Patent foramen ovale and risks of recurrence in stroke of determined etiology

Right Atrial Septal In Situ Microthrombus: A Potential Novel Cause of Patent Foramen Ovale-Associated Stroke

BACKGROUND

Patent foramen ovale (PFO)-associated stroke has a complex and diverse pathogenesis. It mainly results from a paradoxical embolism caused by venous thrombosis. However, few studies have investigated the presence of an in situ thrombus in the right atrium. Transesophageal echocardiography can effectively detect right atrial septal in situ microthrombus. Therefore, we aimed to explore the relationship between a right atrial septal in situ microthrombus and PFO-associated stroke and further dissect the pathophysiological basis of microthrombus formation.

METHODS AND RESULTS

Between April 2022 and October 2023, we prospectively investigated 466 patients who visited our hospital for transesophageal echocardiography with a high clinical suspicion of PFO. Right atrial septal in situ microthrombus was detected in 34 patients (7%), and 23 of them were examined. The microthrombus disappeared in 13 patients and decreased in 7; PFO recanalization and anatomical variations were observed in 2 and 1 patient, respectively. The incidence of index stroke was higher in the microthrombus group than in the nonmicrothrombus group (76.47% versus 61.11%). Univariate and multivariable (adjusted) analyses revealed PFO as an independent risk factor for right atrial septal in situ microthrombus formation (odds ratio, 3.29 [95% CI, 1.49-7.26]; P=0.003).

CONCLUSIONS

Transesophageal echocardiography effectively detects right atrial septal in situ microthrombus. A PFO may promote the formation of right atrial septal in situ microthrombus. Right atrial septal in situ microthrombus significantly increases the risk of PFO-associated stroke. This finding may be crucial in disease management strategies for patients with PFO.

Retrograde cerebral embolism and pulmonary embolism caused by patent ductus arteriosus: a case report

BACKGROUND

Although rare, paradoxical embolism sometimes occurs with patent ductus arteriosus (PDA). This study presents a case of PDA-associated paradoxical embolism with acute ischemic stroke (AIS) and pulmonary embolism (PE) following thoracoscopic surgery.

CASE PRESENTATION

A 65-year-old woman developed acute-onset aphasia and right hemiparesis on the third day following thoracoscopic resection for a right lung tumor. Brain magnetic resonance imaging revealed multiple infarcts, and lower extremity venous Doppler ultrasound revealed deep vein thrombosis. The patient subsequently developed dyspnea, tachycardia, and hypoxemia. PE was confirmed by percutaneous transfemoral venous selective pulmonary angiography, which meanwhile demonstrated a PDA lesion. The patient, after receiving catheter-directed thrombolysis and inferior vena cava filter placement, improved in both neurological and respiratory status.

CONCLUSION

For an uncommon but potentially fatal case with PDA-induced paradoxical embolism causing AIS and PE, early recognition and treatment are vital. Further studies are warranted to determine the optimal management and prognosis of patients with PDA-related embolic events.

In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale

INTRODUCTION

Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO.

METHODS

From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase.

RESULTS

We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30).

CONCLUSION

The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.

A Case of Strange Arterial Embolism After Uterine Curettage

Hysteroscopic local endometrial resection and curettage are common surgical procedures. Postoperative arterial thromboembolism is rare. However, coronary and renal embolism after the procedure has never been reported in the literature, so far. We report a 50-year-old woman who developed arterial thromboembolism 4 hours after local endometrial resection and curettage. Thrombus disappeared after anticoagulant therapy was started as soon as possible. How do strange clots form and by what route do they occur in the arterial system?

Prognostic value of central blood pressure on the outcomes of embolic stroke of undetermined source

We investigated the prognostic impact of central blood pressure (BP) on outcomes in patients with embolic stroke of undetermined source (ESUS). The prognostic value of central BP according to ESUS subtype was also evaluated. We recruited patients with ESUS and data on their central BP parameters (central systolic BP [SBP], central diastolic BP [DBP], central pulse pressure [PP], augmentation pressure [AP], and augmentation index [AIx]) during admission. ESUS subtype classification was arteriogenic embolism, minor cardioembolism, two or more causes, and no cause. Major adverse cardiovascular event (MACE) was defined as recurrent stroke, acute coronary syndrome, hospitalization for heart failure, or death. Over a median of 45.8 months, 746 patients with ESUS were enrolled and followed up. Patients had a mean age of 62.8 years, and 62.2% were male. Multivariable Cox regression analysis showed that central SBP and PP were associated with MACE. All-cause mortality was independently associated with AIx. In patients with no cause ESUS, central SBP and PP, AP, and AIx were independently associated with MACE. AP and AIx were independently associated with all-cause mortality (all p < 0.05). We demonstrated that central BP can predict poor long-term prognosis in patients with ESUS, especially those with the no cause ESUS subtype.