1
|
Badea RŞ, Ribigan AC, Grecu N, Terecoasǎ E, Antochi FA, Bâldea Mihǎilǎ S, Tiu C, Popescu BO. Differences in clinical and biological factors between patients with PFO-related stroke and patients with PFO and no cerebral vascular events. Front Neurol 2023; 14:1104674. [PMID: 36998773 PMCID: PMC10043389 DOI: 10.3389/fneur.2023.1104674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
BackgroundWhile stroke is one of the most dissected topics in neurology, the primary prevention of PFO-related stroke in young patients is still an unaddressed subject. We present a study concerning clinical, demographic, and laboratory factors associated with stroke and transient ischemic attack in patients with patent foramen ovale (PFO), as well as comparing PFO-patients with and without cerebrovascular ischemic events (CVEs).Patients and methodsConsecutive patients with PFO-associated CVEs were included in the study; control group was selected from patients with a PFO and no history of stroke. All participants underwent peripheral routine blood analyses, as well as, on treating physician's recommendations, screening for thrombophilia.ResultsNinety-five patients with CVEs and 41 controls were included. Females had a significantly lower risk of CVEs than males (p = 0.04). PFO size was similar between patients and controls. Patients with CVEs had more often hypertension (n = 33, 34.7%), p = 0.007. No significant differences were found between the two groups with regard to routine laboratory tests and thrombophilia status. Hypertension and gender were identified in a binomial logistic regression model as independent predictors for CVEs, but with an area under the ROC curve of 0.531, suggesting a very poor level of discrimination between the two groups.Discussion and conclusionsThere is little difference between patients with PFO with and without CVEs in terms of PFO size and routine laboratory analyses. While still a controversial topic in the specialty literature, classic first-level thrombophilic mutations are not a risk factor for stroke in patients with PFO. Hypertension and male gender were identified as factors associated with a higher risk of stroke in the setting of PFO.
Collapse
Affiliation(s)
- Raluca Ştefania Badea
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
- *Correspondence: Raluca Ştefania Badea
| | - Athena Cristina Ribigan
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Nicolae Grecu
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Elena Terecoasǎ
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Florina Anca Antochi
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Sorina Bâldea Mihǎilǎ
- Cardiology and Cardiovascular Surgery Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, Bucharest, Romania
| | - Cristina Tiu
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, Colentina Clinical Hospital, Bucharest, Romania
| |
Collapse
|
2
|
Ekker MS, Verhoeven JI, Schellekens MM, Boot EM, van Alebeek ME, Brouwers PJ, Arntz RM, van Dijk GW, Gons RA, van Uden IW, den Heijer T, de Kort PL, de Laat KF, van Norden AG, Vermeer SE, van Zagten MS, van Oostenbrugge RJ, Wermer MJ, Nederkoorn PJ, Zonneveld TP, Kerkhoff H, Rooyer FA, van Rooij FG, van den Wijngaard IR, Klijn CJ, Tuladhar AM, de Leeuw FE. Risk Factors and Causes of Ischemic Stroke in 1322 Young Adults. Stroke 2023; 54:439-447. [PMID: 36511150 PMCID: PMC9855752 DOI: 10.1161/strokeaha.122.040524] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Identification of risk factors and causes of stroke is key to optimize treatment and prevent recurrence. Up to one-third of young patients with stroke have a cryptogenic stroke according to current classification systems (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] and atherosclerosis, small vessel disease, cardiac pathology, other causes, dissection [ASCOD]). The aim was to identify risk factors and leads for (new) causes of cryptogenic ischemic stroke in young adults, using the pediatric classification system from the IPSS study (International Pediatric Stroke Study). METHODS This is a multicenter prospective cohort study conducted in 17 hospitals in the Netherlands, consisting of 1322 patients aged 18 to 49 years with first-ever, imaging confirmed, ischemic stroke between 2013 and 2021. The main outcome was distribution of risk factors according to IPSS classification in patients with cryptogenic and noncryptogenic stroke according to the TOAST and ASCOD classification. RESULTS The median age was 44.2 years, and 697 (52.7%) were men. Of these 1322 patients, 333 (25.2%) had a cryptogenic stroke according to the TOAST classification. Additional classification using the ASCOD criteria reduced the number patients with cryptogenic stroke from 333 to 260 (19.7%). When risk factors according to the IPSS were taken into account, the number of patients with no potential cause or risk factor for stroke reduced to 10 (0.8%). CONCLUSIONS Among young adults aged 18 to 49 years with a cryptogenic ischemic stroke according to the TOAST classification, risk factors for stroke are highly prevalent. Using a pediatric classification system provides new leads for the possible causes in cryptogenic stroke, and could potentially lead to more tailored treatment for young individuals with stroke.
Collapse
Affiliation(s)
- Merel S. Ekker
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| | - Jamie I. Verhoeven
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| | - Mijntje M.I. Schellekens
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| | - Esther M. Boot
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| | - Mayte E. van Alebeek
- Department of Neurology, Amphia Hospital, Breda, the Netherlands (M.E.v.A., A.G.W.v.N)
| | - Paul J.A.M. Brouwers
- Department of Neurology, Medisch Spectrum Twente, Enschede, the Netherlands (P.J.A.M.B., R.M.A.)
| | - Renate M. Arntz
- Department of Neurology, Medisch Spectrum Twente, Enschede, the Netherlands (P.J.A.M.B., R.M.A.)
| | - Gert W. van Dijk
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands (G.W.v.D.)
| | - Rob A.R. Gons
- Department of Neurology, Catharina Hospital, Eindhoven, the Netherlands (R.A.R.G., I.W.M.v.U)
| | - Inge W.M. van Uden
- Department of Neurology, Catharina Hospital, Eindhoven, the Netherlands (R.A.R.G., I.W.M.v.U)
| | - Tom den Heijer
- Department of Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands (T.d.H.)
| | - Paul L.M. de Kort
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg (P.L.M.d.K.)
| | - Karlijn F. de Laat
- Department of Neurology, Haga Hospital, The Hague, Netherlands (K.F.d.L.)
| | - Anouk G.W. van Norden
- Department of Neurology, Amphia Hospital, Breda, the Netherlands (M.E.v.A., A.G.W.v.N)
| | - Sarah E. Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands (S.E.V.)
| | - Marian S.G. van Zagten
- Department of Neurology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands (M.S.G.v.Z.)
| | | | - Marieke J.H. Wermer
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands (M.J.H.W.)
| | - Paul J. Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, the Netherlands (P.J.N., T.P.Z.)
| | - Thomas P. Zonneveld
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, the Netherlands (P.J.N., T.P.Z.)
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (Henk Kerkhoff, MD, PhD)
| | - Fergus A. Rooyer
- Department of Neurology, Zuyderland Hospital, Sittard-Geleen, the Netherlands (F.A.R.)
| | - Frank G. van Rooij
- Department of Neurology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands (F.G.v.R.)
| | | | - Catharina J.M. Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| | - Anil M. Tuladhar
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands (M.S.E., J.I.V., M.M.I.S., E.M.B., C.J.M.K., A.M.T., F.-E.d.L.)
| |
Collapse
|
3
|
Factor V Leiden, Factor II, Protein C, Protein S, and Antithrombin and Ischemic Strokes in Young Adults: A Meta-Analysis. Genes (Basel) 2022; 13:genes13112081. [DOI: 10.3390/genes13112081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/12/2022] Open
Abstract
Ischemic strokes are one of the leading causes of death worldwide. The aim of this meta-analysis is to elaborate on the role of inherited predisposition to thrombophilia in the etiology of ischemic strokes in young adults. The keywords factor V Leiden (FVL), factor II, prothrombin (PT), protein C (PC), protein S (PS), antithrombin (AT), ischemic stroke, and young were used to search different databases. We selected studies with participants who were between 18 and 65 years. A total of 104 studies were eligible for inclusion in the meta-analysis. All the studied genetic markers were risk factors for ischemic stroke according to our results (FVL OR = 1.74; PT OR = 1.95; PC OR = 10.20; PS OR = 1.74; AT OR = 3.47; p < 0.05). There was moderate heterogeneity for most of the results, and subgroup analyses were conducted by dividing the studies according to the geographic location, gender ratio, and selection criteria of the performed study. There were no significant differences between the groups, but different geographic location was a probable source of heterogeneity. All of the studied markers—FVL, prothrombin, PC, PS, and AT—were significantly associated with increased risk of ischemic stroke in young adults and, if tested, could improve the quality of care.
