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Arcadi FA, Morabito R, Marino S, Formica C, Calabrò RS. Cervical Artery Dissection and Patent Foramen Ovale in Juvenile Stroke: Causality or Casuality? A Familiar Case Report. Med Sci (Basel) 2023; 11:medsci11020034. [PMID: 37218986 DOI: 10.3390/medsci11020034] [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: 04/10/2023] [Revised: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023] Open
Abstract
Cervical artery dissection (CAD) and Patent Foramen Ovale (PFO) are important causes of stroke in young patients. Although PFO is considered an independent risk factor for cerebral infarction in young adults with cryptogenic stroke, other concomitant causes may be necessary to cause brain injury. PFO could be a predisposing factor of stroke through several mechanisms including paradoxical embolism from a venous source, thrombus formation in atrial septum, or atrial arrhythmias causing cerebral thromboembolism. The pathophysiology of CAD is poorly understood and includes both constitutional and environmental factors. A causal association is often difficult to establish, as other predisposing factors may also play a role in CAD etiopathogenesis. We present a family with ischemic stroke (a father and his three daughters), in which the two different stroke causes are present. We hypothesized that a paradoxical embolism caused by PFO, associated with arterial wall disease, in the presence of a procoagulant state, could produce arterial dissection and then stroke.
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Affiliation(s)
| | - Rosa Morabito
- IRCCS Centro Neurolesi "Bonino Pulejo", S.S. 113, Contrada Casazza, 98124 Messina, Italy
| | - Silvia Marino
- IRCCS Centro Neurolesi "Bonino Pulejo", S.S. 113, Contrada Casazza, 98124 Messina, Italy
| | - Caterina Formica
- IRCCS Centro Neurolesi "Bonino Pulejo", S.S. 113, Contrada Casazza, 98124 Messina, Italy
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2
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Brisson RT, Arruda JFDL, Silva LD, de Jesus DLJ, Zetola VF, Kauffmann Nogueira MAC. Stroke in Young Military Men With Heterozygous for MTHFR Gene Mutation or Factor V Leiden Gene Mutation Associated With Patent Foramen Ovale: Report of Two Cases and Therapeutic Strategy. Mil Med 2023; 188:e885-e889. [PMID: 33993312 DOI: 10.1093/milmed/usab192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/31/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022] Open
Abstract
We report two cases of Brazilian patients (a 22-year-old male and a 48-year-old male) with ischemic stroke, whose arterial vascular study and echocardiographic investigation did not reveal any steno-occlusive arterial disease or typical cardioembolic finding, such as atrial fibrillation or myocardial dysfunction. A transcranial Doppler ultrasound and a transesophageal echocardiogram showed a patent foramen ovale (PFO), and the laboratory screening for coagulation abnormalities showed heterozygosity for MTHFR C677T and A1298C in one of the patients and heterozygosity for factor V Leiden gene mutations in the other patient. The significance of the association of PFO with Methylenetetrahydrofolate (MTHFR) C677T and A1298C variants or factor V Leiden mutation is discussed as a possible cause of ischemic stroke through paradoxical embolism from a venous source. There is a high prevalence of these two mentioned conditions in the general population, so we discuss two cases in which indication for anticoagulant therapy or percutaneous closure of PFO prevails.
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Affiliation(s)
- Rodrigo Tavares Brisson
- Division of Neurology, Hospital Naval Marcílio Dias, Rio de Janeiro, Rio de Janeiro 20725-090, Brazil
| | | | - Liene Duarte Silva
- Division of Neurology, Hospital Naval Marcílio Dias, Rio de Janeiro, Rio de Janeiro 20725-090, Brazil
| | | | - Viviane Flumignan Zetola
- Neurosonology Laboratory, Cerebrovascular Disease Unit, Federal University of Paraná, Curitiba, Paraná 80060-000, Brazil
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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.
