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Casey A, Jeyaseelan A, Byrne L, Reardon MF. Presentation of basilar artery stroke secondary to patent foramen ovale: a diagnosis made with a 'selfie'. BMJ Case Rep 2024; 17:e256223. [PMID: 38182167 PMCID: PMC10773335 DOI: 10.1136/bcr-2023-256223] [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: 01/07/2024] Open
Abstract
We report the case of a woman in her late 20s, with no significant medical history, who was found unresponsive at home. Her mother revealed a 'selfie' sent to her by the patient 30 min prior to collapse which revealed bilateral ptoses. Initial brain imaging with non-contrast CT of the brain revealed nil of note. A multiphase CT angiogram revealed an acute basilar artery thrombosis. She underwent timely thrombolysis and was transferred for endovascular thrombectomy. Further evaluation with an aim to define the aetiology revealed the diagnosis of patent foramen ovale with a resultant paradoxical embolism. The differential diagnoses of unexplained rapidly evolving neurology with reduced Glasgow coma scale, and relevant appropriate investigations are discussed in this case report.
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Affiliation(s)
- Aoife Casey
- Medicine, Wexford General Hospital, Newtown Road, Carricklawn, Wexford, Ireland
| | - Arveen Jeyaseelan
- Medicine, Wexford General Hospital, Newtown Road, Carricklawn, Wexford, Ireland
| | - Luke Byrne
- Medicine, Wexford General Hospital, Newtown Road, Carricklawn, Wexford, Ireland
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2
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Sposato LA, Albin CSW, Elkind MSV, Kamel H, Saver JL. Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence. Stroke 2024; 55:236-247. [PMID: 38134261 DOI: 10.1161/strokeaha.123.040546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
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Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry (L.A.S.), Western University, London, ON, Canada
- Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada (L.A.S.)
| | - Catherine S W Albin
- Department of Neurology & Neurosurgery, Emory University School of Medicine, Atlanta, GA (C.S.W.A.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
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Aliramezany M, Moazenzadeh M, Sayyadi A, Mohammadi K, Barzegar H, Aliramezany M. Atrial Septal Abnormalities and Cryptogenic Stroke: A Cross-Sectional Study. Cardiovasc Hematol Disord Drug Targets 2024; 24:40-46. [PMID: 38685781 DOI: 10.2174/011871529x294809240415070950] [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] [Received: 12/31/2023] [Revised: 03/19/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Cryptogenic stroke, whose underlying pathology is unknown, accounts for 30-40% of all ischemic strokes. Studies have mentioned the association between atrial septal abnormalities and cryptogenic stroke, but there are still disparities in the results among different studies. OBJECTIVE We aimed to clarify the prevalence of atrial septal abnormalities in patients with cryptogenic stroke. METHODS We conducted a cross-sectional study on 91 patients with cryptogenic stroke/transient ischemic attack from March 2021 to March 2022. We evaluated the demographic data of the patients and also the existence of neurologic attacks. Furthermore, echocardiography was performed to determine the type of atrial septal abnormality. RESULTS Out of 91 patients with cryptogenic stroke/transient ischemic attack, 16 patients (17.5%) had patent foramen ovale, 1 man (1.1%) had atrial septal aneurysm, and 1 woman (1.1%) had an atrial septal defect. Patients with patent foramen ovale were significantly younger than those without. The size of patent foramen ovale in patients with cryptogenic stroke was larger than those with transient ischemic attack, but this difference was not significant. Also, the size of the patent foramen ovale (length and width) was not significantly related to any of the demographic variables (p-value = 0.544, 0.604). CONCLUSION Based on our results, the prevalence of atrial septal abnormalities was relatively high. Considering these issues and the importance of preventing neurological accidents in patients, especially young people, it is recommended to always consider atrial septal disorders and, if diagnosed, to carry out the necessary treatment in this field.