Collapse
|
4
|
Jin S, Yang Q, Chen X, Zhan Y. Etiologies and Mechanisms of Ischemic Stroke Associated with Sexual Intercourse: A Literature Review. Cerebrovasc Dis 2021; 51:273-281. [PMID: 34649242 DOI: 10.1159/000519262] [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: 06/20/2021] [Accepted: 08/22/2021] [Indexed: 12/08/2022] Open
Abstract
BACKGROUND Exposure to some special events, also called stroke triggers, can precipitate the onset of ischemic stroke (IS). Previous studies have presented preliminary hypotheses about sexual intercourse as a trigger of IS in predisposed individuals, but the mechanisms of IS associated with sexual intercourse are still not well defined. This literature review summarizes the etiologies and mechanisms of IS associated with sexual intercourse. Further studies on stroke triggers are warranted, and early recognition and appropriate preventive strategies directed against the short-term risks posed by stroke triggers may complement the long-term risk factor reduction approach. METHODS Articles were selected from PubMed (1946-2021) and Web of Science Core Collection (1990-2021) using the following search terms: ischemic stroke, ischaemic stroke, stroke, cerebral infarction, cerebral ischemia, cerebral embolism, embolism, sexual intercourse, sexual activity, intercourse, coitus, coition, and coital. RESULTS A total of 20 studies, which included 26 patients with IS associated with sexual intercourse, were included. This literature review found that IS associated with sexual intercourse is not rare but has not received enough attention, and paradoxical embolization and postcoital arterial dissection are common etiologies. Other etiologies include drug usage (such as sexual adjuvant drugs and illicit drugs), paroxysmal sympathetic hyperactivity, and reversible cerebral vasoconstriction syndrome. DISCUSSION/CONCLUSION Sexual intercourse should be considered an important trigger for IS. Clinicians should be aware that IS associated with sexual intercourse is not subjective but may be a warning sign of multiple etiologies and mechanisms.
Collapse
Affiliation(s)
- Shouyue Jin
- Department of Neurology, Zhongshan Hospital Xiamen University, Xiamen, China,
| | - Qingwei Yang
- Department of Neurology, Zhongshan Hospital Xiamen University, Xiamen, China
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital Xiamen University, Xiamen, China
| | - Yajing Zhan
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
5
|
Rhoades R, Tzeng D, Ruggiero N. Secondary stroke prevention in patients with patent foramen ovale. Curr Opin Hematol 2021; 28:292-300. [PMID: 34261880 DOI: 10.1097/moh.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although a patent foramen ovale (PFO) is an established risk factor for cryptogenic ischemic stroke, strategies for secondary prevention remain controversial. Increasing evidence over the past decade from well designed clinical trials supports transcatheter PFO closure for selected patients whose stroke was likely attributable to the PFO. However, patient selection using imaging findings, clinical scoring systems, and in some cases, thrombophilia testing, is crucial for determining patients most likely to benefit from closure, anticoagulation, or antiplatelet therapy. RECENT FINDINGS Recent studies have found that patients with a high Risk of Paradoxical Embolism (RoPE) score and those with a thrombophilia benefit more from closure than medical therapy (including antiplatelet or anticoagulant therapy) alone. Meta-analyses have demonstrated an increased short-term risk of atrial fibrillation in closure patients, and that residual shunt after closure predicts stroke recurrence. Last, recent data have been inconclusive as to whether patients receiving medical therapy only benefit more from anticoagulation or antiplatelet therapy, so this remains an area of controversy. SUMMARY Transcatheter PFO closure is an evidence-based, guideline-supported therapy for secondary stroke prevention in patients with a PFO and cryptogenic stroke. However, proper patient selection is critical to achieve benefit, and recent studies have helped clarify those patients most likely to benefit from closure.
Collapse
Affiliation(s)
| | | | - Nicholas Ruggiero
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
6
|
Patent Foramen Ovale Attributable Cryptogenic Embolism With Thrombophilia Has Higher Risk for Recurrence and Responds to Closure. JACC Cardiovasc Interv 2021; 13:2745-2752. [PMID: 33303111 DOI: 10.1016/j.jcin.2020.09.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 07/22/2020] [Accepted: 09/15/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the effect of management on the risk for recurrent events among patients with cryptogenic ischemic stroke or transient ischemic attack. BACKGROUND The combination of patent foramen ovale (PFO) and hypercoagulability may greatly increase the risk for paradoxical embolism. However, previous randomized controlled trials evaluating the efficacy of PFO closure excluded these potential high-risk patients. METHODS Patients diagnosed with PFO attributable cryptogenic embolism were prospectively, without randomization, recruited from January 2005 to March 2018. The relationship between thrombophilia and recurrent events was evaluated in overall patients. Multivariate Cox regression was conducted to assess the relative risk for recurrence in PFO closure and medical therapy groups. RESULTS A total of 591 patients with cryptogenic embolism with PFO were identified. The median duration of follow-up was 53 months, and thrombophilia significantly increased the risk for recurrent events (hazard ratio [HR]: 1.85; 95% confidence interval [CI]: 1.09 to 3.16; p = 0.024). PFO closure was superior to medical therapy in overall patients (HR: 0.16; 95% CI: 0.09 to 0.30; p < 0.001). Of the 134 patients (22.7%) with thrombophilia, there was a difference in the risk for recurrence events between the PFO closure (6 of 89) and medical therapy (15 of 45) groups (HR: 0.25; 95% CI: 0.08 to 0.74; p = 0.012). There was no potential heterogeneity in the further subgroup analysis. CONCLUSIONS Patients with cryptogenic stroke with PFO and hypercoagulable state had increased risk for recurrent stroke or transient ischemic attack. PFO closure provided a lower risk for recurrent events compared with medical therapy alone.
Collapse
|
7
|
Ben-Assa E, Herrero-Garibi J, Cruz-Gonzalez I, Elmariah S, Rengifo-Moreno P, Al-Bawardy R, Sakhuja R, Lima FV, Demirjian ZN, Ning M, Buonanno FS, Inglessis I, Palacios IF. Efficacy and safety of percutaneous patent foramen ovale closure in patients with a hypercoagulable disorder. Catheter Cardiovasc Interv 2021; 98:800-807. [PMID: 34132472 DOI: 10.1002/ccd.29835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 05/19/2021] [Accepted: 06/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduces the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from large randomized trials. OBJECTIVES We compared the safety and efficacy of percutaneous PFO closure in patients with and without a hypercoagulable state. METHODS Data from 800 consecutive patients undergoing percutaneous PFO closure in our medical center were analyzed. All patients were independently evaluated by specialists in neurology, cardiology, hematology, and vascular medicine. A post-procedural treatment of at least 3 months of anticoagulation was utilized in patients with thrombophilia. Follow-up events included death, recurrent neurological events, and the need for reintervention for significant residual shunt. RESULTS A hypercoagulable state was found in 239 patients (29.9%). At median follow-up of 41.9 months, there were no differences in the frequencies of stroke or transient ischemic attack between patients with or without thrombophilia (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p = 0.35). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success, or complications between groups. CONCLUSION Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state.
Collapse
Affiliation(s)
- Eyal Ben-Assa
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cardiology Division, Assuta Ashdod University Hospital, Ben Gurion University, Ashdod, Israel
| | - Jesús Herrero-Garibi
- Servicio de Cardiología, Hospital Clínico Universitario de Salamanca-IBSAL, CIBERCV, Salamanca, Spain
| | - Ignacio Cruz-Gonzalez
- Servicio de Cardiología, Hospital Clínico Universitario de Salamanca-IBSAL, CIBERCV, Salamanca, Spain
| | - Sammy Elmariah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Rasha Al-Bawardy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rahul Sakhuja
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabio V Lima
- Division of Cardiology, Warren Alpert Medical School of Brown University and Rhode Island Hospital Cardiovascular Institute, Providence, Rhode Island, USA
| | - Zareh N Demirjian
- Hematology Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mingming Ning
- Department of Neurology and Cardio-Neurology Clinic, Clinical Proteomics Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ferdinando S Buonanno
- Department of Neurology and Cardio-Neurology Clinic, Clinical Proteomics Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ignacio Inglessis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Igor F Palacios
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Abstract
The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.