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Coagulation Factor XIII Val34Leu Polymorphism in the Prediction of Premature Cardiovascular Events-The Results of Two Meta-Analyses. J Clin Med 2022; 11:jcm11123454. [PMID: 35743524 PMCID: PMC9225267 DOI: 10.3390/jcm11123454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Polymorphisms within the gene that encodes for coagulation factor XIII (FXIII) have been suggested to be involved in the pathogeneses of ischemic stroke (IS) and myocardial infarction (MI). The Val34Leu polymorphism is one of the most commonly analysed FXIII polymorphisms. However, studies on the role of the Val34Leu polymorphism in the aetiology of vascular diseases often show contradictory results. In the present meta-analysis, we aimed to pool data from available articles to assess the relationship between the FXIII Val34Leu polymorphism and the susceptibilities to IS of undetermined source and premature MI in patients aged below 55 years. Methods: We searched databases (PubMed, Embase, Google Scholar, SciELO, and Medline) using specific keywords (the last search was in January 2022). Eventually, 18 studies (627 cases and 1639 controls for IS; 2595 cases and 4255 controls for MI) met the inclusion criteria. Data were analysed using RevMan 5.4 and StatsDirect 3 link software. The relation between Val34Leu polymorphism and disease was analysed in five genetic models, i.e., dominant, recessive, additive, heterozygous, and allelic. Results: No relation between Val34Leu polymorphism and IS in young adults was observed in all analysed genetic models. For premature MI, significant pooled OR was found between the carrier state of the Leu allele (Val/Leu + Leu/Leu vs. Val/Val) and a lack of MI, suggesting its protective role (OR = 0.80 95%CI 0.64–0.99, p = 0.04). A similar finding was observed for the heterozygous model in MI (Val/Leu vs. Val/Val) (OR = 0.77 95%CI 0.61–0.98, p = 0.03). No relation was found for the recessive, additive, and allelic models in MI. Conclusions: In the population of young adults, no positive correlation was found between the FXIII Val34Leu polymorphism and IS of undetermined source in any of the analysed genetic models. In turn, the carrier state of the 34Leu allele as well as FXIII heterozygotes themselves were found to play a protective role in relation to premature MI.
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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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.
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Affiliation(s)
| | | | - Nicholas Ruggiero
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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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.
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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.
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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
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Salehi Omran S, Hartman A, Zakai NA, Navi BB. Thrombophilia Testing After Ischemic Stroke: Why, When, and What? Stroke 2021; 52:1874-1884. [PMID: 33874743 DOI: 10.1161/strokeaha.120.032360] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thrombophilia testing is frequently performed after an ischemic stroke, particularly when cryptogenic. However, there is minimal evidence supporting a significant association between most conditions assessed through thrombophilia testing and ischemic stroke, and the rationale for thrombophilia testing in many clinical situations remains uncertain. In this topical review, we review and contextualize the existing data on the risks, predictors, and outcomes of thrombophilic conditions in patients with ischemic stroke. We report that inherited thrombophilias have an uncertain relationship with ischemic stroke. Conversely, antiphospholipid syndrome, an acquired immune-mediated thrombophilia, seems to be a strong risk factor for arterial thromboembolic events, including ischemic stroke, and especially among young patients. Our findings suggest that certain circumstances may warrant targeted thrombophilia testing, such as stroke in the young, cryptogenic stroke, and high estrogen states. Future prospective studies should investigate the utility and cost effectiveness of thrombophilia testing in various stroke settings, including among patients with patent foramen ovale; as well as the optimal secondary stroke prevention regimen in patients with confirmed thrombophilia, particularly if no other potential stroke mechanism is identified.
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Affiliation(s)
- Setareh Salehi Omran
- Department of Neurology, University of Colorado School of Medicine, Aurora (S.S.O., A.H.)
| | - Adam Hartman
- Department of Neurology, University of Colorado School of Medicine, Aurora (S.S.O., A.H.)
| | - Neil A Zakai
- Department of Medicine and Department of Pathology and Laboratory Medicine, Larner College of Medicine University of Vermont, Burlington (N.A.Z.)
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (B.B.N.)
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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.
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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
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M'barek L, Sakka S, Meghdiche F, Turki D, Maalla K, Dammak M, Kallel C, Mhiri C. MTHFR (C677T, A1298C), FV Leiden polymorphisms, and the prothrombin G20210A mutation in arterial ischemic stroke among young tunisian adults. Metab Brain Dis 2021; 36:421-428. [PMID: 33400068 DOI: 10.1007/s11011-020-00663-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/25/2020] [Indexed: 12/15/2022]
Abstract
Arterial ischemic stroke (AIS) in young adults is less common in older adults, but the underlying pathogenesis and risk factors are more multi-faceted. The role of inherited thrombophilia such as 5, 10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphism, (C677T and A1298C), factor V of Leiden (FVL) polymorphism, and the prothrombin G20210A mutations remains unclear. This study aims to evaluate the role of prothrombin genetic factor in AIS among young adults in Tunisia and to assess the synergistic effect between thrombogenic mutations in the pathogenesis of AIS. In this case-control study, blood samples were collected from patients and healthy controls, all matched for age and gender. The difference between them is evaluated by using the chi-square test. The odds ratio (OR) was carried out to evaluate the associations between each polymorphism and AIS risk using a binary logistic regression model. Values were considered statistically significant when p < 0.05. Patients carrying simultaneously the MTHFR polymorphisms (677T and 1298C) have a higher risk to develop AIS compared to controls. The heterozygous variants FVL increased the risk of AIS only when it is associated with MTHFR C677T or MTHFR A1298C polymorphisms. In conclusion, our study confirmed the involvement of MTHFR polymorphisms as AIS's important risk factors. The existence of FVL polymorphism or prothrombin G20210A mutation alone doesn't correlate with the occurrence of stroke. We assume that the presence of both MTHFR and FVL polymorphisms has a synergistic effect and increased the risk of the AIS.