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Affiliation(s)
- Marzieh Aliramezany
- Department of Cardiology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mansoor Moazenzadeh
- Department of Cardiology, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Amin Sayyadi
- Department of Cardiology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Khadijeh Mohammadi
- Department of Cardiology, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamidreza Barzegar
- Neurology Department, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Aliramezany
- Department of Cardiology, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
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Tariq MB, Qadri SKS, Sharrief A, Tulod K, Dhoble A, Gurung S, Jamilla Lacap M, Okpala M, Manwani B, Smalling RW, Gonzales N. Heart Brain Clinic: An Integrated Approach to Stroke Care. Neurol Clin Pract 2023; 13:e200206. [PMID: 38495079 PMCID: PMC10942000 DOI: 10.1212/cpj.0000000000200206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/21/2023] [Indexed: 03/19/2024]
Abstract
Background and Objectives Multidisciplinary clinics have been shown to improve care. Patients with patent foramen ovale (PFO)-associated stroke need evaluation by cardiology and neurology specialists. We report our experience creating a multidisciplinary Structural Heart Brain Clinic (HBC) with a focus on patients with PFO-associated stroke. Methods Demographic and clinical data were retrospectively collected for patients with PFO-associated ischemic stroke. Patients with PFO-associated stroke were divided into a standard care group and Heart Brain Clinic group for analysis. Outcome measures included time from stroke to PFO closure and number of clinic visits before decision regarding closure. Nonparametric analysis evaluated differences in median time to visit and clinical decision, while the chi square analysis compared differences in categorical variables between groups. Results From February 2017 to December 2021, 120 patients were evaluated for PFO-associated stroke. The Structural HBC began in 12/2018 with coordination between Departments of Neurology and Cardiology. For this analysis, 41 patients were considered in the standard care group and 79 patients in the HBC group. During data analysis, 107 patients had received recommendations about PFO closure. HBC patients required fewer clinic visits (p = 0.001) before decision about closure; however, among patients who underwent PFO closure, there was no significant difference in weeks from stroke to PFO closure. Clinicians were more likely to recommend against PFO closure among patients seen in HBC compared with those seen in standard care (p = 0.021). Discussion Our data demonstrate that a multidisciplinary, patient-centered approach to management of patients with PFO-associated ischemic stroke is feasible and may improve the quality of care in this younger patient population. The difference in recommendation to not pursue PFO closure between groups may reflect selection and referral bias. Additional work is needed to determine whether this approach improves other aspects of care and outcomes.
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Affiliation(s)
- Muhammad Bilal Tariq
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Syed Kalimullah S Qadri
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Anjail Sharrief
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Kathleen Tulod
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Abhijeet Dhoble
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Sidhanta Gurung
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Maria Jamilla Lacap
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Munachi Okpala
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Bharti Manwani
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Richard W Smalling
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
| | - Nicole Gonzales
- Department of Neurology (MBT), University of Texas Health Science Center at Houston; Department of Neurology (SKSQ), University of California Los Angeles; Department of Neurology and Stroke Institute (AS, KT, MO, BM), University of Texas Health Science Center at Houston; Department of Cardiology (AD, SG, MJL, RWS), University of Texas Health Science Center at Houston; and Department of Neurology (NG), University of Colorado Anschutz Medical Campus
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Kanemaru K, Ueno Y, Kikuno M, Tateishi Y, Shimizu T, Kuriki A, Doijiri R, Takekawa H, Shimada Y, Yamaguchi E, Koga M, Kamiya Y, Ihara M, Tsujino A, Hirata K, Hasegawa Y, Aizawa H, Hattori N, Urabe T. High-risk patent foramen ovale and elderly in cryptogenic stroke. J Stroke Cerebrovasc Dis 2023; 32:107344. [PMID: 37722223 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND High-risk patent foramen ovale (PFO) could be pathological in cryptogenic stroke (CS), but its clinical characteristics have not been fully studied, especially in elderly patients. METHODS Patients with CS were enrolled in the CHALLENGE ESUS/CS registry, a multicenter registry of CS patients undergoing transesophageal echocardiography. Clinical characteristics were compared among three groups: high-risk PFO group, large shunt PFO (≥25 microbubbles) or PFO with atrial septal aneurysm (ASA); right-to-left shunt (RLS) group, RLS including PFO with <25 microbubbles or without ASA; and no-RLS group. RESULTS In total, 654 patients were analyzed: 91, 221, and 342 in the high-risk PFO, RLS, and no-RLS groups, respectively. In multinomial logistic regression analysis, the male sex (odds ratio [OR] 1.825 [1.067-3.122]) was independently associated with high-risk PFO, but hypertension (OR, 0.562 [0.327-0.967]), multiple infarctions (OR, 0.601 [0.435-0.830]), and other cardioaortic embologenic risks (OR, 0.514 [0.294-0.897]) were inversely associated with high-risk PFO compared with non-RLS. In 517 patients aged ≥60 years, multiple infarctions (OR, 0.549 [0.382-0.788]) and other cardioaortic embologenic risks (OR, 0.523 [0.286-0.959]) were inversely associated with high-risk PFO. CONCLUSIONS High-risk PFO had specific clinical characteristics and possible mechanistic associations, and this trend was consistent among CS patients aged ≥60 years. CLINICAL TRIAL REGISTRATION INFORMATION http://www.umin.ac.jp/ctr/ (UMIN000032957).
