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Patent foramen ovale in a cohort of young patients with cryptogenic ischemic stroke
Silva, Marcus Tulius T.;Rodrigues, Roíza;Tress, Jo?o;Victer, Rosaura;Chamiê, Francisco;
Arquivos de Neuro-Psiquiatria , 2005, DOI: 10.1590/S0004-282X2005000300012
Abstract: objective: although its role is a matter of debate, some studies described a higher prevalence of patent foramen ovale (pfo) and atrial septal aneurysm (asa) in young stroke patients, with higher risk with pfo / asa association (or 4.96). the aim of this study was determine the prevalence of pfo and asa in a cohort of cryptogenic ischemic stroke (is) patients younger than 55 years and to follow-up after surgical or percutaneous endovascular closure (pec). method: in 21 months we identified all patients less than 55 years old with is who were admitted to our hospital. cryptogenic is was considered if there is not an identifiably cause to cerebral ischemia. transesophageal echocardiography (tee) was performed in all patients. after interatrial septal abnormalities diagnosis, percutaneous device closure was offered to all. patients were followed monthly and keeped with oral aas or clopidogrel. results: we identified 189 patients with is and 32 were less than 55 years old (16.9%). in 29 the is was cryptogenic. tee was performed in all patients and some form of interatrial septal abnormality was identified in 12 (12/29 - 41.3%); 5 had a pfo and in 7 there was pfo plus asa. ten patients were submitted to pec and 2 were submitted to surgical closure. in mid-term follow-up (28 months) no ischemic events occurred and 2 patients related disappearance of migraine symptoms. conclusion: our small series description is in accordance with other studies and suggests a possible relation between interatrial septal abnormalities and is in a cohort of young patient.
Patent Foramen Ovale in Young Adults with Cryptogenic Stroke or Transient Ischemic Attack
Afsoon Fazlinezhad,Sara Azimi,Mahmoodreza Azarpazhooh,Mohammad Khajedaluee
Journal of Tehran University Heart Center , 2009,
Abstract: Background: Stroke, one of the most important causes of morbidity and mortality in the world, is of great importance in young adults (15-45 years), amongst whom the causes of stroke and transient ischemic attack (TIA) are different from those in older ages and a significant portion of them have no known etiology. Patent foramen ovale (PFO) is considered a probable cause in this group.Methods: Patients between 15 and 45 years of age with TIA or stroke were examined and evaluated for causes of cerebrovascular accidents. Patients with no definite cause for stroke or TIA, except for PFO, despite our extensive evaluations were categorized as cryptogenic. The controls were comprised of those between 15 and 45 years old who underwent transesophageal echocardiography (TEE) for reasons other than stroke. The frequency of PFO and its characteristics were compared between the two groups.Results: The case group comprised 48 patients with cryptogenic stroke (n=31) and TIA (n=17), and the control group consisted of 57 patients. The age distribution of the groups was normal, and there was no significant difference between the age and gender of the two groups. The frequency of PFO in the case and control groups was 52% and 25%, respectively (p value=0.003, odds ratio=3.33, confidence interval=1.46-7.63). The exaggerated motion of the interatrial septum (IAS) in the case and control groups was 18.8% and 0%, respectively. Right-to-left shunt at rest in the case and control groups was 78% and 28%, respectively (significant differences). The differences in terms of PFO size, number of bubbles, and atrial septal aneurysm were not significant between the two groups.Conclusion: PFO had a relation with stroke and TIA in the young adults, and right-to-left shunt at rest and exaggerated motion of the IAS could increase the possibility of paradoxical emboli. It seems that the presence of atrial septal aneurysm, number of bubbles, and PFO size did not increase the risk of cerebrovascular accidents.