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Affiliation(s)
- Lamia M'barek
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR-12-SP-19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia.
- Clinical Investigation Center (CIC), Habib Bourguiba University Hospital, Sfax, Tunisia.
| | - Salma Sakka
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR-12-SP-19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
| | - Fatma Meghdiche
- Laboratory of Hematology, Habib Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Dhaker Turki
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR-12-SP-19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
| | - Khadija Maalla
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR-12-SP-19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
| | - Mariem Dammak
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR-12-SP-19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
| | - Choumous Kallel
- Laboratory of Hematology, Habib Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Chokri Mhiri
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR-12-SP-19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
- Clinical Investigation Center (CIC), Habib Bourguiba University Hospital, Sfax, Tunisia
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12
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Elgendy AY, Saver JL, Amin Z, Boudoulas KD, Carroll JD, Elgendy IY, Grunwald IQ, Gertz ZM, Hijazi ZM, Horlick EM, Kasner SE, Kent DM, Kumar P, Kavinsky CJ, Liebeskind DS, Lutsep H, Mojadidi MK, Messé SR, Mas JL, Mattle HP, Meier B, Mahmoud A, Mahmoud AN, Nietlispach F, Patel NK, Rhodes JF, Reisman M, Sommer RJ, Sievert H, Søndergaard L, Zaman MO, Thaler D, Tobis JM. Proposal for Updated Nomenclature and Classification of Potential Causative Mechanism in Patent Foramen Ovale-Associated Stroke. JAMA Neurol 2021; 77:878-886. [PMID: 32282016 DOI: 10.1001/jamaneurol.2020.0458] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance Recent epidemiologic and therapeutic advances have transformed understanding of the role of and therapeutic approach to patent foramen ovale (PFO) in ischemic stroke. Patent foramen ovale is likely responsible for approximately 5% of all ischemic strokes and 10% of those occurring in young and middle-aged adults. Observations Randomized clinical trials have demonstrated that, to prevent recurrent ischemic stroke in patients with PFO and an otherwise-cryptogenic index ischemic stroke, PFO closure is superior to antiplatelet medical therapy alone; these trials have provided some evidence that, among medical therapy options, anticoagulants may be more effective than antiplatelet agents. Conclusions and Relevance These new data indicate a need to update classification schemes of causative mechanisms in stroke, developed in an era in which an association between PFO and stroke was viewed as uncertain. We propose a revised general nomenclature and classification framework for PFO-associated stroke and detailed revisions for the 3 major stroke subtyping algorithms in wide use.
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Affiliation(s)
- Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Jeffrey L Saver
- Comprehensive Stroke Center, David Geffen School of Medicine, Department of Neurology, University of California, Los Angeles, Los Angeles
| | - Zahid Amin
- Children's Hospital of Georgia, Department of Pediatric Cardiology, Augusta University, Augusta, Georgia
| | | | - John D Carroll
- Division of Cardiology, Department of Medicine, University of Colorado, Denver, Aurora
| | - Islam Y Elgendy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Iris Q Grunwald
- Cardiovascular Center Frankfurt, Frankfurt, Germany.,Anglia Ruskin University, Chelmsford, United Kingdom
| | - Zachary M Gertz
- Division of Cardiovascular Medicine, Department of Medicine, Virginia Commonwealth University, Richmond
| | - Ziyad M Hijazi
- Sidra Heart Center, Sidra Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Eric M Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Scott E Kasner
- Perelman School of Medicine, Department of Neurology, University of Pennsylvania, Philadelphia
| | - David M Kent
- Department of Neurology, Tufts University School of Medicine, Boston, Massachusetts
| | - Preetham Kumar
- David Geffen School of Medicine, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles
| | | | - David S Liebeskind
- Comprehensive Stroke Center, David Geffen School of Medicine, Department of Neurology, University of California, Los Angeles, Los Angeles
| | - Helmi Lutsep
- Department of Neurology, Oregon Health & Science University, Portland
| | - Mohammad K Mojadidi
- Division of Cardiovascular Medicine, Department of Medicine, Virginia Commonwealth University, Richmond
| | - Steven R Messé
- Perelman School of Medicine, Department of Neurology, University of Pennsylvania, Philadelphia
| | - Jean-Louis Mas
- Sainte-Anne Hospital, Department of Neurology, Département Hospitalo-Universitaire NeuroVasc Sorbonne Paris-Cité, Institut National de la Santé et de la Recherche Médicale 894, Paris, France
| | - Heinrich P Mattle
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Ahmad Mahmoud
- Department of Medicine, University of Florida, Gainesville
| | - Ahmed N Mahmoud
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle
| | - Fabian Nietlispach
- CardioVascular Center Zurich, Hirslanden Klinik Im Park, Zürich, Switzerland
| | - Nimesh K Patel
- Division of Cardiovascular Medicine, Department of Medicine, Virginia Commonwealth University, Richmond
| | | | - Mark Reisman
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle
| | - Robert J Sommer
- Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center, Columbia University Medical Center, New York, New York
| | - Horst Sievert
- Cardiovascular Center Frankfurt, Frankfurt, Germany.,Anglia Ruskin University, Chelmsford, United Kingdom
| | | | | | - David Thaler
- Department of Neurology, Tufts University School of Medicine, Boston, Massachusetts
| | - Jonathan M Tobis
- David Geffen School of Medicine, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles
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13
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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.