Collapse
Affiliation(s)
- Samuel A Berkman
- Division of Hematology-Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shlee S Song
- Department of Neurology, Comprehensive Stroke Center Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
9
|
Filomena D, Cimino S, Maestrini V, Monosilio S, Birtolo LI, Vicenzini E, Mancone M, Fedele F, Agati L. The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism. Echocardiography 2021; 38:657-675. [PMID: 33740289 DOI: 10.1111/echo.15018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.
Collapse
Affiliation(s)
- Domenico Filomena
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Cimino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Monosilio
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Edoardo Vicenzini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Luciano Agati
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| |
Collapse
|
10
|
Buber J, Guetta V, Orion D, Lubetsky A, Borik S, Vatury O, Israel A. Patent Foramen Ovale Closure among Patients with Hypercoagulable States Maintained on Antithrombotic Therapy. Cardiology 2021; 146:375-383. [PMID: 33582661 DOI: 10.1159/000512184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Percutaneous device closure was shown to effectively prevent recurrent strokes in patients with patent foramen ovale (PFO). Whether this protective effect is relevant for patients with hypercoagulable states (HCSs) is unknown as they were not represented in prior studies. METHODS Data on 136 consecutive patients with a PFO and clinically significant HCS were retrospectively collected. PFO closure and antithrombotic regimen were decided on an individual basis by the treating physicians, and adherence to therapy was routinely evaluated. The outcome was the occurrence of cerebrovascular accident (CVA) or transient ischemic attack (TIA). RESULTS HCS types consisted of antiphospholipid syndrome (31%), factor-5 Leiden mutation (22%), prothrombin mutation (18%), protein S deficiency (15%), protein C deficiency (7%), methyl-tetra-hydro folate reductase mutation (5%), and essential thrombocytosis (2%). 102 patients (75%) were maintained on anticoagulants and the remaining on antiplatelet therapy. PFO closure was undertaken in 85 (63%); antithrombotic therapy was not interrupted prior to or after the procedures. At a mean follow-up of 46 ± 8 months, 23 patients (17%; 95% confidence interval, 9.3-22%) experienced an outcome event, mainly in the form of CVAs (n = 15, 65%). In multivariable analysis, PFO closure was associated with a 5-fold decrease in the risk of CVA/TIA (p = 0.02). This effect was independent of the type of HCS or antithrombotic therapy. CONCLUSIONS Among patients with HCSs maintained on anticoagulant or antiplatelet therapies, PFO closure was associated with a significantly lower risk of CVA or TIA.
Collapse
Affiliation(s)
- Jonathan Buber
- Heart Center, Chaim Sheba Medical Centre, Tel-Hashomer, Israel, .,Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA,
| | - Victor Guetta
- Heart Center, Chaim Sheba Medical Centre, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Orion
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Neurology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Coagulation Service, Hematology Department, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - Sharon Borik
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Safra International Center for Congenital Heart Disease, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - Ori Vatury
- Heart Center, Chaim Sheba Medical Centre, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Israel
- Department of Family Medicine, Clalit Health Services, Tel-Aviv, Israel
| |
Collapse
|
11
|
Poudel S, Zeb M, Kondapaneni V, Gutlapalli SD, Choudhari J, Sodiya OT, Toulassi IA, Cancarevic I. Association of G20210A Prothrombin Gene Mutation and Cerebral Ischemic Stroke in Young Patients. Cureus 2020; 12:e11984. [PMID: 33437541 PMCID: PMC7793372 DOI: 10.7759/cureus.11984] [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] [Indexed: 12/04/2022] Open
Abstract
Ischemic stroke is an acute episode of neurological dysfunction resulting from the focal brain and spinal cord infarction. Many etiologies have been reported and vary significantly with the age of the patients. This study aims to show the association of G20210A prothrombin gene mutation and cerebral ischemic stroke in young patients. The prothrombin gene mutation is the second most common inherited thrombophilia after the factor V mutation. In this single missense mutation, guanine is substituted by adenine base pair in the nucleotide position 20210 of the 3'-untranslated region of the prothrombin gene, resulting in abnormal thrombin production predisposing to both arterial or venous thrombosis. Forty-seven relevant articles were selected after a thorough screening process using a regular keyword ‘G20210A Prothrombin’ and/or ‘Ischemic Stroke’ mostly from the PubMed database. We included the studies that are published in the last 22 years with patients age ≤57 years. This review article depicts the association of G20210A prothrombin gene mutation with ischemic stroke in young patients irrespective of ethnicity and zygosity status of their genotype. However, more multicenter prospective studies are needed to better understand the application of prothrombin gene mutation in predicting the associated risk of ischemic stroke in young patients and its importance in deciding the patients' treatment or prognosis.
Collapse
Affiliation(s)
- Sujan Poudel
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mehwish Zeb
- Internal Medicine, Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Pediatrics, Khyber Teaching Hospital, Peshawar, PAK
| | - Varshitha Kondapaneni
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Dheeraj Gutlapalli
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jinal Choudhari
- Orthopedics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Olusegun T Sodiya
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ijeoma A Toulassi
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
12
|
Sgarra L, Bortone AS, Potenza MA, Nacci C, De Salvia MA, Acquaviva T, De Cillis E, Ciccone MM, Grimaldi M, Montagnani M. Endothelial Dysfunction May Link Interatrial Septal Abnormalities and MTHFR-Inherited Defects to Cryptogenic Stroke Predisposition. Biomolecules 2020; 10:biom10060861. [PMID: 32512924 PMCID: PMC7355772 DOI: 10.3390/biom10060861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/22/2020] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
We explored the significance of the L-Arginine/asymmetric dimethylarginine (L-Arg/ADMA) ratio as a biomarker of endothelial dysfunction in stroke patients. To this aim, we evaluated the correlation, in terms of severity, between the degree of endothelial dysfunction (by L-Arg/ADMA ratio), the methylene tetrahydrofolate reductase (MTHFR) genotype, and the interatrial septum (IAS) phenotype in subject with a history of stroke. Methods and Results: L-Arg, ADMA, and MTHFR genotypes were evaluated; the IAS phenotype was assessed by transesophageal echocardiography. Patients were grouped according to the severity of IAS defects and the residual enzymatic activity of MTHFR-mutated variants, and values of L-Arg/ADMA ratio were measured in each subgroup. Of 57 patients, 10 had a septum integrum (SI), 38 a patent foramen ovale (PFO), and 9 an ostium secundum (OS). The L-Arg/ADMA ratio differed across septum phenotypes (p ≤ 0.01), and was higher in SI than in PFO or OS patients (p ≤ 0.05, p ≤ 0.01, respectively). In the PFO subgroup a negative correlation was found between the L-Arg/ADMA ratio and PFO tunnel length/height ratio (p ≤ 0.05; r = − 0.37; R2 = 0.14). Interestingly, the L-Arg/ADMA ratio varied across MTHFR genotypes (p ≤ 0.0001) and was lower in subgroups carrying the most impaired enzyme with respect to patients carrying the conservative MTHFR (p ≤ 0.0001, p ≤ 0.05, respectively). Consistently, OS patients carried the most dysfunctional MTHFR genotypes, whereas SI patients the least ones. Conclusions: A low L-Arg/ADMA ratio correlates with impaired activity of MTHFR and with the jeopardized IAS phenotype along a severity spectrum encompassing OS, PFO with long/tight tunnel, PFO with short/large tunnel, and SI. This infers that genetic MTHFR defects may underlie endothelial dysfunction-related IAS abnormalities, and predispose to a cryptogenic stroke. Our findings emphasize the role of the L-Arg/ADMA ratio as a reliable marker of stroke susceptibility in carriers of IAS abnormalities, and suggest its potential use both as a diagnostic tool and as a decision aid for therapy.