Decrease in shunt volume in patients with cryptogenic stroke and patent foramen ovale
Christian Tanislav, Manfred Kaps, Marek Jauss, Erwin Stolz, Wolfgang Pabst, Max Nedelmann, Mathias Grebe, Frank Reichenberger, Jens Allendoerfer
BMC Neurology , 2010, DOI: 10.1186/1471-2377-10-123
Abstract: The RLS volume assessed during hospitalisation for stroke (index event/T0) was compared with the RLS volume on follow-up (T1) (median time between T0 and T1 was 10 months). In 102 patients with a history of stroke and PFO the RLS volume was re-assessed on follow-up using contrast-enhanced transcranial Doppler/duplex (ce-TCD) ultrasound. A change in RLS volume was defined as a difference of ≥20 microembolic signals (MES) or no evidence of RLS during ce-TCD ultrasound on follow-up.There was evidence of a marked reduction in RLS volume in 31/102 patients; in 14/31 patients a PFO was no longer detectable. An index event classified as cryptogenic stroke (P < 0.001; OD = 39.2, 95% confidence interval 6.0 to 258.2) and the time interval to the follow-up visit (P = 0.03) were independently associated with a change in RLS volume over time.RLS volume across a PFO decreases over time, especially in patients with cryptogenic stroke. These may determine the development of new strategies for the management in the secondary stroke prevention.Several studies identified an increased frequency of patent foramen ovale (PFO) in patients with stroke of undetermined aetiology, also referred to as cryptogenic stroke (CS) [1,2]. Nevertheless the clinical relevance of PFO in cerebral ischemic disease is still a topic of debate [3,4]. In patients with PFO, the proposed mechanism for stroke is paradoxical embolism (PDE) [5,6]. PDE diagnosis can be regarded as definitive if observed during transesophageal echocardiography (TEE), as well if a thrombus within the PFO is found on autopsy [7-9]. It is therefore difficult to establish a cause-and-effect relationship between PFO and PDE [10,11], resulting in a lack of clear guidelines for appropriate management to prevent recurrent stroke [12,13].If PDE is the suspected cause of stroke, and a physiologic trajectory of PFO throughout life-time is considered, secondary prevention measures should target further PDE events. However, there have been anec
Surgical prophylaxis secundary to cryptogenic stroke or transient ischemic attack in patients with patent foramen ovale
Guffi, Michele E.A.;
Revista Brasileira de Cirurgia Cardiovascular , 2003, DOI: 10.1590/S0102-76382003000300009
Abstract: introduction: prevention of recurrent cryptogenic strokes or transient ischemic attacks in adults with patent foramen ovale (pfo) represents a therapeutic challenge. antithrombotic pharmacological treatment is widely used, but its indication is limited because of its significant complications. objective: to demonstrate the efficacy of the surgical closure of patent foramen ovale (pfo) as prophylaxis secondary to cryptogenic strokes or transient ischemic attacks of undetermined origin. method: in this study, 31 men and 16 women with previous ischemic cerebral events underwent direct surgical closure of the pfo. mean age was 40 years (from 27 to 59 years). no coexisting cause of the stroke was found after extensive investigation, including blood coagulation tests, transesophageal contrast echocardiography (tee), extracranial and transcranial doppler ultrasonography, 24-hour electrocardiographic monitoring, brain magnetic resonance (bmr) and ct scan. criteria for operation also included at least two of the following: atrial septal aneurysm, multiple cerebral infarcts, multiple cerebral events and a history of valsalva strain before stroke. before operation, only one patient had two shunts (1 pfo and 1 intrapulmonary shunt). results: no complications occurred during or after the operation, but a few hours after the operation transient arrhythmias developed in four patients without atrial fibrillation, hemodynamic instability nor embolism. all patients survived in class i (nyha) and during a mean follow-up of 36 months, no patient had recurrence of the stroke or transient ischemic attacks. all patients prospectively underwent bmr and contrast tee with simultaneous transcranial doppler ultrasonography. a residual right-to-left shunt, smaller than the preoperative one, was observed in only one patient, whereas no lesion was seen on the bmr. conclusion: it is concluded that surgical closure of pfo in patients with presumed paradoxical embolism is safe and avoids recurrent s