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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
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14
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Relationship between non-headache symptoms and right to left shunt in episodic migraine. A single-center cross-sectional study. J Clin Neurosci 2021; 86:38-44. [PMID: 33775344 DOI: 10.1016/j.jocn.2021.01.004] [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: 02/27/2020] [Revised: 11/03/2020] [Accepted: 01/07/2021] [Indexed: 11/20/2022]
Abstract
The relationship between right to left shunt (RLS) and non-headache symptoms (NHS) in episodic migraine is unknown. This study aimed to investigate the incidence and classification of RLS in episodic migraineurs, calculate the occurrence rate of NHS, and analyze the associations between RLS and NHS. We consecutively recruited 204 episodic migraine patients. Contrast-enhanced transcranial doppler was adopted to screen RLS. Structured questionnaire via face-to-face survey was conducted to collect clinical data. A total of 172 episodic migraineurs were included in the final analysis, of which 20 cases were migraine with aura. The positive rate of RLS was 47.1%, of which 50 cases (29.0%) had small shunt (Grade 1) and 31 cases (18.1%) had mid-large shunt (Grade 2-4). The most common NHS was nausea (115 (66.9%)), followed by headache aggravation with physical activity (96 (55.8%)), dizziness (93 (54.1%)), vomiting (77 (44.8%)) and phonophobia (74 (43.0%)). Yawning was more common in Grade 2-4 group than Grade 0 group (p = 0.012), while no statistical differences among other groups. Grade 2-4 group had a higher rate of headache aggravation with physical activity than grade 0 group (p = 0.008). Binary logistic regression analysis showed that yawning at premonitory phase, headache aggravation with physical activity and cranial autonomic symptoms during attack are independent predictors of RLS. In conclusion, yawning and headache aggravation with physical activity are more common in migraine patients with RLS. Besides aura, particular NHS may also serve as indicators for screening RLS in episodic migraineurs.
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15
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Gerstein NS, Clegg SD, Levin DB, Fish AC, Tolstrup K, Nakanishi K, Yoshida Y, Homma S. A Case-Based Discussion on the Management of Cryptogenic Stroke and Patent Foramen Ovale in the Patient With a Hypercoagulable Disorder. J Cardiothorac Vasc Anesth 2019; 33:3476-3485. [PMID: 31473116 DOI: 10.1053/j.jvca.2019.07.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/21/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico - School of Medicine, Albuquerque, NM.
| | - Stacey D Clegg
- Department of Medicine, Division of Cardiology, University of New Mexico - School of Medicine, Albuquerque, NM
| | - Daniel B Levin
- Department of Medicine, Division of Cardiology, University of New Mexico - School of Medicine, Albuquerque, NM
| | - Adam C Fish
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico - School of Medicine, Albuquerque, NM
| | - Kirsten Tolstrup
- Department of Medicine, University of California, San Francisco, CA
| | - Koki Nakanishi
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuriko Yoshida
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunichi Homma
- Department of Medicine, Columbia University, New York, NY
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16
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Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
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17
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Coughlan JJ, Daly A, Arnous S, Kiernan TJ. Patent foramen ovale and cryptogenic stroke: contemporary evidence and treatment. Expert Rev Cardiovasc Ther 2017; 16:27-37. [PMID: 29256291 DOI: 10.1080/14779072.2018.1419064] [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] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Patent foramen ovale (PFO) is a common anatomical variant in the adult circulation. It is a channel allowing communication between the left and right atria and is a remnant of the foetal circulation. In approximately 25% of the population, this channel persists into adulthood. PFO has been proposed as a potential pathophysiological mechanism for cryptogenic stroke. Areas covered: This review will examine the contemporary evidence for both the association between cryptogenic stroke and PFO and the management of this condition. The authors hope to provide a comprehensive overview of the current evidence and best practice in relation to PFO closure. In addition, the authors will propose some potential avenues for future research in this controversial area and try to predict how PFOs in cryptogenic stroke will be managed in the near future. Expert commentary: In carefully selected patients with cryptogenic stroke, PFO closure represents an evidence based treatment option for the prevention of further ischemic neurological events. A multidisciplinary approach is necessary to ensure appropriate patient selection for the procedure. This should include a vascular neurologist/stroke physician and an interventional cardiologist with an interest in PFO closure.