Collapse
Affiliation(s)
- Luca Sgarra
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Alessandro Santo Bortone
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Maria Assunta Potenza
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Carmela Nacci
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Maria Antonietta De Salvia
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Tommaso Acquaviva
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Emanuela De Cillis
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Marco Matteo Ciccone
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Massimo Grimaldi
- General Hospital “F. Miulli” Acquaviva delle Fonti, 70021 Bari, Italy;
| | - Monica Montagnani
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
- Correspondence:
| |
Collapse
|
13
|
Kargiotis O, Psychogios K, Safouris A, Magoufis G, Zervas PD, Stamboulis E, Tsivgoulis G. The Role of Transcranial Doppler Monitoring in Patients with Multi‐Territory Acute Embolic Strokes: A Review. J Neuroimaging 2019; 29:309-322. [DOI: 10.1111/jon.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
| | | | - Apostolos Safouris
- Stroke UnitMetropolitan Hospital Piraeus Greece
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Paschalis D. Zervas
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Georgios Tsivgoulis
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
- Department of NeurologyThe University of Tennessee Health Science Center Memphis TN
| |
Collapse
|
14
|
Samim D, Marques-Vidal P, Alberio L, Waeber G, Méan M. Do hospital doctors test for thrombophilia in patients with venous thromboembolism? J Thromb Thrombolysis 2019; 46:238-243. [PMID: 29922879 DOI: 10.1007/s11239-018-1702-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The predictive value of factor V Leiden and the G20210A prothrombin mutation regarding recurrent venous thromboembolism (VTE) is limited and does not influence subsequent patient management. Systematic testing for such genetic thrombophilia should be avoided, but to which extent such testing is practiced in a Swiss Hospital is unknown. To examine the current practice of factor V Leiden and/or G20210A prothrombin mutation testing in a University Hospital, and to assess the clinical consequences of testing on patients. 1388 adult patients (48.7% women) with a main diagnosis of VTE hospitalized at the Lausanne university hospital between January 2013 and December 2015. FV Leiden and/or prothrombin G20210A mutation testing was performed in 61 (4.4%) patients with VTE, an average of 20 patients/year. On multivariable analysis, age < 65 years [odds ratio and (95% confidence interval) 5.91 (3.12-11.19)], being admitted in a medical ward [5.71 (2.02-16.16)] and staying in the intensive care unit [0.34 (0.12-0.97)] were associated with thrombophilia testing. No differences were found between patients with and without testing regarding in-hospital mortality [OR and 95% CI for tested vs. non-tested: 0.23 (0.03-1.73), p = 0.153] and length of stay (multivariable adjusted average ± standard error: 16.9 ± 3.3 vs. 20.0 ± 0.7 days for tested and non-tested patients, respectively, p = 0.875). Thrombophilia testing in hospitalized patients with a main diagnosis of VTE is seldom performed. FV Leiden and/or prothrombin G20210A mutation should not be routinely assessed in patients with acute VTE.
Collapse
Affiliation(s)
- Daryoush Samim
- Department of Medicine, Service of Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Pedro Marques-Vidal
- Department of Medicine, Service of Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Lorenzo Alberio
- Department of Oncology, Haematology, Lausanne University Hospital, Lausanne, Switzerland
| | - Gérard Waeber
- Department of Medicine, Service of Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Marie Méan
- Department of Medicine, Service of Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| |
Collapse
|
15
|
Vasudeva K, Munshi A. Genetics of platelet traits in ischaemic stroke: focus on mean platelet volume and platelet count. Int J Neurosci 2018; 129:511-522. [PMID: 30371123 DOI: 10.1080/00207454.2018.1538991] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose/Aim of the study: The aim of this review is to summarize the role of genetic variants affecting mean platelet volume (MPV) and platelet count (PLT) leading to higher platelet reactivity and in turn to thrombotic events like stroke and cardiovascular diseases. MATERIALS AND METHODS A search was conducted in PUBMED, MEDLINE, EMBASE, PROQUEST, Science Direct, Cochrane Library, and Google Scholar related to the studies focussing on genome-wide association studies (GWAS), whole exome sequencing (WES), whole genome sequencing (WGS), phenome-wide association studies (PheWAS) and multi-omic analysis that have been employed to identify the genetic variants influencing MPV and PLT. RESULTS Antiplatelet agents underscore the crucial role of platelets in the pathogenesis of stroke. Higher platelet reactivity in terms of mean platelet volume (MPV) and platelet count (PLT) contributes significantly to the interindividual variation in platelet reaction at the site of vessel wall injury. Some individuals encounter thrombotic events as platelets get occluded at the site of vessel wall injury whereas others heal the injury without occluding the circulation. Evidence suggests that MPV and PLT have a strong genetic component. High throughput techniques including genome-wide association studies (GWAS), whole exome sequencing (WES), whole genome sequencing (WGS), phenome-wide association studies (PheWAS) and multi-omic analysis have identified different genetic variants influencing MPV and PLT. CONCLUSIONS Identification of complex genetic cross talks affecting PLT and MPV might help to develop novel treatment strategies in treating neurovascular diseases like stroke.
Collapse
Affiliation(s)
- Kanika Vasudeva
- a Department of Human Genetics and Molecular Medicine , Central University of Punjab Bathinda , Punjab , India
| | - Anjana Munshi
- a Department of Human Genetics and Molecular Medicine , Central University of Punjab Bathinda , Punjab , India
| |
Collapse
|
16
|
Alhazzani AA, Kumar A, Selim M. Association between Factor V Gene Polymorphism and Risk of Ischemic Stroke: An Updated Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:1252-1261. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/20/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022] Open
|
17
|
Kim YD, Song D, Nam HS, Lee K, Yoo J, Hong GR, Lee HS, Nam CM, Heo JH. D-dimer for prediction of long-term outcome in cryptogenic stroke patients with patent foramen ovale. Thromb Haemost 2017; 114:614-22. [DOI: 10.1160/th14-12-1040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/03/2015] [Indexed: 11/05/2022]
Abstract
SummaryPatent foramen ovale (PFO) is a potential cause of cryptogenic stroke, given the possibility of paradoxical embolism from venous to systemic circulation. D-dimer level is used to screen venous thrombosis. We investigated the risk of embolism and mortality according to the presence of PFO and D-dimer levels in cryptogenic stroke patients. A total of 570 first-ever cryptogenic stroke patients who underwent transesophageal echocardiography were included in this study. D-dimer was assessed using latex agglutination assay during admission. The association of long-term outcomes with the presence of PFO and D-dimer levels was investigated. PFO was detected in 241 patients (42.3 %). During a mean 34.0 ± 22.8 months of follow-up, all-cause death occurred in 58 (10.2 %) patients, ischaemic stroke in 33 (5.8 %), and pulmonary thromboembolism in 6 (1.1 %). Multivariate Cox regression analysis showed that a D-dimer level of > 1,000 ng/ml was an independent predictor for recurrent ischaemic stroke in patients with PFO (hazard ratio 5.341, 95 % confidence interval 1.648–17.309, p=0.005), but not in those without PFO. However, in patients without PFO, a D-dimer level of > 1,000 ng/ml was independently related with all-cause mortality. The risk of pulmonary thromboembolism tended to be high in patients with high D-dimer levels, regardless of PFO. Elevated D-dimer levels in cryptogenic stroke were predictive of the long-term outcome, which differed according to the presence of PFO. The coexistence of PFO and a high D-dimer level increased the risk of recurrent ischaemic stroke. The D-dimer test in cryptogenic stroke patients may be useful for predicting outcomes and deciding treatment strategy.