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Affiliation(s)
- Kodai Kanemaru
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan.
| | - Muneaki Kikuno
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Shimizu
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Ayako Kuriki
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | | | - Yoshiaki Shimada
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Eriko Yamaguchi
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hitoshi Aizawa
- Department of Neurology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
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Farjat‐Pasos JI, Guedeney P, Houde C, Alperi A, Robichaud M, Côté M, Montalescot G, Rodés‐Cabau J. Sex Differences in Patients With Cryptogenic Cerebrovascular Events Undergoing Transcatheter Closure of Patent Foramen Ovale. J Am Heart Assoc 2023; 12:e030359. [PMID: 37776218 PMCID: PMC10727268 DOI: 10.1161/jaha.123.030359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/18/2023] [Indexed: 10/02/2023]
Abstract
Background Scarce data exist on sex differences in patients with cryptogenic cerebrovascular events undergoing patent foramen ovale (PFO) closure. This study aimed to determine the sex differences in clinical profile, procedural characteristics, and long-term outcomes of patients with cryptogenic cerebrovascular events undergoing PFO closure. Methods and Results A retrospective cohort was used, including 1076 consecutive patients undergoing PFO closure because of a cryptogenic cerebrovascular event. Patients were divided into 2 groups: 469 (43.6%) women and 607 (56.4%) men. The median follow-up was 3 years (interquartile range, 2-8 years). Women were younger (46±13 versus 50±12 years; P<0.01) and had a higher risk of paradoxical embolism score (6.9±1.7 versus 6.6±1.6; P<0.01). Procedural characteristics and postprocedural antithrombotic therapy were similar. At follow-up, there were no differences in atrial fibrillation (women versus men: 0.47 versus 0.97 per 100 patient-years; incidence rate ratio [IRR], 0.55 [95% CI, 0.27-1.11]; P=0.095; adjusted P=0.901), stroke (0.17 versus 0.07 per 100 patient-years; IRR, 2.58 [95% CI, 0.47-14.1]; P=0.274; adjusted P=0.201), or transient ischemic attack (0.43 versus 0.18 per 100 patient-years; IRR, 2.58 [95% CI, 0.88-7.54]; P=0.084; adjusted P=0.121); nevertheless, women exhibited a higher incidence of combined ischemic cerebrovascular events (0.61 versus 0.26 per 100 patient-years; IRR, 2.58 [95% CI, 1.04-6.39]; P=0.041; adjusted P=0.028) and bleeding events (1.04 versus 0.45 per 100 patient-years; IRR, 2.82 [95% CI, 1.41-5.65]; P=0.003; adjusted P=0.004). Conclusions Compared with men, women with cryptogenic cerebrovascular events undergoing PFO closure were younger and had a higher risk of paradoxical embolism score. After a median follow-up of 3 years, there were no differences in stroke events, but women exhibited a higher rate of combined (stroke and transient ischemic attack) cerebrovascular events and bleeding complications. Additional studies are warranted to clarify sex-related outcomes after PFO closure further.
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Affiliation(s)
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP‐HP)ParisFrance
| | - Christine Houde
- Centre Hospitalier Universitaire de QuebecLaval UniversityQuebec CityQuebecCanada
| | - Alberto Alperi
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Mathieu Robichaud
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP‐HP)ParisFrance
| | - Josep Rodés‐Cabau
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
- Centre Hospitalier Universitaire de QuebecLaval UniversityQuebec CityQuebecCanada
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Capone J, Brown IE, Mukherji J. Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return. A A Pract 2023; 17:e01669. [PMID: 37043390 PMCID: PMC10144289 DOI: 10.1213/xaa.0000000000001669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Joseph Capone
- From the Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Irwin E. Brown
- From the Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Jayanta Mukherji
- From the Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois
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8
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Asghar A, Stefanescu Schmidt AC, Sahakyan Y, Horlick EM, Abrahamyan L. Sex differences in baseline profiles and short-term outcomes in patients undergoing closure of patent foramen ovale. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100199. [PMID: 38559747 PMCID: PMC10978392 DOI: 10.1016/j.ahjo.2022.100199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 04/04/2024]
Abstract
Objectives Although sex differences have been emphasized in stroke and congenital heart disease, there has been limited investigation into their role in patent foramen ovale (PFO) closure for secondary prevention of stroke. We aimed to explore differences by sex in baseline profiles, procedural characteristics, and short-term outcomes of patients undergoing transcatheter PFO closure. Methods Data of adult patients undergoing transcatheter PFO closure at the Toronto General Hospital from 1997 to 2017 was retrospectively analyzed. Baseline information included demographic characteristics, medical history, diagnostic, and procedural information, and periprocedural complications. Post-closure outcomes were captured at index hospitalization and during the first follow-up. Results From 1031 patients in the cohort sample, 80.7 % underwent closure for cryptogenic stroke and 44.7 % (n = 461) were females. We observed significant sex-related differences in baseline characteristics; females were younger, less likely to have a history of smoking, and less likely to have several cardiovascular risk factors at baseline (p < 0.05). The median time to first follow-up was 89 days for both groups. Recurrent stroke was observed in 0.1 % and TIA observed in 0.4 % of in the 'cryptogenic stroke/TIA' group; in the 'other indications' group, 1.4 % stroke and no TIA were reported. No significant differences were present between sexes. Conclusions There were no differences in procedural and short-term outcomes between males and females undergoing transcatheter PFO closure, but significant baseline differences in risk factors were identified. There is a critical need for long-term, systematic studies to understand sex and gender differences in the PFO population.