Factors associated with shunt dynamic in patients with cryptogenic stroke and patent foramen ovale: an observational cohort study
Christian Tanislav, Maximilian Puille, Mathias Grebe, Nicole Sieweke, Jens Allend?rfer, Wolfgang Pabst, Manfred Kaps, Frank Reichenberger
BMC Cardiovascular Disorders , 2011, DOI: 10.1186/1471-2261-11-54
Abstract: On index event PFO and RLS were proven by transesophageal echocardiography and contrast-enhanced transcranial Doppler-sonography (ce-TCD). Silent PE was proved by ventilation perfusion scintigraphy (V/Q) within the stroke work-up on index event; all scans were re-evaluated in a blinded manner by two experts. The RLS was re-assessed on follow-up by ce-TCD. A reduction in shunt volume was defined as a difference of ≥20 microembolic signals (MES) or the lack of evidence of RLS on follow-up. For subsequent analyses patients with CS were considered; parameters such as deep vein thrombosis (DVT) and silent pulmonary embolism (PE) were analysed.In 39 PFO patients suffering of a CS the RLS was re-assessed on follow-up. In all patients (n = 39) with CS a V/Q was performed; the median age was 40 years, 24 (61.5%) patients were female. In 27 patients a reduction in RLS was evident. Silent PE was evident in 18/39 patients (46.2%). Factors such as atrial septum aneurysm, DVT or even silent PE were not associated with RLS dynamics. A greater time delay from index event to follow-up assessment was associated with a decrease in shunt volume (median 12 vs. 6 months, p = 0.013).In patients with CS a reduction in RLS is not associated with the presence of a venous embolic event such as DVT or silent PE. A greater time delay between the initial and the follow-up investigation increases the likelihood for the detection of a reduction in RLS.As previously reported there is evidence for a reduction in right to left shunt (RLS) or even a functional closure of a patent foramen ovale (PFO) on follow-up with predominance in patients with cryptogenic stroke (CS) [1]. As a functional PFO closure was observed after treatment of acute massive pulmonary emboli, a fluctuation in pulmonary atrial pressure might be involved in the mechanism of shunt dynamic across a PFO [2-4]. Considering that silent pulmonary embolism (PE) is a frequent finding in patients with CS and PFO, it raises the question whe
Foramen ovale permeable y ataque criptogénico: Papel de la ecocardiografía y estado del arte Patent foramen ovale and cryptogenic stroke: Echocardiography role and state of the art
Mario H Jaramillo U
Revista Colombiana de Cardiología , 2008,
Abstract: Las causas de ataque isquémico en pacientes jóvenes, son difíciles de encontrar pese a las investigaciones sistemáticas dirigidas a descartar origen cardiaco, alteraciones de la coagulación o cualquier otro tipo de enfermedades vasculares; de ahí la definición de criptogénico . Se especula acerca del papel potencial de los cortocircuitos intracardiacos de derecha a izquierda como vía de embolismos paradójicos que culminan en enfermedad cerebral isquémica. Se demostró que la ecocardiografía transesofágica con inyección venosa periférica de solución salina agitada, es el método de elección para diagnosticar foramen ovale permeable y cortocircuito de derecha a izquierda. Estudios prospectivos que utilizan tratamiento con ácido acetil salicílico o warfarina, no demuestran una reducción significativa de los ataques recurrentes. Aunque, tanto el cierre quirúrgico del foramen ovale permeable como el percutáneo, muestran una disminución de la tasa de eventos embólicos subsecuentes, aún se discute su indicación, al menos hasta que aparezcan resultados de trabajos con escogencia al azar, que están en proceso en la actualidad. Sin embargo, los casos de embolismo paradójico recurrente y en los buzos profesionales, ambos casos con aneurisma del septum auricular y foramen ovale permeable asociados, son las únicas indicaciones inequívocas de cierre percutáneo. El cierre exitoso, definido por ecocardiografía transesofágica, parece predecir la ausencia de eventos embólicos