Collapse
|
18
|
Clinical outcomes and a high prevalence of abnormalities on comprehensive arterial and venous thrombophilia screening in TIA or ischaemic stroke patients with a patent foramen ovale, an interatrial septal aneurysm or both. J Neurol Sci 2017; 377:227-233. [DOI: 10.1016/j.jns.2017.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/09/2017] [Accepted: 04/10/2017] [Indexed: 11/22/2022]
|
19
|
Sleep apnea syndrome and patent foramen ovale: a dangerous association in ischemic stroke? Sleep Med 2016; 25:29-33. [PMID: 27823712 DOI: 10.1016/j.sleep.2016.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/12/2016] [Accepted: 07/20/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The coexistence of patent foramen ovale (PFO) and sleep apnea syndrome (SAS) might be related to the pathogenesis of cryptogenic stroke (CS). We aimed to determine the prevalence of SAS in patients with cryptogenic stroke and PFO. METHODS This is a prospective case-control study in which we included ischemic stroke patients consecutively admitted to our hospital's Acute Stroke Unit. Contrast transcranial Doppler (c-TCD) and sleep polygraphy within the first 72 h after stroke onset were performed to detect PFO and SAS. Demographic and clinical characteristics, time of stroke onset, score in the National Institute of Health Stroke Scale (NIHSS), and stroke subtype were registered. RESULTS A total of 97 patients were studied. Overall, 76% were men, with a mean ± SD age of 61 ± 13 years, and an NIHSS of 5 ± 5. Subtype of stroke was cryptogenic (CS) in 28 (29%) and non-CS in 69 (71%) of patients. PFO was more frequent among patients with CS (64% vs 29%, p = 0.002) and without SAS (60% vs 32%, p = 0.013). SAS was diagnosed in 74% of the whole group, with a higher prevalence in patients with known stroke etiology (83% vs 53%, p = 0.003). Finally, the prevalence of SAS and PFO coexistence was similar in patients with or without cryptogenic stroke (25% vs 22%, p = 1), and when comparing the group of patients with cryptogenic wake-up stroke to the other stroke patients (43% vs 21%, p = 0.35). CONCLUSIONS According to our results, there is no evidence of an association of PFO and SAS in the pathogenesis of cryptogenic stroke.
Collapse
|
20
|
Börjesson M, Assanelli D, Carré F, Dugmore D, Panhuyzen-Goedkoop NM, Seiler C, Senden J, Solberg EE. ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease. ACTA ACUST UNITED AC 2016; 13:137-49. [PMID: 16575266 DOI: 10.1097/01.hjr.0000199494.46708.5a] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Evidence for the proper management of ischemic heart disease (IHD) in the general population is well established, but recommendations for physical activity and competitive sports in these patients are scarce. The aim of the present paper was to provide such recommendations to complement existing ESC and international guidelines on rehabilitation and primary/secondary prevention. DESIGN AND METHODS Due to the lack of studies in this field, the current recommendations are the result of consensus among experts. Sports are classified into low/moderate/high dynamic and low/moderate/high static, respectively. RESULTS Patients with a definitive IHD and higher probability of cardiac events are not eligible for competitive sports (CS) but for individually designed leisure time physical activity (LPA); patients with definitive IHD and lower probability of cardiac events as well as those with no IHD but with a positive exercise test and high risk profile (SCORE > 5%) are eligible for low/moderate static and low dynamic (IA-IIA) sports and individually designed LPA. Patients without IHD and a high risk profile+ a negative exercise-test and those with a low risk profile (SCORE < 5%) are allowed all LPA and competitive sports with a few exceptions. CONCLUSIONS Individually designed LPA is possible and encouraged in patients with and without established IHD. Competitive sports may be restricted for patients with IHD, depending on the probability of cardiac events and the demands of the sport according to the current classification.
Collapse
|
21
|
Chen L, Deng W, Palacios I, Inglessis-Azuaje I, McMullin D, Zhou D, Lo EH, Buonanno F, Ning M. Patent foramen ovale (PFO), stroke and pregnancy. J Investig Med 2016; 64:992-1000. [PMID: 26988903 PMCID: PMC6083869 DOI: 10.1136/jim-2016-000103] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO)-related stroke is increasingly recognized as an important etiology of ischemic embolic stroke-accounting for up to 50% of strokes previously considered 'cryptogenic' or with an unknown mechanism. As a 'back door to the brain,' PFO can allow venous clots to enter arterial circulation via interatrial right-to-left shunting, potentially resulting in ischemic stroke. We observe that clinically, PFO-related stroke affects women of childbearing age, and that pregnancy-owing to major changes in hemocoagulative, hormonal, and cardiovascular parameters-can enhance stroke risks. However, no systematic study has been performed and little is known regarding complications, pregnancy outcomes and treatment for PFO-related stroke during pregnancy. To identify and characterize the complications and clinical outcomes related to PFOs during pregnancy, we performed a literature review and analysis from all reported cases of pregnancy with PFO-related complications in the medical literature from 1970 to 2015. We find that during pregnancy and post-partum, PFO is associated with complications affecting multiple organs, including the brain, heart and lung. The three principal complications reported are stroke, pulmonary emboli and myocardial infarction. In contrast to other pregnancy-related stroke etiologies, which peak during later pregnancy and postpartum, PFO-related stroke peaks during early pregnancy (first and second trimester-60%), and most patients had good neurological outcome (77%). In patients with PFO with recurrent stroke during pregnancy, additional key factors include high-risk PFO morphology (atrial septal aneurysm), larger right-to-left shunt, multiple gestation and concurrent hypercoagulability. Compared to strokes of other etiologies during pregnancy, most PFO stroke patients experienced uneventful delivery (93%) of healthy babies with a good clinical outcome. We conclude with recommended clinical treatment strategies for pregnant patients with PFO suggested by the data from these cases, and the clinical experience of our Cardio-Neurology Clinic.
Collapse
Affiliation(s)
- Lei Chen
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, West China Hospital in Sichuan University, Chengdu, China
| | - Wenjun Deng
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Igor Palacios
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ignacio Inglessis-Azuaje
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David McMullin
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dong Zhou
- Department of Neurology, West China Hospital in Sichuan University, Chengdu, China
| | - Eng H Lo
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ferdinando Buonanno
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - MingMing Ning
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
22
|
Homma S, Messé SR, Rundek T, Sun YP, Franke J, Davidson K, Sievert H, Sacco RL, Di Tullio MR. Patent foramen ovale. Nat Rev Dis Primers 2016; 2:15086. [PMID: 27188965 DOI: 10.1038/nrdp.2015.86] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.
Collapse
Affiliation(s)
- Shunichi Homma
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Yee-Ping Sun
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Karina Davidson
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| |
Collapse
|
23
|
Pahus SH, Hansen AT, Hvas AM. Thrombophilia testing in young patients with ischemic stroke. Thromb Res 2016; 137:108-112. [DOI: 10.1016/j.thromres.2015.11.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/01/2015] [Accepted: 11/06/2015] [Indexed: 12/26/2022]
|
24
|
Bayar N, Arslan Ş, Çağırcı G, Erkal Z, Üreyen ÇM, Çay S, Köklü E, Yüksel İÖ, Küçükseymen S. Assessment of Morphology of Patent Foramen Ovale with Transesophageal Echocardiography in Symptomatic and Asymptomatic Patients. J Stroke Cerebrovasc Dis 2015; 24:1282-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/18/2015] [Accepted: 01/30/2015] [Indexed: 11/25/2022] Open
|
25
|
Amin H, Nowak RJ, Schindler JL. Cardioembolic Stroke: Practical Considerations for Patient Risk Management and Secondary Prevention. Postgrad Med 2015; 126:55-65. [DOI: 10.3810/pgm.2014.01.2725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
26
|
Abstract
Stroke and especially its complications are a leading cause of death. Despite reduced morbidity in some developed countries, mortality in stroke patients is still high worldwide. In the past decades, treatment of acute stroke has focused on early intervention, such as revascularization and cerebral edema prevention. However, long-term clinical observations indicate that poststroke pneumonia, cardiovascular complications, and vascular embolism are the major reasons for the increased death rate after stroke. Few evidence-based data are available currently to guide the management of these complications. Thus, systematic studies of these adverse events are essential and urgent to improve survival after stroke.
Collapse
|
27
|
Harrer JU, Wessels T, Franke A, Lucas S, Berlit P, Klötzsch C. Stroke Recurrence and its Prevention in Patients with Patent Foramen Ovale. Can J Neurol Sci 2014; 33:39-47. [PMID: 16583720 DOI: 10.1017/s0317167100004674] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence. METHODS Over a period of ten years, 124 patients (mean age 51 +/- 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 +/- 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed. RESULTS Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%2.2%/year). Patients suffering from recurrence after transcatheter closure (n = 2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p > 0.05, OR = 0.31, and OR = 0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p < 0.05, OR = 5.0, and OR = 4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p < 0.001, and p < 0.01). CONCLUSIONS The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.