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Affiliation(s)
- Areeba Asghar
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ada C. Stefanescu Schmidt
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, UHN, Toronto, Ontario, Canada
| | - Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Ontario, Canada
| | - Eric M. Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, UHN, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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9
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Shimfessel TT, El-Dalati SA, Sekela M, Ahmed T. Paradoxical embolisation in right-sided infective endocarditis and patent foramen ovale. BMJ Case Rep 2022; 15:e250272. [PMID: 35623657 PMCID: PMC9150164 DOI: 10.1136/bcr-2022-250272] [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] [Accepted: 05/13/2022] [Indexed: 11/03/2022] Open
Abstract
Intravenous drug use (IVDU) is a growing public health crisis worldwide. A known complication of IVDU is right-sided infective endocarditis (RSIE) involving the tricuspid valve. As the tricuspid valve is burdened with infectious vegetations, it becomes a potential source of pulmonary and, very rarely, paradoxical systemic emboli. We report two patients with RSIE involving the tricuspid valve presenting with acute change in mental status. Subsequent imaging demonstrated embolisation to the brain in the setting of elevated right atrial pressures and the presence of a patent foramen ovale (PFO) with right-to-left shunting. We employed a strategy of percutaneous closure of PFO, to prevent further embolisation, as a successful bridge to definitive surgical management of RSIE. We emphasise that clinicians should evaluate for intracardiac shunting and pursue transesophageal echocardiography when encountering systemic emboli of unknown origin, particularly in patients with RSIE.
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Affiliation(s)
- Tyler T Shimfessel
- Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Sami A El-Dalati
- Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Michael Sekela
- Cardiothoracic Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Taha Ahmed
- Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
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10
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Gajo EC, Kavinsky CJ, Murphy J, Suradi HS. The pivotal role of PFO in paradoxical embolism following venous sclerotherapy: a unique case report with pathological correlations. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab228. [PMID: 34514300 PMCID: PMC8422334 DOI: 10.1093/ehjcr/ytab228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/14/2022]
Abstract
Background Vein sclerosing therapy for varicose veins remains an extremely popular procedure. Cerebrovascular accidents can be a serious complication. A patent foramen ovale (PFO) can act as a conduit to the arterial circulation, which could explain the adverse neurologic consequence of this procedure. This case provides pathologic evidence of this concept. Case summary A 66-year-old female presented with syncope after undergoing varicose vein sclerotherapy. A computed tomography angiography of the head and neck in the emergency room revealed an occluded right distal M1 middle cerebral artery. Clot retrieval was performed with final pathology revealing amorphous material consistent with an exogenous agent, polidocanol foam, which was used for the patient’s vein sclerotherapy. A transthoracic echocardiogram and transoesophageal echocardiogram showed a PFO, which was ultimately closed percutaneously. Discussion In a quarter of the population, lack of closure of the intrauterine interatrial shunt leads to the existence of a PFO. This direct communication between the atria provides an anatomical conduit for paradoxical emboli and eventually infarction of affected tissues. While a paradoxical embolism is an uncommon cause of acute arterial occlusion, it can have catastrophic sequelae. Historically, the presence of an arterial thrombus from the venous circulation has been difficult to establish unless the thrombus is visualized in transit through a PFO. Complications from vein sclerotherapy have been reported in the literature and include transient ischaemic attacks and strokes, however, this is the first case to provide pathological proof of a paradoxical embolism, which ultimately resulted in percutaneous closure of the PFO.