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Affiliation(s)
- J J Coughlan
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Aidan Daly
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Samer Arnous
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Tom J Kiernan
- b Department of Cardiology, Graduate Entry Medical School , University of Limerick , Limerick , Ireland.,c Graduate Entry Medical School , University of Limerick , Limerick , Ireland
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18
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Nakanishi K, Yoshiyama M, Homma S. Patent foramen ovale and cryptogenic stroke. Trends Cardiovasc Med 2017; 27:575-581. [DOI: 10.1016/j.tcm.2017.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 10/19/2022]
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19
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Kleber FX, Hauschild T, Schulz A, Winkelmann A, Bruch L. Epidemiology of Myocardial Infarction Caused by Presumed Paradoxical Embolism via a Patent Foramen Ovale. Circ J 2017; 81:1484-1489. [DOI: 10.1253/circj.cj-16-0995] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Franz X. Kleber
- Cardio Centrum Berlin Academic Teaching Institution, Charité University Medicine Berlin
| | - Telse Hauschild
- Ernst von Bergmann Klinikum Potsdam, Academic Teaching Hospital, Charité University Medicine Berlin
| | - Antonia Schulz
- Cardio Centrum Berlin Academic Teaching Institution, Charité University Medicine Berlin
| | - Anne Winkelmann
- Unfallkrankenhaus Berlin, Academic Teaching Hospital, Charité University Medicine Berlin
| | - Leonhard Bruch
- Unfallkrankenhaus Berlin, Academic Teaching Hospital, Charité University Medicine Berlin
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20
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Zier LS, Sievert H, Mahadevan VS. To close or not to close: contemporary indications for patent foramen ovale closure. Expert Rev Cardiovasc Ther 2016; 14:1235-1244. [DOI: 10.1080/14779072.2016.1224178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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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.
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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
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22
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Homma S, Messé SR, Rundek T, Sun YP, Franke J, Davidson K, Sievert H, Sacco RL, Di Tullio MR. Patent foramen ovale. Nat Rev Dis Primers 2016; 2:15086. [PMID: 27188965 DOI: 10.1038/nrdp.2015.86] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.
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Affiliation(s)
- Shunichi Homma
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Yee-Ping Sun
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Karina Davidson
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
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Abstract
Objectives: To report an unusual case of suicide attempt secondary complicated of pulmonary and systemic embolisms. Data Source: A 49-year-old-woman, with a factor V Leiden mutation and a notion of chronic depression, admitted to our intensive care unit for a suicide attempt by ingestion ofmepronizine and lormetazepam. Data Extraction: We report the rare evolution of this patient with a persistent alteration of consciousness associating a respiratory degradation. Despite the drug intoxication and possibility of aspiration, we performed a computed tomography (CT) angiography which confirmed the presence of a bilateral, proximal, pulmonary embolism suspected on transthoracic echocardiography. A cerebral CT showed left sylvian and cerebellar infarctions complicated of perilesional edema. Association of stroke and pulmonary embolism led us to suspect a patent foramen ovale (PFO). There was also a context of genetical perturbation of hemostasis. Transesophageal echocardiography confirmed the presence of a PFO undiagnosed by transthoracic echography. The PFO was complicated by an entrapped thrombus. The thrombotic complications were treated by unfractionated heparin. Data Synthesis: Neurological and respiratory degradation following voluntary drug intoxication led to the discovery of both a pulmonary and cerebral embolism secondary to a PFO entrapped thrombus. Conclusions: An entrapped thrombus in a PFO is a rare and dangerous situation, associated with many complications. Association of systemic and pulmonary embolisms should lead to PFO detection to guide therapeutic interventions.
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Affiliation(s)
- Renaud Prevel
- Department of Respiratory, Hospital, Pellegrin, France ; Université Bordeaux-II Segalen, Bordeaux, France
| | - Philippe Garcon
- Department of Cardiology, Groupe Hospitalier Paris Saint Joseph, Paris, France ; University of Paris Descartes, Sorbonne Cite, Paris, France
| | - François Philippart
- Department of Critical Care, Groupe Hospitalier Paris Saint Joseph, Paris, France
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24
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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.
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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
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25
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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.