Collapse
Affiliation(s)
- J U Harrer
- Department of Neurology, Aachen University Hospital, Aachen, Germany
| | | | | | | | | | | |
Collapse
|
28
|
Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 973] [Impact Index Per Article: 97.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
Collapse
|
29
|
Düzel B, Eren NK, Berilgen R, Kocabaş U, Gönençer M, Nazli C, Ergene O. Decline in mean platelet volume in patients with patent foramen ovale undergoing percutaneous closure. Cardiovasc J Afr 2014; 25:165-7. [PMID: 25192299 PMCID: PMC4170178 DOI: 10.5830/cvja-2014-027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 05/09/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction The presence of patent foramen ovale (PFO) is considered a possible cause for cryptogenic stroke. The mechanism underlying the ischaemic neurological events in the presence of PFO has not been firmly established. The purpose of this study was to compare: (1) the mean platelet volume levels in PFO patients with and without a cryptogenic stroke, and (2) pre- and post-procedural mean platelet volumes (MPV) in patients undergoing percutaneous PFO closure. Methods Sixteen PFO patients undergoing percutaneous closure to prevent recurrent ischaemic events and 15 asymptomatic patients with PFO were enrolled in the study. Mean platelet volume was compared between patients with and without a history of stroke. We also compared pre- and postprocedural MPV levels in patients undergoing percutaneous PFO closure. Results Mean platelet volume, which is a marker for platelet activity, was similar in PFO patients with and without stroke (9.34 ± 1.64 vs 9.1 ± 1.34 fl; p = 0.526). Interestingly, MPV decreased significantly after percutaneous closure compared to pre-procedural levels (9.34 ± 1.64 vs 8.3 ± 1.12 fl; p = 0.001). Conclusion Our findings suggest interatrial communication through a PFO may be related to increased MPV and increased platelet activity.
Collapse
Affiliation(s)
| | - Nihan Kahya Eren
- Izmir Katip Çelebi University, Cardiology Clinic, Atatürk Research and Education Hospital, Turkey.
| | | | - Uğur Kocabaş
- Izmir Katip Çelebi University, Cardiology Clinic, Atatürk Research and Education Hospital, Turkey
| | - Mustafa Gönençer
- Izmir Katip Çelebi University, Cardiology Clinic, Atatürk Research and Education Hospital, Turkey
| | - Cem Nazli
- Izmir Katip Çelebi University, Cardiology Clinic, Atatürk Research and Education Hospital, Turkey
| | - Oktay Ergene
- Izmir Katip Çelebi University, Cardiology Clinic, Atatürk Research and Education Hospital, Turkey
| |
Collapse
|
30
|
López Fernández JC, Rodríguez Esparragón F, Buset Ríos N. [Update on the genetics of stroke]. Med Clin (Barc) 2014; 143:176-9. [PMID: 24703417 DOI: 10.1016/j.medcli.2014.02.009] [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: 11/04/2013] [Revised: 02/03/2014] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Abstract
Stroke is a disease with significant morbidity, mortality, and economic and social impacts. It is a complex entity whose pathogenesis involves multiple environmental and genetic factors, with the latter having a role in up to 50% of strokes. The objective of the review is to analyze the available methods for the genetic diagnosis including linkage studies of variation in copy number, gene - candidate approximations, or whole genome (GWAS) and polymorphisms associated with its pathogenesis. We describe several single nucleotide polymorphisms (SNPs) associated with stroke in association studies and GWAS such as SNPs of angiotensin, the aldosterone system, paraoxonases, nitric oxide, coagulation, and fibrinolysis system, among others. We also analyze the role of certain polymorphisms in the phenotype of the carotid plaque, intracranial aneurysms and lobar hemorrhages. Pharmacogenomic aspects in which SNPs affect the response and safety regarding the use of different drugs are also described. Several SNPs that significantly contribute to the risk of stroke are also described. The advent of techniques like GWAS has contributed to the understanding of genetics and pharmacogenomics of stroke.
Collapse
Affiliation(s)
- Juan Carlos López Fernández
- Servicio de Neurología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España.
| | | | - Nisa Buset Ríos
- Unidad de Investigación, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
| |
Collapse
|
31
|
Prevalence of patent foramen ovale in ischemic stroke in Italy: the SISIFO study. Neurol Sci 2014; 35:867-73. [PMID: 24381113 DOI: 10.1007/s10072-013-1615-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
Abstract
Patent foramen ovale (PFO) is a common congenital anatomical defect in the general population with a mean prevalence of 20 %. Transcranial Doppler sonography and echocardiography, both with infusion of agitated saline as an echo contrast, have been introduced for the diagnosis of PFO. Transesophageal echocardiography is considered the gold standard. Several studies have suggested an association between cryptogenetic stroke and PFO, but the role of this condition as a risk factor for stroke is still debated. The aims of this prospective multicentre study are the evaluation of PFO prevalence in the whole ischemic stroke population and the identification of a stroke recurrence profile risk in patients with PFO. All consecutive patients admitted for acute ischemic stroke and with a confirmed diagnosis at discharge are eligible cases for the study. Demographic and vascular risk factors are registered. Clinical severity is summarized by the National Institute of Health stroke scale. Echocardiographic and transcranial studies are performed in each patient to detect the presence of PFO. Prevalence of PFO will be calculated with 95 % CIs. Univariate analysis will be performed to detect the correlation of PFO with different registered factors and multivariable analysis with PFO as independent variable. The present study should contribute to better identify the role of PFO in ischemic stroke risk and recurrence-related events. Qualifying findings of the study are represented by the high number of enrolled patients, the prospective methodology of the study and the presence of secondary instrumental endpoints.
Collapse
|
32
|
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SCC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160-236. [PMID: 24788967 DOI: 10.1161/str.0000000000000024] [Citation(s) in RCA: 2837] [Impact Index Per Article: 283.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
Collapse
|
33
|
Cruz-González I, Solis J, Kiernan TJ, Yan BP, Lam YY, Palacios IF. Clinical manifestation and current management of patent foramen ovale. Expert Rev Cardiovasc Ther 2014; 7:1011-22. [DOI: 10.1586/erc.09.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
34
|
Allais G, Gabellari IC, De Lorenzo C, Mana O, Benedetto C. Oral contraceptives in migraine. Expert Rev Neurother 2014; 9:381-93. [DOI: 10.1586/14737175.9.3.381] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
35
|
Martinelli I, Passamonti SM, Bucciarelli P. Thrombophilic states. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:1061-71. [DOI: 10.1016/b978-0-7020-4087-0.00071-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
36
|
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: 9] [Impact Index Per Article: 0.9] [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
Collapse
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
| |
Collapse
|
37
|
|
38
|
Patent foramen ovale and cryptogenic stroke - a statistical or cause-and-effect relationship? A neurological point of view. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:272-4. [PMID: 24570731 PMCID: PMC3916003 DOI: 10.5114/pwki.2013.37508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 06/22/2013] [Accepted: 06/28/2013] [Indexed: 12/02/2022] Open
Abstract
Patent foramen ovale and atrial septal aneurysm are considered to be factors conducive to the occurrence of stroke and transient ischaemic attacks. However, there is no clear answer to the question whether patent foramen ovale is an independent risk factor for stroke and what the mechanism of potential cerebral ischaemia in patients with an interatrial septal abnormality is. The paper presents the results of studies regarding the issue, including epidemiological, clinical and neuroimaging data. The subject of secondary prevention in patients with cryptogenic stroke and patent foramen ovale, including the results of research into the effectiveness of pharmacological methods and percutaneous closure of interatrial septal defects, is raised. The available research results do not conclusively suggest a causal relationship between patent foramen ovale and stroke. There is a probable summative effect of atrial septal abnormality and other factors (haemostatic and genetic ones as well as those that are associated with cerebral vessels) leading to cerebral ischaemia. There are no indications for the use of anticoagulant treatment in patients with stroke and presence of patent foramen ovale. In patients at a high risk for stroke, invasive treatment should be considered, which is consistent with the position of the European Stroke Organisation.