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Affiliation(s)
- Eileen C Gajo
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 West Harrison Street, Chicago, IL 60612, USA
| | - Clifford J Kavinsky
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 West Harrison Street, Chicago, IL 60612, USA
| | - Joshua Murphy
- Division of Cardiology, Department of Pediatrics, Rush University Medical Center, 1620 West Harrison Stress, Chicago, IL 60612, USA
| | - Hussam S Suradi
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 West Harrison Street, Chicago, IL 60612, USA
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11
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Powers WJ. Clinical utility of echocardiography in secondary ischemic stroke prevention. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:359-375. [PMID: 33632453 DOI: 10.1016/b978-0-12-819814-8.00022-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Echocardiography employs ultrasound to evaluate cardiac function, structure and pathology. The clinical value in secondary ischemic stroke prevention depends on identification of associated conditions for which a change in treatment from antiplatelet agents and risk factor intervention leads to improved outcomes. Such therapeutically relevant findings include primarily intracardiac thrombus, valvular heart disease and, in highly selected patients, patent foramen ovale (PFO). Echocardiography in unselected patients with ischemic stroke has a very low yield of therapeutically relevant findings and is not cost-effective. With the exception of PFO, findings on echocardiography that are therapeutically relevant for secondary stroke prevention are almost always associated with history, signs or symptoms of cardiac or systemic disease. Choice of specific echocardiographic modalities should be based on the specific pathology or pathologies that are under consideration for the individual clinical situation. Transthoracic echocardiography (TTE) with agitated saline has comparable accuracy to transesophageal echocardiography (TEE) for PFO detection. For other therapeutically relevant pathologies, with the possible exception of left ventricular thrombus (LVT), TEE is more sensitive than TTE. Professional societies recommend TTE as the initial test but these recommendations do not take cost into account. In contrast, cost-effectiveness studies have determined that the most sensitive echocardiographic modality should be selected as the initial and only test.
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Affiliation(s)
- William J Powers
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
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12
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Lak HM, Ahmed T, Nair R, Maroo A. Simultaneous Multifocal Paradoxical Embolism in an Elderly Patient with Patent Foramen Ovale: A Case Report. Cureus 2020; 12:e6992. [PMID: 32206456 PMCID: PMC7077121 DOI: 10.7759/cureus.6992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 12/16/2022] Open
Abstract
About one-third of ischemic strokes may be associated with a patent foramen ovale (PFO). This article presents an unusual case of a 68-year-old woman with simultaneous paradoxical thrombo-embolization to different systemic sites. The patient presented initially with visual deficits and intracerebellar hemorrhage but was found to have concomitant saddle pulmonary embolism, sub-acute cerebral infarction with focal neurological deficits, and thromboembolism to the superior mesenteric artery (SMA) that resulted in an ischemic bowel. The unifying diagnosis was paradoxical embolism through a PFO and an atrial septal aneurysm with high-risk features. The patient underwent percutaneous closure of the PFO with an Amplatzer device.
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Affiliation(s)
- Hassan M Lak
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Taha Ahmed
- Internal Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Raunak Nair
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Anjli Maroo
- Cardiology, Cleveland Clinic - Fairview Hospital, Cleveland, USA
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13
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Wasser K, Weber-Krüger M, Jürries F, Liman J, Hamann GF, Kermer P, Uphaus T, Protsenko E, Seegers J, Mende M, Gröschel K, Wachter R. The cardiac diagnostic work-up in stroke patients-A subanalysis of the Find-AFRANDOMISED trial. PLoS One 2019; 14:e0216530. [PMID: 31071137 PMCID: PMC6508702 DOI: 10.1371/journal.pone.0216530] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 04/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background The cardiac diagnostic workup of stroke patients, especially the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis. Methods Find-AFRANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to enhanced and prolonged Holter-ECG monitoring or usual stroke unit care. This substudy compared therapeutic consequences of echocardiography and routine Holter-ECG or enhanced and prolonged Holter-ECG monitoring, respectively, and prognosis of patients with or without pathologic findings in echocardiography or Holter-ECG monitoring. Results 50.3% received enhanced and prolonged Holter-ECG monitoring and 49.7% routine ECG monitoring. 82.9% underwent transthoracic echocardiography (TTE), 38.9% transesophageal echocardiography (TEE) and 25.6% both procedures. 14/89 TEE pathologies and 1/90 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 330 (p < 0.001), respectively. In comparison, enhanced and prolonged Holter-ECG monitoring found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively, p < 0.001). Conclusions Most changes in therapeutic decisions were triggered by enhanced and prolonged Holter-ECG monitoring, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials. Trial registration ClinicalTrials.gov NCT01855035
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Affiliation(s)
- Katrin Wasser
- Clinic for Neurology, University of Göttingen, Göttingen, Germany
| | - Mark Weber-Krüger
- Clinic for Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
| | - Falko Jürries
- Clinic for Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
| | - Jan Liman
- Clinic for Neurology, University of Göttingen, Göttingen, Germany
| | - Gerhard F. Hamann
- Clinic for Neurology and Neurorehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Pawel Kermer
- Clinic for Neurology, Nordwest-Krankenhaus Sanderbusch, Sande, Germany
| | - Timo Uphaus
- Clinic and Polyclinic for Neurology, University of Mainz, Mainz, Germany