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26
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Cruz-González I, Solis J, Kiernan TJ, Yan BP, Lam YY, Palacios IF. Clinical manifestation and current management of patent foramen ovale. Expert Rev Cardiovasc Ther 2014; 7:1011-22. [DOI: 10.1586/erc.09.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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27
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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]
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They-They TP, Battas O, Nadifi S. Synergistic effect of MTHFR C677T and F2 G20210A polymorphisms on ischemic stroke. Neurosci Bull 2013; 29:725-30. [PMID: 24132798 DOI: 10.1007/s12264-013-1381-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 04/01/2013] [Indexed: 11/30/2022] Open
Abstract
The predisposition to stroke might involve interactive effects among variants in several genes. We tested this hypothesis by examining the influence of polymorphisms in methylenetetrahydrofolate reductase (MTHFR) (C677T) and prothrombin (F2) (G20210A) as risk factors for stroke in Morocco. The polymerase chain reaction-restriction fragment length polymorphism methods were used to analyze DNA from 91 stroke patients and 182 controls. Association between the two polymorphisms and the risk of stroke was estimated by four-level models for the analysis of genetic interaction. Neither the MTHFR 677TT nor the F2 20210GA genotype showed any significant association compared to the MTHFR CC and F2 GG genotypes, respectively. An interactive effect between the MTHFR 677TT and F2 20210GA polymorphisms showed an increased risk of stroke. The odds ratios, in univariate and multivariate analysis, for the combined polymorphisms were 4.99 (95% CI, 1.75-14.2, P = 0.001) and 5.29 (95% CI, 1.63-17.1, P = 0.005), respectively.
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Affiliation(s)
- Thierry Paluku They-They
- Department of Clinical Neuroscience and Biological Psychiatry, Hassan II University, BP 9154, 10000, Casablanca, Morocco,
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29
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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.
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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.
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Affiliation(s)
- Mingming Ning
- Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, USA.
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Lantz M, Sjöstrand C, Kostulas K. Ischemic Stroke and Patent Foramen Ovale: Risk Factors and Genetic Profile. J Stroke Cerebrovasc Dis 2013; 22:841-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/28/2012] [Accepted: 06/04/2012] [Indexed: 10/28/2022] Open
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Moskau S, Smolka K, Semmler A, Schweichel D, Harbrecht U, Müller J, Pohl C, Klockgether T, Linnebank M. Common genetic coagulation variants are not associated with ischemic stroke in a case-control study. Neurol Res 2013; 32:519-22. [DOI: 10.1179/016164109x12464612122533] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Di Tullio MR, Jin Z, Russo C, Elkind MSV, Rundek T, Yoshita M, DeCarli C, Wright CB, Homma S, Sacco RL. Patent foramen ovale, subclinical cerebrovascular disease, and ischemic stroke in a population-based cohort. J Am Coll Cardiol 2013; 62:35-41. [PMID: 23644084 DOI: 10.1016/j.jacc.2013.03.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/28/2013] [Accepted: 03/26/2013] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the relationship between patent foramen ovale (PFO), ischemic stroke, and subclinical cerebrovascular disease in the general population. BACKGROUND PFO is found more frequently in stroke patients than in stroke-free controls. However, the PFO-related stroke risk in the general population is not well established, and the relationship between PFO and silent brain infarcts (SBI) is not known. METHODS PFO presence was assessed by transthoracic echocardiography with saline contrast injection in 1,100 stroke-free individuals over age 39 of a community-based sample followed for a mean of 11 years. In addition, 360 participants underwent brain magnetic resonance imaging (MRI) for SBI detection. We evaluated the risk of stroke associated with PFO after adjusting for established stroke risk factors and examined the odds of having SBI among those with and without PFO. RESULTS PFO was present in 164 participants (14.9%). Over a mean follow-up of 11.0 ± 4.5 years, 111 ischemic strokes occurred (10.1%), 15 (9.2%) in the PFO+ and 96 (10.3%) in the PFO- groups. The 12.5-year cumulative risk of stroke was 10.1% (standard error: 2.5%) in the PFO+ and 10.4% (standard error: 1.1%) in the PFO- group (p = 0.46). The adjusted hazard ratio for PFO and stroke was 1.10 (95% confidence interval [CI]: 0.64 to 1.91). In the MRI subcohort, PFO was not associated with SBI (adjusted odds ratio: 1.15, 95% CI: 0.50 to 2.62). CONCLUSIONS In this community-based cohort, PFO was not associated with an increased risk of clinical stroke or subclinical cerebrovascular disease.