Collapse
|
39
|
Ning M, Lo EH, Ning PC, Xu SY, McMullin D, Demirjian Z, Inglessis I, Dec GW, Palacios I, Buonanno FS. The brain's heart - therapeutic opportunities for patent foramen ovale (PFO) and neurovascular disease. Pharmacol Ther 2013; 139:111-23. [PMID: 23528225 PMCID: PMC3740210 DOI: 10.1016/j.pharmthera.2013.03.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 01/18/2023]
Abstract
Patent foramen ovale (PFO), a common congenital cardiac abnormality, is a connection between the right and left atria in the heart. As a "back door to the brain", PFO can serve as a conduit for paradoxical embolism, allowing venous thrombi to enter the arterial circulation, avoiding filtration by the lungs, and causing ischemic stroke. PFO-related strokes affect more than 150,000 people per year in the US, and PFO is present in up to 60% of migraine patients with aura, and in one out of four normal individuals. So, in such a highly prevalent condition, what are the best treatment and prevention strategies? Emerging studies show PFO-related neurovascular disease to be a multi-organ condition with varying individual risk factors that may require individualized therapeutic approaches - opening the field for new pharmacologic and therapeutic targets. The anatomy of PFO suggests that, in addition to thrombi, it can also allow harmful circulatory factors to travel directly from the venous to the arterial circulation, a concept important in finding novel therapeutic targets for PFO-related neurovascular injury. Here, we: 1) review emerging data on PFO-related injuries and clinical trials; 2) discuss potential mechanisms of PFO-related neurovascular disease in the context of multi-organ interaction and heart-brain signaling; and 3) discuss novel therapeutic targets and research frontiers. Clinical studies and molecular mapping of the circulatory landscape of this multi-organ disease will both be necessary in order to better individualize clinical treatment for a condition affecting more than a quarter of the world's population.
Collapse
Affiliation(s)
- Mingming Ning
- Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Ning MM, Lopez M, Sarracino D, Cao J, Karchin M, McMullin D, Wang X, Buonanno FS, Lo EH. Pharmaco-proteomics opportunities for individualizing neurovascular treatment. Neurol Res 2013; 35:448-56. [PMID: 23711324 PMCID: PMC4153693 DOI: 10.1179/1743132813y.0000000213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Neurovascular disease often involves multi-organ system injury. For example, patent foramen ovale (PFO) related ischemic strokes involve not just the brain, but also the heart, the lung, and the peripheral vascular circulation. For higher-risk but high-reward systemic therapy (e.g., thrombolytics, therapeutic hypothermia (TH), PFO closure) to be implemented safely, very careful patient selection and close monitoring of disease progression and therapeutic efficacy are imperative. For example, more than a decade after the approval of therapeutic hypothermic and intravenous thrombolysis treatments, they both remain extremely under-utilized, in part due to lack of clinical tools for patient selection or to follow therapeutic efficacy. Therefore, in understanding the complexity of the global effects of clinical neurovascular diseases and their therapies, a systemic approach may offer a unique perspective and provide tools with clinical utility. Clinical proteomic approaches may be promising to monitor systemic changes in complex multi-organ diseases - especially where the disease process can be 'sampled' in clinically accessible fluids such as blood, urine, and CSF. Here, we describe a 'pharmaco-proteomic' approach to three major challenges in translational neurovascular research directly at bedside - in order to better stratify risk, widen therapeutic windows, and explore novel targets to be validated at the bench - (i) thrombolytic treatment for ischemic stroke, (ii) therapeutic hypothermia for post-cardiac arrest syndrome, and (iii) treatment for PFO related paradoxical embolic stroke. In the future, this clinical proteomics approach may help to improve patient selection, ensure more precise clinical phenotyping for clinical trials, and individualize patient treatment.
Collapse
Affiliation(s)
- MM Ning
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - M Lopez
- Thermo-Fisher BRIMS, Cambridge, MA
| | | | - J Cao
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
| | - M Karchin
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
| | - D McMullin
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
| | - X Wang
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - FS Buonanno
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - EH Lo
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
41
|
Tomomasa R, Yamashiro K, Tanaka R, Hattori N. Cerebral infarction in an HIV-infected patient with combined protein S and C deficiency and a patent foramen ovale. J Stroke Cerebrovasc Dis 2013; 22:e650-2. [PMID: 23664714 DOI: 10.1016/j.jstrokecerebrovasdis.2013.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 04/11/2013] [Accepted: 04/14/2013] [Indexed: 02/07/2023] Open
Abstract
A 41-year-old male with a history of human immunodeficiency virus (HIV) infection developed motor aphasia, dysarthria, and right hemiparesis. A magnetic resonance imaging scan of the brain revealed a cerebral infarction in the territory of the left middle cerebral artery. The laboratory data showed decreased levels of protein S and protein C. Transesophageal contrast-enhanced echocardiography revealed a patent foramen ovale (PFO). Prothrombotic states, such as protein S and C deficiency, have been reported in HIV-infected patients. In addition, previous studies have reported prothrombotic states to be risk factors for PFO-related cerebral infarction. An association between combined protein S and C deficiency caused by HIV infection and PFO-related cerebral infarction was suggested in our patient.
Collapse
Affiliation(s)
- Ran Tomomasa
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | | | | | | |
Collapse
|
42
|
Agarwal S, Bajaj NS, Kumbhani DJ, Tuzcu EM, Kapadia SR. Meta-analysis of transcatheter closure versus medical therapy for patent foramen ovale in prevention of recurrent neurological events after presumed paradoxical embolism. JACC Cardiovasc Interv 2012; 5:777-89. [PMID: 22814784 DOI: 10.1016/j.jcin.2012.02.021] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 02/18/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES In this study, a meta-analysis of observational studies was performed to compare the rate of recurrent neurological events (RNE) between transcatheter closure and medical management of patients with cryptogenic stroke/transient ischemic attack (TIA) and concomitant patent foramen ovale (PFO). BACKGROUND A significant controversy surrounds the optimal strategy for treatment of cryptogenic stroke/TIA and coexistent PFO. METHODS We conducted a MEDLINE search with standard search terms to determine eligible studies. RESULTS Adjusted incidence rates of RNE were 0.8 (95% confidence interval [CI]: 0.5 to 1.1) events and 5.0 (95% CI: 3.6 to 6.9) events/100 person-years (PY) in the transcatheter closure and medical management arms, respectively. Meta-analysis of the limited number of comparative studies and meta-regression analysis suggested that the transcatheter closure might be superior to the medical therapy in prevention of RNE after cryptogenic stroke. Comparison of the anticoagulation and antiplatelet therapy subgroups of the medical arm yielded a significantly lower risk of RNE within patients treated with anticoagulants. Device-related complications were encountered at the rate of 4.1 (95% CI: 3.2 to 5.0) events/100 PY, with atrial arrhythmias being the most frequent complication. After transcatheter closure, RNE did not seem to be related to the pre-treatment shunt size or the presence of residual shunting in the follow-up period. Significant benefit of transcatheter PFO closure was apparent in elderly patients, patients with concomitant atrial septal aneurysm, and patients with thrombophilia. CONCLUSIONS Rates of RNE with transcatheter closure and medical therapy in patients presenting with cryptogenic stroke or TIA were estimated at 0.8 and 5.0 events/100 PY. Further randomized controlled trials are needed to conclusively compare these 2 management strategies.