| | - Evgeny Protsenko
- Clinic for Neurology, Nordwest-Krankenhaus Sanderbusch, Sande, Germany
| | - Joachim Seegers
- Department of Internal Medicine II, Division of Cardiology, University Hospital Regensburg, Regensburg, Germany
| | - Meinhard Mende
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Hospital Leipzig, Leipzig, Germany
| | - Klaus Gröschel
- Clinic and Polyclinic for Neurology, University of Mainz, Mainz, Germany
| | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Germany
- * E-mail:
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Wilhelm CM, Sisk TL, Roble SL, Chisolm JL, Janevski I, Cheatham JP, Cua CL. Accuracy of Imaging Modalities in Detection of Baffle Leaks in Patients Following Atrial Switch Operation. Echocardiography 2015; 33:437-42. [DOI: 10.1111/echo.13097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Tracey L. Sisk
- The Heart Center; Nationwide Children's Hospital; Columbus Ohio
| | - Sharon L. Roble
- The Heart Center; Nationwide Children's Hospital; Columbus Ohio
| | | | - Ilija Janevski
- The Heart Center; Nationwide Children's Hospital; Columbus Ohio
| | | | - Clifford L. Cua
- The Heart Center; Nationwide Children's Hospital; Columbus Ohio
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15
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Dong J, Elmadhoun O, Ma X. Aetiological diagnosis of middle-aged and elderly cryptogenic ischaemic cerebral vascular disease. Neurol Res 2015; 37:744-9. [PMID: 26004758 DOI: 10.1179/1743132815y.0000000056] [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: 10/31/2022]
Abstract
Although tremendous efforts have been made to explore the potential aetiologies of cryptogenic ischaemic cerebral vascular disease (CICVD), it remains a great challenge for neurologists to get a comprehensive picture of CICVD across the world. Part of the reason why is that the vast majority of studies have focussed on CICVD in young stroke patients while the underlying causes of CICVD in middle-aged or elderly stroke population have not been fully investigated. The focus of this paper has been dedicated to review the different studies that explore the aetiologies of CICVD cases in this patient population. While there is a set of heterogeneous causes that can lead to CICVD in middle-aged and elderly patients, our review reveals that emboli originated from or across occult places within the heart or produced by transient arrhythmias could possibly be the main culprit. Dislodged aortic plaques might also account for certain CICVD cases and in fewer cases, hereditary arteriopathy and thrombophilia can also play a role. The aforementioned factors have similar roles in middle-aged and elderly CICVD patients as in their younger counterparts. However, more studies are needed to explore the role of these factors in older patients.
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16
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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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17
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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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18
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Mallick AA, O’Callaghan FJK. Risk factors and treatment outcomes of childhood stroke. Expert Rev Neurother 2014; 10:1331-46. [DOI: 10.1586/ern.10.106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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19
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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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20
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Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C. How to Understand Patent Foramen Ovale Clinical Significance: Part I. J Cardiovasc Echogr 2014; 24:114-121. [PMID: 28465918 PMCID: PMC5353567 DOI: 10.4103/2211-4122.147202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Patent foramen ovale (PFO) is a remnant of fetal circulation commonly found in healthy population. However, a large number of clinical conditions have been linked to PFO, the most important being ischemic strokes of undetermined cause (cryptogenic strokes) and migraine, especially migraine with aura. Coexistent atrial septal aneurysm, size of PFO, degree of the shunt, shunt at rest, pelvic deep vein thrombosis, and prothrombotic states (G20210A prothrombin gene mutation, Factor V Leiden mutation, MTHFR: C677T, basal homocystine, recent surgery, trauma, or use of contraceptives) could enhance stroke risk in subjects with PFO. Owing to the complexity of this issue, for any individual presenting with a PFO, particularly in the setting of cryptogenic stroke, it is not clear whether the PFO is pathogenically related to the neurological event or an incidental finding. Thus, a heart-brain team, which individually plans the best strategy, in accordance with neuroimaging findings and anatomical characteristics of PFO, is strongly recommended. In the first part of this review, we discuss the embryologic and anatomic features of PFO, the diagnostic techniques for its identification and evaluation, and the relationship between PFO and neurological syndromes. A special attention is made to provide some key points, useful in a daily clinical practice, which summarize how better we understand PFO clinical significance
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Affiliation(s)
- Gabriella Falanga
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Giuseppe Oreto
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Bijoy K Khandheria
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin, USA
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
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21
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Leong MC, Uebing A, Gatzoulis MA. Percutaneous patent foramen ovale occlusion: Current evidence and evolving clinical practice. Int J Cardiol 2013; 169:238-43. [DOI: 10.1016/j.ijcard.2013.08.095] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 08/11/2013] [Accepted: 08/29/2013] [Indexed: 11/29/2022]
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22
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Kumar T, Budnur SC, Mahadevappa NC, Singla V. Paradoxical embolism via a patent foramen ovale. BMJ Case Rep 2013; 2013:bcr-2013-009818. [PMID: 23704458 DOI: 10.1136/bcr-2013-009818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tarun Kumar
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences, Bengaluru, Karnataka, India.
