our institute. Thirty patients (6.3%) had features consistent with May-Thurner syndrome on magnetic resonance venography. These patients were predominantly female (80%) with a mean age of 43.6+/-11.9 years. Twelve patients (40%) had abnormalities in their laboratory thrombophilia evaluation and 13 females (54.1%) were taking hormone-related birth control pills. Only 2 patients had a history and signs of chronic venous insufficiency. All patent foramen ovales demonstrated right-to-left shunting on transesophageal echocardiography. Atrial septal aneurysms/hypermobile atrial septa were present in 70% of patients with May-Thurner syndrome.

CONCLUSIONS

May-Thurner syndrome has an important clinical association with cryptogenic stroke and patent foramen ovale.

D-dimer level and the risk for thrombosis in systemic lupus erythematosus

BACKGROUND AND OBJECTIVES

Patients who have systemic lupus erythematosus (SLE) and manifest antiphospholipid antibodies (APA) are at increased risk for thrombosis; however, it is difficult to predict who will clot. This study tested the hypothesis that peak D-dimer level measured routinely during follow-up identifies whether a hypercoagulable state is developing and, therefore, the patient is at increased risk for thrombosis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

One hundred consecutive patients who had SLE with recurrent activity (71% renal SLE) and were evaluated for or enrolled in the Ohio SLE Study were studied. D-dimer testing was done annually and usually at SLE flare or other serious illness. When D-dimer was elevated, evaluation for thrombosis (large vessel, small vessel, or Libman-Sacks) was undertaken. Mean follow-up was 37.5 +/- 15 SD months.

RESULTS

Of those with peak D-dimer <0.5 microg/ml (n = 46), 0% thrombosed, 33% had APA. Of those with peak D-dimer 0.5 to 2.0 microg/ml (n = 19), 6% thrombosed, 44% had APA. Of those with peak D-dimer >2.0 microg/ml (n = 36), 42% thrombosed, 76% had APA. The most common causes of elevated D-dimer in the absence of demonstrable thrombosis were SLE flare and systemic infection. D-dimer levels were usually elevated for several months before thrombosis.

CONCLUSIONS

Patients with SLE and normal D-dimer levels are at low risk for thrombosis, irrespective of APA status. Those with persistent unexplained elevated D-dimer levels, particularly when >2.0 microg/ml, are at high risk for thrombosis.

Lack of association between right-to-left shunt and cerebral ischemia after adjustment for gender and age

Introduction

A number of studies has addressed the possible association between patent foramen ovale (PFO) and stroke. However, the role of PFO in the pathogenesis of cerebral ischemia has remained controversial and most studies did not analyze patient subgroups stratified for gender, age and origin of stroke.

Methods

To address the role of PFO for the occurrence of cerebral ischemia, we investigated the prevalence of right-to-left shunt in a large group of patients with acute stroke or TIA. 763 consecutive patients admitted to our hospital with cerebral ischemia were analyzed. All patients were screened for the presence of PFO by contrast-enhanced transcranial Doppler sonography at rest and during Valsalva maneuver. Subgroup analyses were performed in patients stratified for gender, age and origin of stroke.

Results

A right-to-left shunt was detected in 140 (28%) male and in 114 (42%) female patients during Valsalva maneuver, and in 66 (13%) and 44 (16%) at rest respectively. Patients with right-to-left shunt were younger than those without (P < 0.001). PFO was associated with stroke of unknown origin in male (P = 0.001) but not female patients (P > 0.05). After adjusting for age no significant association between PFO and stroke of unknown origin was found in either group.

Conclusion

Our findings argue against paradoxical embolization as a major cause of cerebral ischemia in patients with right-to-left shunt. Our data demonstrate substantial gender-and age-related differences that should be taken into account in future studies.

Is transesophageal echocardiography still necessary to exclude patent foramen ovale?

OBJECTIVES

Current guidelines still recommend transesophageal echocardiography (TEE) as reference method to diagnose interatrial shunts. The aim was to test the accuracy of high-end transthoracal echocardiography (TTE) to exclude inter-atrial shunts.

METHODS

Prospective TTE and TEE study with second harmonic imaging to determine left-to-right shunt (L/R) by both colour Doppler or R/L by contrast echocardiography in patients with unexplained cerebrovascular incidents or newly detected valvular or myocardial disease.

RESULTS

An inter-atrial shunt was diagnosed in 200 of 438 analyzed patients (117 males). Colour Doppler echocardiography visualized a shunt in 67 patients (34%) on TTE vs. 84 (42%) patients on TEE (p <0.0001). However injection of agitated blood with a valsalva maneuver detected 190 (95%) interatrial shunts by both TTE and TEE, but 10 shunts (5%) only by TTE.

CONCLUSIONS

Our study shows that patent foramen ovale can safely be demonstrated with high-end transthoracic contrast- echocardiography. If additional studies confirm our results, TTE has the potential to become the method of choice in the diagnosis of PFO.