recurrentes. En la medida en que la tasa de complicaciones de la implantación de dispositivos disminuya y que éstos sean técnicamente más sencillos, el cierre percutáneo se impondrá al quirúrgico. The causes of ischemic stroke in young patients are difficult to find, in spite of systematic investigations directed to rule out heart etiology, alterations in coagulation or any other type of vascular disease; hence the cryptogenic definition. There have been speculations regarding the potential role of right-to-left intracardiac shunts as a path for paradoxical embolisms that result in ischemic cerebral disease. Transesophagic echocardiography with peripheral venous injection of saline contrast has shown to be the preferred method for the diagnosis of patent foramen ovale and right-to-left shunt. Prospective studies using acetylsalicylic acid or warfarin have not shown significant reduction of recurrent strokes. Even though both surgical and percutaneous closure of the patent foramen ovale have shown to decrease the rate of subsequent embolic episodes, their indication remains under discussion, at leas
The Risk of Paradoxical Embolism (RoPE) Study: Developing risk models for application to ongoing randomized trials of percutaneous patent foramen ovale closure for cryptogenic stroke
David M Kent, David E Thaler, RoPE Study Investigators
Trials , 2011, DOI: 10.1186/1745-6215-12-185
Abstract: The goal of the Risk of Paradoxical Embolism (RoPE) Study is to develop and test a set of predictive models that can identify those patients most likely to benefit from preventive treatments for PFO-related stroke recurrence, such as PFO closure. To do this, we will construct a database of patients with CS, both with and without PFO, by combining existing cohort studies. We will use this pooled database to identify patient characteristics associated with the presence (versus the absence) of a PFO, and to use this "PFO propensity" to estimate the patient-specific probability that a PFO was pathogenically related to the index stroke (Model #1). We will also develop, among patients with both a CS and a PFO, a predictive model to estimate patient-specific stroke recurrence risk based on clinical, radiographic and echocardiographic characteristics. (Model #2). We will then combine Models #1 and #2 into a composite index that can rank patients with CS and PFO by their conditional probability that their PFO was pathogenically related to the index stroke and the risk of stroke recurrence. Finally, we will apply this composite index to completed clinical trials (currently on-going) testing endovascular PFO closure against medical therapy, to stratify patients from low-expected-benefit to high-expected-benefit.Approximately 40% of all strokes are classified as cryptogenic, meaning that the cause is unknown despite an extensive work up [1]. While patent foramen ovale (PFO) is a common and generally benign condition found on autopsy in about 25% of the population [2-4], approximately 40% to 50% of patients younger than age 55 with cryptogenic stroke (CS) have PFO on transesophageal echocardiography (TEE) [4-7]. Furthermore, a PFO is found more frequently in patients with CS than in patients with a known cause of stroke, even in the elderly patient[7-9], These association suggest that PFO has an etiological role in CS, presumably via paradoxical emboli (PE) (i.e. venous emboli t
Ischemic stroke and patent foramen ovale: case report
Silva, Carlos Eduardo Amaral Pereira da;Vale, Thiago Cardoso;Leite, Flávio José Barbosa;Casali, Thais Gomes;Ramalho, Gustavo de Moraes;Cruzeiro, Marcelo Maroco;
Arquivos de Neuro-Psiquiatria , 2006, DOI: 10.1590/S0004-282X2006000500028
Abstract: approximately 40% of ischemic strokes have no clearly definable etiology and are termed cryptogenic strokes. patent foramen ovale, a small communication between the left and right atria, is considered to be a risk factor for cerebral embolism. in this study, we report the case of a 29-year-old woman with diagnosis of ischemic stroke due to patent foramen ovale who has undergone percutaneous endovascular closure. the aim of this report is to discuss the relevant aspects of the patent foramen ovale and the cryptogenic stroke, its clinical presentation, diagnosis, management and recurrence.