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23
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Sathasivam S, Sathasivam S. Patent foramen ovale and migraine: What is the relationship between the two? J Cardiol 2013; 61:256-9. [DOI: 10.1016/j.jjcc.2012.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 11/23/2012] [Accepted: 12/04/2012] [Indexed: 01/16/2023]
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24
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Smith CE. Understanding the role of patent foramen ovale in stroke. Nursing 2013; 43:52-55. [PMID: 23507950 DOI: 10.1097/01.nurse.0000425864.42078.f7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Carolyn E Smith
- ortho/neuro/trauma unit of York Hospital and York College of Pennsylvania, York, Pa., USA
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25
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Abstract
Ischemic stroke in younger people is common, and often remains unexplained. There is a well-documented association between unexplained stroke in younger people, and the presence of a patent foramen ovale. Therefore, in the absence of a clear cause of stroke, the heart is often assessed in detail for such lower risk causes of stroke. This usually involves imaging with a transesophageal echo, and investigation for a right-to-left shunt. An understanding of the anatomy of the atrial septum, and its associated abnormalities, is important for the stroke neurologist charged with decision making regarding appropriate secondary prevention. In this paper, we review the development and anatomy of the right heart with a focus on patent foramen ovale, and other associated abnormalities. We discuss how the heart can be imaged in the case of unexplained stroke, and provide examples. Finally, we suggest a method of investigation, in light of the recent European Association of Echocardiography guidance. Our aim is to provide the neurologist with an understanding on how the heart can be investigated in unexplained stroke, and the significance of abnormalities detected.
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Affiliation(s)
- Paul E Cotter
- Department of Medicine, University of Cambridge, Cambridge, UK.
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26
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Di Legge S, Sallustio F, De Marchis E, Rossi C, Koch G, Diomedi M, Borzi M, Romeo F, Stanzione P. Short-Term and Two-Year Rate of Recurrent Cerebrovascular Events in Patients with Acute Cerebral Ischemia of Undetermined Aetiology, with and without a Patent Foramen Ovale. ISRN NEUROLOGY 2011; 2011:959483. [PMID: 22389838 PMCID: PMC3263533 DOI: 10.5402/2011/959483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/10/2011] [Indexed: 11/24/2022]
Abstract
Purpose. We investigated stroke recurrence in patients with acute ischemic stroke of undetermined aetiology, with or without a patent foramen ovale (PFO). Methods. Consecutive stroke patients underwent to Transcranial Doppler and Transesophageal Echocardiography for PFO detection. Secondary stroke prevention was based on current guidelines. Results. PFO was detected in 57/129 (44%) patients. The rate of recurrent stroke did not significantly differ between patients with and without a PFO: 0.0% versus 1.4% (1 week), 1.7% versus 2.7% (1 month), and 3.5% versus 4.2% (3 months), respectively. The 2-year rates were 10.4% (5/48) in medically treated PFO and 8.3% (6/72) in PFO-negative patients (P = 0.65), with a relative risk of 1.25. No recurrent events occurred in 9 patients treated with percutaneous closure of PFO. Conclusion. PFO was not associated with increased rate of recurrent stroke. Age-related factors associated with stroke recurrence in cryptogenic stroke should be taken into account when patients older than 55 years are included in PFO studies.