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Sathasivam S, Sathasivam S. Patent foramen ovale and migraine: What is the relationship between the two? J Cardiol 2013; 61:256-9. [DOI: 10.1016/j.jjcc.2012.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 11/23/2012] [Accepted: 12/04/2012] [Indexed: 01/16/2023]
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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]
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36
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Patent foramen ovale and atrial septal aneurysm can cause ischemic stroke in patients with antiphospholipid syndrome. J Neurol 2012; 260:189-96. [PMID: 22836909 DOI: 10.1007/s00415-012-6613-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 06/18/2012] [Accepted: 07/06/2012] [Indexed: 10/28/2022]
Abstract
The purpose of the present study was to evaluate the contributions of embolic etiologies, patent foramen ovale (PFO) and atrial septal aneurysm (ASA) to the pathogenesis of ischemic stroke in patients with antiphospholipid syndrome (APS). We performed transesophageal echocardiography (TEE) examination for consecutive stroke patients who had been diagnosed with APS (APS group) to detect potential embolic sources. APS was diagnosed based on the modified Sapporo criteria. The control stroke group comprised age- and sex-matched cryptogenic stroke patients undergoing TEE. We assessed and compared the clinical characteristics and TEE findings between stroke patients with APS and control stroke groups. Among 582 patients, nine patients (nine women; mean age, 50 ± 18 years) were classified into the APS group. In 137 patients undergoing TEE, 41 age-matched female stroke patients were recruited to the control stroke group. Prevalences of PFO and ASA were significantly higher in the APS group than in the control stroke group (89 vs. 41 %, p = 0.027; 67 vs. 20 %, p = 0.015, respectively). Multiple logistic regression analysis showed that PFO (odds ratio (OR), 13.71; 95 % confidence interval (CI), 1.01-185.62; p = 0.049) and ASA (OR, 8.06; 95 % CI, 1.17-55.59; p = 0.034) were independently associated with the APS group. PFO and ASA were strongly associated with the APS group, and could thus represent potential embolic sources in ischemic stroke patients with APS.
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Sharma A, Gheewala N, Silver P. Role of patent foramen ovale in migraine etiology and treatment: a review. Echocardiography 2011; 28:913-7. [PMID: 21827543 DOI: 10.1111/j.1540-8175.2011.01460.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
An increased prevalence between patent formen ovale (PFOs) and migraine exists but there is conflicting data regarding causal relationship between these two conditions. It is controversial whether cardiac screening and intervention like PFO closure provides any benefit in this population and so this area still remains under intense investigation. The management of migraine lies at the intersection between the practice of primary care physicians, neurologists, and cardiologists. There is no consensus as to what is the best practice for the evaluation of these patients with difficult to control migraine given the millions of dollars spent on physician visits and pharmacotherapy. This review seeks to summarize the current literature on this association and studies that have investigated PFO closure in this population.
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Affiliation(s)
- Ambika Sharma
- George Washington University School of Medicine, Washington, DC, USA.
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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.
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Affiliation(s)
- Dayna Griffiths
- Department of Neurology, Gosford Hospital, P.O. Box 361, Gosford, NSW 2250, Australia
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Pellaton C, Heinzer R, Michel P, Eeckhout E. Patent foramen ovale and obstructive sleep apnoea: from pathophysiology to diagnosis of a potentially dangerous association. Arch Cardiovasc Dis 2011; 104:242-51. [PMID: 21624791 DOI: 10.1016/j.acvd.2010.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 12/14/2010] [Indexed: 11/17/2022]
Abstract
Patent foramen ovale and obstructive sleep apnoea are frequently encountered in the general population. Owing to their prevalence, they may coexist fortuitously; however, the prevalence of patent foramen ovale seems to be higher in patients with obstructive sleep apnoea. We have reviewed the epidemiological data, pathophysiology, and the diagnostic and therapeutic options for both patent foramen ovale and obstructive sleep apnoea. We focus on the interesting pathophysiological links that could explain a potential association between both pathologies and their implications, especially on the risk of stroke.
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Affiliation(s)
- Cyril Pellaton
- Service of cardiology, CHU Vaudois (CHUV), University of Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland
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40
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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]
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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%.
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Affiliation(s)
- Tetsuya Kibe
- Department of Pediatrics, Seirei-Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
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Botto N, Maffei S, Manfredi S, Colombo MG, Mazzone AM, Andreassi MG. Prothrombotic mutations, family history and the risk of thrombosis in postmenopausal women: implications for hormone replacement therapy. Climacteric 2011; 14:25-30. [DOI: 10.3109/13697137.2010.528814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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de Lau LML, Leebeek FWG, de Maat MPM, Koudstaal PJ, Dippel DWJ. A review of hereditary and acquired coagulation disorders in the aetiology of ischaemic stroke. Int J Stroke 2011; 5:385-94. [PMID: 20854623 DOI: 10.1111/j.1747-4949.2010.00468.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The diagnostic workup in patients with ischaemic stroke often includes testing for prothrombotic conditions. However, the clinical relevance of coagulation abnormalities in ischaemic stroke is uncertain. Therefore, we reviewed what is presently known about the association between inherited and acquired coagulation disorders and ischaemic stroke, with a special emphasis on the methodological aspects. Good-quality data in this field are scarce, and most studies fall short on epidemiological criteria for causal inference. While inherited coagulation disorders are recognised risk factors for venous thrombosis, there is no substantial evidence for an association with arterial ischaemic stroke. Possible exceptions are the prothrombin G20210A mutation in adults and protein C deficiency in children. There is proof of an association between the antiphospholipid syndrome and ischaemic stroke, but the clinical significance of isolated mildly elevated antiphospholipid antibody titres is unclear. Evidence also suggests significant associations of increased homocysteine and fibrinogen concentrations with ischaemic stroke, but whether these associations are causal is still debated. Data on other acquired coagulation abnormalities are insufficient to allow conclusions regarding causality. For most coagulation disorders, a causal relation with ischaemic stroke has not been definitely established. Hence, at present, there is no valid indication for testing all patients with ischaemic stroke for these conditions. Large prospective population-based studies allowing the evaluation of interactive and subgroup effects are required to appreciate the role of coagulation disorders in the pathophysiology of arterial ischaemic stroke and to guide the management of individual patients.