The presence of a right-to-left shunt is associated with dramatic improvement after thrombolytic therapy in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

The efficacy of pharmacological thrombolysis using tissue plasminogen activator depends on the relative fibrin content of the thrombus. We investigated whether patients with stroke with a right-to-left shunt (RLS), whose embolic source was associated with fibrin-rich thrombus formed in the venous system, were more likely to improve dramatically after thrombolytic therapy than those without RLS.

METHODS

Patients with acute stroke treated with tissue plasminogen activator were assessed prospectively to determine the clinical factors associated with "dramatic improvement" after tissue plasminogen activator administration. "Dramatic improvement" was defined as a >/=10-point reduction in the total National Institutes of Health Stroke Scale score or a total National Institutes of Health Stroke Scale score of 0 or 1 at 7 days. The presence of an RLS was determined using contrast transcranial Doppler within 6 hours of stroke onset.

RESULTS

Forty-four patients (26 males; mean age; 73.0+/-10.7 years; baseline National Institutes of Health Stroke Scale score,13.4+/-6.6) were enrolled. Twenty-one patients had dramatic improvement (D group). Contrast transcranial Doppler demonstrated an RLS in 17 (35.4%) patients. On multivariate logistic regression analysis using hyperlipidemia, atrial fibrillation, RLS, DWI-ASPECTS (>8), baseline National Institutes of Health Stroke Scale score (<10), and glucose (<120 mg/dL) as variables with a P<0.1 on univariate analysis, RLS (OR, 5.9; CI,1.3 to 27.3; P=0.022) was the only independent factor associated with dramatic improvement.

CONCLUSIONS

The presence of an RLS on contrast transcranial Doppler was an independent factor associated with dramatic improvement after tissue plasminogen activator administration.

Unilateral versus bilateral middle cerebral artery detection of right-to-left shunt by power M-mode transcranial doppler

BACKGROUND AND PURPOSE

Comparison was performed between unilateral and bilateral power M-mode transcranial Doppler to detect right-to-left circulatory shunt (RLS).

METHODS

Recorded Doppler data from 87 patients with confirmed RLS referred for transcatheter closure of patent foramen ovale were reanalyzed for embolic tracks (ET) counted from left and right temporal bone windows during bubble study. Unilateral counts were obtained by multiplying each side by 2; bilateral counts were obtained by summing left and right ET. Both unilateral and bilateral ET were converted to a 6-point logarithmic grade. Sex and age group subanalyses were performed.

RESULTS

At rest, significantly more ET were detected with bilateral versus unilateral detection (P= .01), but not following Valsalva (P= .13). Unilateral and bilateral detection were equally able to detect large RLS (grades IV or V) following Valsalva (P= 1.00). For the group aged > or =55 years, the right-hand side yielded greater ET than the left-hand side (mean difference 9%+/- 37; 95% confidence interval -3 to 21%) at rest (P= .01), but not following Valsalva (mean difference 1%+/- 25; 95% confidence interval -7 to 9%, P= .10).

CONCLUSIONS

Unilateral detection of ET by power M-mode transcranial Doppler is equivalent to bilateral detection to assess RLS.

Prevalence of atrial septal abnormalities in older patients with cryptogenic ischemic stroke or transient ischemic attack

OBJECTIVE

To evaluate the association of atrial septal abnormalities--patent foramen ovale (PFO), atrial septal aneurysm (ASA), or the combination of both (PFO+ASA)--with cryptogenic stroke or transient ischemic attack (TIA) in older patients.

METHODS

We examined the prevalences of PFO, ASA, and PFO+ASA in 132 consecutive patients aged 55 years or more who underwent transesophageal echocardiography (TEE) for evaluation of ischemic stroke or TIA. We compared patients with cryptogenic stroke/TIA and those with stroke/TIA of known cause.

RESULTS

PFO+ASA was more common in patients with cryptogenic stroke/TIA than in patients with stroke/TIA of known cause (12/62 or 19% vs. 2/70 or 3%; adjusted odds ratio, 7.4; 95% CI, 1.4-38.2). Differences between groups for isolated PFO, and isolated ASA were not significant. The association of PFO+ASA with cryptogenic stroke/TIA was confirmed in the subgroup of patients aged 75 years or more (odds ratio, 15.0; 95% CI, 1.5-146.7).

CONCLUSION

This study indicates a significant association of PFO+ASA with cryptogenic stroke or TIA in older patients.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Patent foramen ovale percutaneous closure: the no-implant approach

Currently available catheter techniques for closure of a patent foramen ovale (PFO) rely on the placement of an implantable closure device. Sievert et al. evaluated the safety and feasibility of transcatheter closure of PFO using radiofrequency energy without an implanted device in patients with cryptogenic stroke or transient ischemic attack. In total, 30 patients were enrolled (15 females; mean age 48 years). Technical success was achieved in 90% of the patients. All 30 patients did not present any serious procedure-related adverse events. No recurrent strokes, deaths or perforations occurred as a result of the procedure. The mean follow-up was 6 months, and 13 out of the 30 (43%) patients experienced PFO closure after the first procedure. Complete closure after a second procedure was achieved in 63% of the cases. The authors demonstrate that transcatheter closure of an intracardiac defect without a permanent implant is technically feasible. However, future improvements in the technique and materials are needed.