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Affiliation(s)
- Silvia Di Legge
- Department of Clinical Neurological Sciences, Stroke Unit, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Rome, Italy
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27
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De Marchis E, Di Legge S, Sallustio F, Stanzione P, Borzi M, Romeo F. Cryptogenic cerebral ischemia. J Cardiovasc Med (Hagerstown) 2011; 12:530-7. [DOI: 10.2459/jcm.0b013e328344e4ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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28
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Yerlioglu E, Krishnamoorthy V, Jeon H, Gustin A, Nicolau-Raducu R. Patent foramen ovale and intracardiac thrombus identified by transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 2011; 26:1069-73. [PMID: 21757375 DOI: 10.1053/j.jvca.2011.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Indexed: 12/17/2022]
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29
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Vyas A, Singh A, Vyas P, Kranis M, Pacifico L, Bojar R. A rare case of simultaneous pulmonary and paradoxical emboli with a thrombus straddling a patent foramen ovale. J Cardiol Cases 2011; 4:e47-e49. [PMID: 30532868 DOI: 10.1016/j.jccase.2011.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 05/15/2011] [Accepted: 05/23/2011] [Indexed: 11/28/2022] Open
Abstract
Background Paradoxical embolism is a rare event and the exact contribution of patent foramen ovale in stroke is unclear. Intracardiac thrombi or 'embolus-in-transit' are associated with high mortality. Acutely elevated pulmonary arterial pressure due to pulmonary embolism or Valsalva maneuver make foramen ovale patent and promote right to left migration of intraatrial clot. A large thrombus trapped during its passage produces impending paradoxical embolism, which though proposed, is documented very rarely in live patients. This is a high-risk situation. Surgical embolectomy, like our case, has shown to have better outcomes in overall patient survival. Case A 66-year-old female with acute left main cerebral artery infarct and acute bilateral pulmonary embolism. In initial assessment, lower extremities venous Doppler study revealed left leg deep venous thrombosis and transthoracic echocardiogram showed a long biatrial clot straddling through patent foramen ovale and a right-to-left interatrial shunt. After heparinization and inferior vena caval filter placement, she underwent successful surgical embolectomy along with closure of patent foramen ovale with subsequent uneventful recovery. Conclusion 'Embolus in transit' is a high-risk situation and should be actively searched for in patients of pulmonary embolism and stroke. We recommend surgical embolectomy over other treatment modalities in such situations.
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Affiliation(s)
- Ashish Vyas
- Department of Neurology, NYU Hospitals, New York, NY, USA
| | - Aniruddha Singh
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA, USA
| | - Priyanka Vyas
- Department of Internal Medicine, Reading Hospital, Reading, PA, USA
| | - Mark Kranis
- Department of Cardiology, Saint Vincent Hospital, Worcester, MA, USA
| | - Luigi Pacifico
- Department of Cardiology, Saint Vincent Hospital, Worcester, MA, USA
| | - Robert Bojar
- Department of Cardiothoracic surgery, Saint Vincent Hospital, Worcester, MA, USA
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30
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99mTc-MAA lung scan can be an alternative in detection and follow-up of patent foramen ovale. Int J Cardiol 2011; 147:296-8. [DOI: 10.1016/j.ijcard.2010.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 12/04/2010] [Indexed: 11/19/2022]
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31
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Naqvi TZ, Rafie R, Daneshvar S. ORIGINAL INVESTIGATIONS: Potential Faces of Patent Foramen Ovale (PFO PFO). Echocardiography 2010; 27:897-907. [DOI: 10.1111/j.1540-8175.2010.01165.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Patent foramen ovale has become the subject of increasing interest in modern cardiovascular disease. This has been the result of several factors including, among others, description of paradoxical embolism, documentation of patent foramen ovale with right to left shunt, the rather ubiquitous use of echocardiography, the issue of stroke prevention, and more recently, the relationship between patent foramen ovale and migraine.
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Monte I, Grasso S, Licciardi S, Badano LP. Head-to-head comparison of real-time three-dimensional transthoracic echocardiography with transthoracic and transesophageal two-dimensional contrast echocardiography for the detection of patent foramen ovale. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 11:245-9. [DOI: 10.1093/ejechocard/jep195] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Diagnosis of Secondary Source of Right-to-Left Shunt With Balloon Occlusion of Patent Foramen Ovale and Power M-Mode Transcranial Doppler. JACC Cardiovasc Interv 2009; 2:561-7. [DOI: 10.1016/j.jcin.2009.04.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 02/25/2009] [Accepted: 04/20/2009] [Indexed: 11/17/2022]
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Zito C, Dattilo G, Oreto G, Di Bella G, Lamari A, Iudicello R, Trio O, Caracciolo G, Coglitore S, Arrigo F, Carerj S. Patent Foramen Ovale: Comparison among Diagnostic Strategies in Cryptogenic Stroke and Migraine. Echocardiography 2009; 26:495-503. [DOI: 10.1111/j.1540-8175.2008.00852.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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