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Affiliation(s)
- Lonneke M L de Lau
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Janssen AWM, de Leeuw FE, Janssen MCH. Risk factors for ischemic stroke and transient ischemic attack in patients under age 50. J Thromb Thrombolysis 2011; 31:85-91. [PMID: 20532956 PMCID: PMC3017300 DOI: 10.1007/s11239-010-0491-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To analyze risk factors for ischemic stroke and transient ischemic attack (TIA) in young adults under the age of 50. To make recommendations for additional research and practical consequences. From 97 patients with ischemic stroke or TIA under the age of 50, classical cardiovascular risk factors, coagulation disorders, history of migraine, use of oral contraceptives, cardiac abnormalities on ECG and echocardiography, and the results of duplex ultrasound were retrospectively analyzed. Literature was reviewed and compared to the results. 56.4% of the patients had hypertension, 12.1% increased total cholesterol, 20% hypertriglyceridemia, 31.5% an increased LDL-level, 32.6% a decreased HDL-level and 7.2% a disturbed glucose tolerance. Thrombophilia investigation was abnormal in 21 patients and auto-immune serology was abnormal in 15 patients. Ten of these patients were already known with a systemic disease associated with an increased risk for ischemic stroke (i.e. systemic lupus erythematosus). The ECG was abnormal in 16.7% of the cases, the echocardiography in 12.1% and duplex ultrasound of the carotid arteries was in 31.8% of the cases abnormal. Conventional cardiovascular risk factors are not only important in patients over the age of 50 with ischemic stroke or TIA, but also in this younger population under the age of 50. Thrombophilia investigation and/ or autoimmune serology should be restricted to patients without conventional cardiovascular risk factors and a history or other clinical symptoms associated with hypercoagulability and/ or autoimmune diseases.
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Affiliation(s)
- A W M Janssen
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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45
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Laufs U, Hoppe UC, Rosenkranz S, Kirchhof P, Böhm M, Diener HC, Endres M, Grond M, Hacke W, Meinertz T, Ringelstein EB, Röther J, Dichgans M. [Cardiac workup after cerebral ischemia. Consensus paper of the Working Group on Heart and Brain of the German Cardiac Society and German Stroke Society]. DER NERVENARZT 2010; 81:444-62. [PMID: 20177655 DOI: 10.1007/s00115-009-2901-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- U Laufs
- Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, 66421 Homburg.
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Kleber FX, Winkelmann A, Stretz A, Sonntag SM, Bruch L, Rademacher G, Sparenberg P, Schmehl I. Occlusion of PFO with a dedicated adjustable device: influence on one year outcome. EUROINTERVENTION 2010; 6:367-70. [DOI: 10.4244/eijv6i3a61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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47
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Affiliation(s)
- G P Anzola
- Service of Neurology, S. Orsola Hospital - Fondazione Poliambulanza, Brescia, Italy.
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Stankovic S, Majkic-Singh N. Genetic aspects of ischemic stroke: coagulation, homocysteine, and lipoprotein metabolism as potential risk factors. Crit Rev Clin Lab Sci 2010; 47:72-123. [DOI: 10.3109/10408361003791520] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
The presence of a patent foramen ovale has been found to be associated with an increased risk of ischemic stroke of otherwise unknown origin (cryptogenic stroke). The present article will review the evidence regarding this association, the technical aspects of PFO detection, and the preventive options to decrease the risk of recurrent cerebral events.
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Affiliation(s)
- Shunichi Homma
- Division of Cardiology, Columbia University, College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032, USA.
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50
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Abstract
Patent foramen ovale is found in 24% of healthy adults and 38% of patients with cryptogenic stroke. This ratio and case reports indicate that patent foramen ovale and stroke are associated, probably because of paradoxical embolism. In healthy people with patent foramen ovale, embolic events are not more frequent than in controls, and therefore no primary prevention is needed. However, once ischaemic events occur, the risk of recurrence is substantial and prevention becomes an issue. Acetylsalicylic acid and warfarin reduce this risk to the same level as in patients without patent foramen ovale. Patent foramen ovale with a coinciding atrial septal aneurysm, spontaneous or large right-to-left shunt, or multiple ischaemic events potentiates the risk of recurrence. Transcatheter device closure has therefore become an intriguing addition to medical treatment, but its therapeutic value still needs to be confirmed by randomised-controlled trials.
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Affiliation(s)
| | - B. Meier
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - K. Nedeltchev
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
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