Juxtacortical spots on fluid-attenuated inversion recovery images in cryptogenic transient ischemic attack

Different patterns of white matter lesions among patent foramen ovale, atherosclerotic cerebral small vessel disease and cerebral venous thrombosis

None of studies are available on the predictive ability of white matter lesions (WMLs) among patent foramen ovale (PFO), atherosclerotic cerebral small vessel disease (aCSVD) and cerebral venous thrombosis (CVT). Herein, we aimed to uncover the difference of the WML patterns among the three disease entities in a real-world setting to provide clinical references for predicting probable WML etiologies. We retrospectively reviewed data from consecutive patients with imaging-confirmed PFO, aCSVD, or CVT enrolled from 2014 through 2020. WMLs presented on fluid-attenuated inversion recovery (FLAIR) maps were compared among the three groups based on visual evaluation, Fazekas and modified Scheltens scales. Propensity score matching (PSM) was implemented to correct age and hypertension differences among groups. A total of 401 patients were entered into final analysis, including PFO (n = 112, 46.5 ± 12.8 years), aCSVD (n = 177, 61.6 ± 11.8 years) and CVT (n = 112, 37.4 ± 11.4 years) groups. In this study, WMLs occurred in all of the involved patients in the three groups (100%), which were independent to age, symptom onset and disease durations. On visual evaluation, PFO-WMLs were multiple spots distributed asymmetrically around bilateral subcortex and peri-ventricles. aCSVD-WMLs were dots or sheets distributed symmetrically in subcortex and peri-ventricles, and often coexisted with lacunar infarctions. CVT-WMLs were cloud-like around bilateral peri-ventricles, and enabled to attenuate after recanalization. Fazekas and modified Scheltens scores of PFO-WML vs. aCSVD-WML were significantly different even after being matched by 1:2 PSM (all p < 0.05), meaning that the WML burden in aCSVD was considerably heavier than that in PFO. WML patterns induced by PFO, aCSVD and CVT were obviously different, and were therefore of great clinical significance to preliminarily predict and differentiate the three diseases entities.

Pathogeneses and Imaging Features of Cerebral White Matter Lesions of Vascular Origins

White matter lesion (WML), also known as white matter hyperintensities or leukoaraiosis, was first termed in 1986 to describe the hyperintense signals on T2-weighted imaging (T2WI) and fluid-attenuated inversion recovery (FLAIR) maps. Over the past decades, a growing body of pathophysiological findings regarding WMLs have been discovered and discussed. Currently, the generally accepted WML pathogeneses mainly include hypoxia-ischemia, endothelial dysfunction, blood-brain barrier disruption, and infiltration of inflammatory mediators or cytokines. However, none of them can explain the whole dynamics of WML formation. Herein, we primarily focus on the pathogeneses and neuroimaging features of vascular WMLs. To achieve this goal, we searched papers with any type published in PubMed from 1950 to 2020 and cross-referenced the keywords including “leukoencephalopathy”, “leukoaraiosis”, “white matter hyperintensity”, “white matter lesion”, “pathogenesis”, “pathology”, “pathophysiology”, and “neuroimaging”. Moreover, references of the selected articles were browsed and searched for additional pertinent articles. We believe this work will supply the robust references for clinicians to further understand the different WML patterns of varying vascular etiologies and thus make customized treatment.

Transcranial Doppler as a Screening Tool for High-Risk Patent Foramen Ovale in Cryptogenic Stroke

BACKGROUND AND PURPOSE

The identification of high-risk patent foramen ovale (PFO) is important for selecting suitable patients for PFO closure to prevent recurrent stroke in those with cryptogenic stroke. We aimed to evaluate the predictability of transcranial Doppler (TCD) in diagnosing high-risk PFO compared with that of transesophageal echocardiography (TEE), which is not feasible for some stroke patients.

METHODS

We retrospectively reviewed the data of 461 cryptogenic stroke patients who underwent TEE and TCD for PFO evaluation. High-risk PFO on TEE was defined as PFO with atrial septal aneurysm (phasic septal excursion ≥10 mm) or large PFO (≥2 mm). Spencer grading of right-to-left shunt was used to classify the amount of shunt on TCD.

RESULTS

PFO on TEE was observed for 242 (52.5%) patients, and high-risk PFO was detected for 123 (26.7%) patients. However, PFO on TCD was observed for 336 (72.9%) patients. Among patients with significant shunt (Spencer grade III or higher) who underwent TCD after Valsalva maneuver (VM), 60.0% of patients had high-risk PFO. However, only 5.3% of patients had high-risk PFO among those without significant shunt. Receiver operating characteristic curves showed that significant shunt after VM had higher predictability (AUC = .876, 95% CI: .843-.905) for detecting the high-risk PFO compared with the predictability based on significant shunt at rest (AUC = .718, 95% CI: .674-.759). (P<.0001 for the differences between two AUCs).

CONCLUSIONS

TCD is a good screening tool for evaluating high-risk PFO. VM is important for the evaluation of PFO. Patients with minimal or no shunt on TCD after VM are unlikely to have high-risk PFO.

Patent foramen ovale closure with GORE HELEX or CARDIOFORM Septal Occluder vs. antiplatelet therapy for reduction of recurrent stroke or new brain infarct in patients with prior cryptogenic stroke: Design of the randomized Gore REDUCE Clinical Study

Rationale The utility of patent foramen ovale (PFO) closure for secondary prevention in patients with prior cryptogenic stroke is uncertain despite multiple randomized trials completed to date. Aims The Gore REDUCE Clinical Study (REDUCE) aims to establish superiority of patent foramen ovale closure in conjunction with antiplatelet therapy over antiplatelet therapy alone in reducing the risk of recurrent clinical ischemic stroke or new silent brain infarct in patients who have had a cryptogenic stroke. Methods and design This controlled, open-label trial randomized 664 subjects with cryptogenic stroke at 63 multinational sites in a 2:1 ratio to either antiplatelet therapy plus patent foramen ovale closure (with GORE® HELEX® Septal Occluder or GORE® CARDIOFORM Septal Occluder) or antiplatelet therapy alone. Subjects will be prospectively followed for up to five years. Neuroimaging is required for all subjects at baseline and at two years or study exit. Study outcomes The two co-primary endpoints for the study are freedom from recurrent clinical ischemic stroke through at least 24 months post-randomization and incidence of new brain infarct (defined as clinical ischemic stroke or silent brain infarct) through 24 months. The primary analyses are an unadjusted log-rank test and a binomial test of subject-based proportions, respectively, both on the intent-to-treat population, with adjustment for testing multiplicity. Discussion The REDUCE trial aims to target a patient population with truly cryptogenic strokes. Medical therapy is limited to antiplatelet agents in both arms thereby reducing confounding. The trial should determine whether patent foramen ovale closure with the Gore septal occluders is safe and more effective than medical therapy alone for the prevention of recurrent clinical ischemic stroke or new silent brain infarct; the neuroimaging data will provide an opportunity to further support the proof of concept. The main results are anticipated in 2017. Registration Clinical trial registration-URL: http://clinicaltrials.gov/show/NCT00738894.