Percutaneous Patent Foramen Ovale Closure versus Medical Therapy in Cryptogenic Stroke: An Update Meta-Analysis of Randomized Controlled Trials  [PDF]
Xiaohui Luo, Dandan Yan, Hui Shao, Yajuan Du
World Journal of Cardiovascular Diseases (WJCD) , 2018, DOI: 10.4236/wjcd.2018.88040
Abstract: Objectives: Concerns regarding the real efficacy of transcatheter patent foramen ovale (PFO) closure versus medical therapy in patients with cryptogenic stroke remained unresolved. We performed a meta-analysis using the randomized controlled trials on the efficacy and safety of transcatheter PFO closure in patients with cryptogenic stroke. Methods: Web of Science, EMBASE, PubMed, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs). The primary outcome was recurrent stroke and transient-ischemic attack (TIA). Original data, hazard ratio (HR) with 95% confidence interval (95% CI) were abstracted to calculate a pooled effect size. Results: Our meta-analysis showed benefit with device closure when compared with medical therapy with an HR of 0.54 (95% CI: 0.39 - 0.74, P = 0.108) in the intention-to-treat cohort, 0.44 (95% CI: 0.24 - 0.82, P = 0.103) in the per-protocol populations, and 0.43 (95% CI: 0.31 - 0.60, P = 0.019) in the as-treated populations. There was a significantly higher incidence of new-onset atrial fibrillation in PFO closure patients (OR = 4.53, 95% CI: 2.58 -
Randomized clinical trial comparing percutaneous closure of patent foramen ovale (PFO) using the Amplatzer PFO Occluder with medical treatment in patients with cryptogenic embolism (PC-Trial): rationale and design
Ahmed A Khattab, Stephan Windecker, Peter Jüni, David Hildick-Smith, Dariusz Dudek, Henning R Andersen, Reda Ibrahim, Gerhard Schuler, Antony S Walton, Andreas Wahl, Heinrich P Mattle, Bernhard Meier
Trials , 2011, DOI: 10.1186/1745-6215-12-56
Abstract: The PC-Trial is a randomized clinical trial comparing the efficacy of percutaneous closure of the PFO using the Amplatzer PFO occluder with best medical treatment in patients with cryptogenic embolism, i.e. mostly cryptogenic stroke. Warfarin for 6 months followed by antiplatelet agents is recommended as medical treatment. Randomization is stratified according to patients age (<45 versus ≥45 years), presence of atrial septal aneurysm (ASA yes or no) and number of embolic events before randomization (one versus more than one event). Primary endpoints are death, nonfatal stroke and peripheral embolism.patients were randomized in 29 centers of Europe, Canada, and Australia. Randomization started February 2000. Enrollment of 414 patients was completed in February 2009. All patients will be followed-up longitudinally. Follow-up is maintained until the last enrolled patient is beyond 2.5 years of follow-up (expected in 2011).Trial listed in ClinicalTrials.gov as NCT00166257 and sponsored by AGA Medical, Plymouth, MN, USAThe cause of ischemic stroke is considered cryptogenic in 35-40% of cases [1]. Paradoxical embolism can be the cause of systemic embolism under all circumstances provided there is a right to left shunt, but it is blamed for an embolic event typically only in the absence of a left-sided thromboembolic source. Hence, paradoxical embolism via a patent foramen ovale (PFO) is entertained in the differential diagnosis especially in young patients (<60 years old) [2]. The detection of thrombus in the venous system or right atrium is not to be considered a prerequisite as non-detectable small clots are the most common culprits. Since the direct detection of thrombus within a PFO is rare [3-6], the diagnosis of paradoxical embolism is usually presumptive. While there is currently no proof for a cause-effect relationship, several studies have confirmed a strong association between the presence of a PFO and the risk for paradoxical embolism or stroke [7-11]. A PFO wi
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