Collapse
Affiliation(s)
- Shikhar Agarwal
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
| | | | | | | | | |
Collapse
|
43
|
Favaretto E, Sartori M, Conti E, Legnani C, Palareti G. G1691A factor V and G20210A FII mutations, acute ischemic stroke of unknown cause, and patent foramen ovale. Thromb Res 2012; 130:720-4. [DOI: 10.1016/j.thromres.2012.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 06/17/2012] [Accepted: 07/17/2012] [Indexed: 12/22/2022]
|
44
|
Hamzi K, Tazzite A, Nadifi S. Large-scale meta-analysis of genetic studies in ischemic stroke: Five genes involving 152,797 individuals. INDIAN JOURNAL OF HUMAN GENETICS 2012; 17:212-7. [PMID: 22345995 PMCID: PMC3276992 DOI: 10.4103/0971-6866.92105] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND: Ischemic stroke descent has a genetic basis. Stroke represents a complex trait, which is assumed to be polygenic. On this topic, the role of a wide number of candidate genes has been investigated in stroke through association studies. MATERIALS AND METHODS: We performed a literature-based systematic review of genetic association studies in stroke abound several populations. Odds ratios (ORs) and 95% confidence intervals (CIs) were determined for each gene-disease association. Following a review of 300 manuscripts, five candidate gene variants were analyzed among 152,797 individuals (45,433 cases and 107,364 controls). RESULTS: For these five candidate genes studied, the prothrombin OR is 1,57 (1,23-2,89), the factor V Leiden OR is 1,43 (0,67-6,24), the mean OR of angiotensin I converting enzyme (ACE) insertion/deletion (I/D) polymorphism is 1,11 (1,02-1,25), the summary OR for the C677T variant of 5,10-methylenetetrahydrofolate reductase (MTHFR) is 1,23 (0,61-1,47) and the pooled OR for the apolipoprotein E (APOE) gene is 0,95 (0,77-1,14) . CONCLUSION: These data suggest the genetic associations of some genes with ischemic stroke and it is necessary to compete with other genes. Our findings could represent an epidemiological base and a useful tool to address further molecular investigations and to realize more detailed meta-analyses.
Collapse
Affiliation(s)
- Khalil Hamzi
- Laboratory of Human Genetics and Molecular Pathology, Facullty of medicine, UH2C - Casablanca, Morocco
| | | | | |
Collapse
|
45
|
Faggiano P, Frattini S, Piovesana P, Lorusso R, Chiari E, Scolari F, Padovani A, Cas LD. Low cerebrovascular event rate in subjects with patent foramen ovale and different clinical presentations. Int J Cardiol 2012; 156:47-52. [DOI: 10.1016/j.ijcard.2010.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Revised: 08/22/2010] [Accepted: 10/23/2010] [Indexed: 11/25/2022]
|
46
|
Griffiths D, Sturm J. Epidemiology and etiology of young stroke. Stroke Res Treat 2011; 2011:209370. [PMID: 21789269 PMCID: PMC3140048 DOI: 10.4061/2011/209370] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/12/2010] [Accepted: 03/27/2011] [Indexed: 01/05/2023] Open
Abstract
Introduction. Stroke in people under 45 years of age is less frequent than in older populations but has a major impact on the individual and society. In this article we provide an overview of the epidemiology and etiology of young stroke. Methods. This paper is based on a review of population-based studies on stroke incidence that have included subgroup analyses for patients under 45 years of age, as well as smaller community-based studies and case-series specifically examining the incidence of stroke in the young. Trends are discussed along with the relative frequencies of various etiologies. Discussion. Stroke in the young requires a different approach to investigation and management than stroke in the elderly given differences in the relative frequencies of possible underlying causes. It remains the case, however, that atherosclerosis contributes to a large proportion of stroke in young patients, thus, conventional risk factors must be targeted aggressively.
Collapse
Affiliation(s)
- Dayna Griffiths
- Department of Neurology, Gosford Hospital, P.O. Box 361, Gosford, NSW 2250, Australia
| | | |
Collapse
|
47
|
Calabrò RS, Gervasi G, Bramanti P. Can interaction between atrial septal abnormalities and genetic prothrombotic polymorphisms play a role in cryptogenic ischemic stroke? Description of a family. Neurol Sci 2011; 33:117-9. [PMID: 21614578 DOI: 10.1007/s10072-011-0635-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 05/13/2011] [Indexed: 10/18/2022]
|
48
|
Kefer J, Sluysmans T, Hermans C, El Khoury R, Lambert C, Van de Wyngaert F, Ovaert C, Pasquet A. Percutaneous transcatheter closure of interatrial septal defect in adults: procedural outcome and long-term results. Catheter Cardiovasc Interv 2011; 79:322-30. [PMID: 21523898 DOI: 10.1002/ccd.23119] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 03/07/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Percutaneous transcatheter closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has been shown to be feasible. AIM The aim of this study was to evaluate the safety and efficacy of transcatheter interatrial septal shunt closure with prosthesis implantation in adults patients during long-term follow-up. In addition, the impact of thrombophilia and pulmonary hypertension on the outcome were investigated. METHODS Between June 1999 and November 2009, 287 patients (112 males, 43 ± 14 years) were treated in our institution by transcatheter closure of PFO (N = 175) or ASD (N = 112). Clinical and echocardiographic follow-up were prospectively performed at 1, 6 and 12 months followed by a 1 once a year evaluation. RESULTS All procedures were successful with eight procedural complications (2.7%): one stroke, two femoral pseudoaneurysms, three transient atrial fibrillation, two minors pericardial effusions. Among patients with presumed paradoxical embolism, thrombophilia was observed in 29 patients (17%); only one of them experienced a recurrent stroke. Among patients with ASD, pulmonary hypertension was observed in 32 cases (28%) and significantly reduced 6 months after shunt closure (from 47 ± 7 to 31 ± 11 mm Hg, P < 0.0001). 99% of patients achieved a complete follow-up. Clinical improvement was observed in 93%. Freedom from death, cardiac surgery or recurrent embolism was 98 ± 1% at 5 years. CONCLUSION Percutaneous transcatheter interatrial septal defect closure is a safe and effective treatment in adults patients, even in case of thrombophilia or pulmonary hypertension, during a long-term follow-up, up to 11 years.
Collapse
Affiliation(s)
- Joelle Kefer
- Division of Cardiology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Kibe T, Mori Y, Okanishi T, Shimojima K, Yokochi K, Yamamoto T. Two concurrent chromosomal aberrations involving interstitial deletion in 1q24.2q25.2 and inverted duplication and deletion in 10q26 in a patient with stroke associated with antithrombin deficiency and a patent foramen ovale. Am J Med Genet A 2011; 155A:215-20. [PMID: 21204235 DOI: 10.1002/ajmg.a.33786] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Advanced high-throughput molecular cytogenetic analysis has enabled the identification of small chromosomal rearrangements, and two or more concurrently occurring chromosomal rearrangements have been identified using this technique. A girl with severe psychomotor developmental delay associated with an uncertain abnormality (detected by conventional karyotyping) in chromosome 10q had a sudden stroke at the age of 35 months. Laboratory and radiographic examinations revealed antithrombin (AT) deficiency and a patent foramen ovale (PFO). Two concurrent chromosomal aberrations, inverted duplication and deletion in the 10q26 region and a microdeletion in the 1q24.2q25.2 region including the AT gene (SERPINC1), were identified by microarray-based comparative genomic hybridization analysis. Both chromosomal aberrations were found to be of paternal origin. This study described the concurrence of chromosomal rearrangements involving two chromosomes, and estimated the frequency of two or more chromosomal aberrations as 2-4%.
Collapse
Affiliation(s)
- Tetsuya Kibe
- Department of Pediatrics, Seirei-Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | | | | | | | | | | |
Collapse
|
50
|
Ng KWP, Loh PK, Sharma VK. Role of investigating thrombophilic disorders in young stroke. Stroke Res Treat 2011; 2011:670138. [PMID: 21331344 PMCID: PMC3038796 DOI: 10.4061/2011/670138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 12/22/2010] [Accepted: 01/05/2011] [Indexed: 11/20/2022] Open
Abstract
Our knowledge about various inherited and acquired causes of thrombophilic disorders has increased significantly during the past decade. Technology for various diagnostic tests for these rare disorders has matched the rapid advances in our understanding about the thrombophilic disorders. Inherited thrombophilic disorders predispose young patients for various venous or arterial thrombotic and thromboembolic episodes. Our understanding has also improved about various gene-gene and gene-environment interactions and their impact on the resultant heterogenous clinical manifestations. We describe various thrombophilic disorders, their diagnostic tests, pathogenic potential in isolation or with other concurrent inherited/acquired defects and possible therapeutic and prophylactic strategies. Better understanding, optimal diagnostic and screening protocols are expected to improve the diagnostic yield and help to reduce morbidity, disability, and mortality in relatively younger patients harbouring these inherited and acquired thrombophilic disorders.
Collapse
Affiliation(s)
- Kay W P Ng
- Division of Neurology, Department of Medicine, National University Hospital, 1E, Kent Ridge Road, Singapore 119228
| | | | | |
Collapse
|