Recurrent Stroke and Massive Right-to-Left Shunt (original) (raw)
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Stroke, 2008
on Behalf of the CODICIA (Right-to-Left Shunt in Cryptogenic Stroke) Study; for the Stroke Project of the Cerebrovascular Diseases Study Group, Spanish Society of Neurology Background and Purpose-Few studies have prospectively examined the risk of recurrent stroke associated with patent foramen ovale. We present the results of the Spanish right-to-left shunt (RLSh) multicenter study. Methods-Four hundred eighty-six patients with cryptogenic stoke were included at 17 participating hospitals. Patients were examined by contrast transcranial Doppler methods at baseline. The magnitude of RLSh was quantified during the Valsalva maneuver. Transthoracic and/or transesophageal echocardiography, computed tomography scan, or magnetic resonance imaging was performed. Functional outcome and stroke recurrence were evaluated at 3 months and yearly thereafter. The independent relation between RLSh magnitude and stroke recurrence was analyzed by logistic-regression analysis in the whole group and in the younger subgroup (Ͻ55 years).
Permanent Right-to-Left Shunt Is the Key Factor in Managing Patent Foramen Ovale
Journal of the American College of Cardiology, 2011
We sought to prospectively evaluate risk of stroke and impact of transcatheter patent foramen ovale (PFO) closure in patients with permanent right-to left shunt compared with those with Valsalva maneuver-induced right-toleft shunt. Background Pathophysiology and properly management of PFO still remain far from being fully clarified: in particular, the contribution of permanent right-to-left shunt remains unknown. Methods Between March 2006 and October 2010, we enrolled 180 (mean age 44 Ϯ 10.9 years, 98 women) of 320 consecutive patients referred to our center for transcatheter PFO closure, who had spontaneous permanent right-toleft shunt on transcranial Doppler and transthoracic/transesophageal echocardiography. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative transesophageal echocardiography and brain magnetic resonance imaging, with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. We compared the clinical echocardiographic characteristics of these patients (Permanent Group) with the rest of 140 patients with right-to-left shunt only during Valsalva maneuver (Valsalva Group). Results Compared with the Valsalva Group patients, patients of the Permanent Group had increased frequency of multiple ischemic brain lesions on magnetic resonance imaging, previous recurrent stroke, previous peripheral arteries embolism, migraine with aura, and-more frequently-atrial septal aneurysm and prominent Eustachian valve. The presence of permanent shunt confers the highest risk of recurrent stroke (odds ratio: 5.9, 95% confidence interval: 2.0 to 12, p Ͻ 0.001). No differences were recorded between the 2 groups with regard to recurrence of ischemic events after the closure procedure. Conclusions Despite its small-sample nature, our study suggests that patients with permanent right-to-left shunt have potentially a higher risk of paradoxical embolism compared with those without.
International Journal of Cardiology, 2007
Background: We sought to determine whether migraine headache with aura (MHA) and spontaneous large right-to-left (R-L) shunt are risk factors for recurrent cerebral ischemic events in cryptogenic stroke patients with a patent foramen ovale (PFO). Methods: 140 patients with a PFO and cryptogenic stroke underwent transcatheter defect closure at our institution at a mean age of 45 ± 13 years. We retrospectively analyzed follow-up data from the first cerebral ischemic event to the time of PFO closure. Before the procedure, all patients underwent transesophageal echocardiography (TEE); Transcranial Doppler scanning (TCD) was additionally performed on the last 59 patients. We analyzed the impact of MHA, thrombophilia, spontaneous large R-L shunt, and atrial septal aneurysm (ASA) on the risk of recurrent cerebral ischemic events. Results: 44 patients (31%) had had at least 1 recurrent event during a follow-up of 2.2 ± 2.6 years. Patients with recurrent events were more commonly females ( p = 0.0001), had more often an associated thrombophilia ( p = 0.0077), and had a higher prevalence of spontaneously large R-L shunt both at TEE and at TCD ( p b 0.05). They also had more commonly a history of MHA ( p = 0.0009) and more frequent episodes of MHA ( p = 0.0048). Patients with MHA had a higher risk of recurrent events when compared to patients without (odds ratio 3.87, 95% CI 1.75 to 8.50). Thrombophilia ( p = 0.001) and spontaneous large R-L shunt ( p = 0.02) were independent predictors of recurrent stroke. Conclusions: In cryptogenic stroke patients with a PFO, a history of MHA, large spontaneous large R-L shunt, and thrombophilia are all associated with a higher risk of recurrent events.
Recurrent stroke and patent foramen ovale: a systematic review and meta-analysis
Stroke; a journal of cerebral circulation, 2014
T he frequency of patent foramen ovale (PFO) in the general population has been estimated to be 15% to 35%. 1 In patients with cryptogenic stroke, PFO is more common, but a clear causative relationship is not well established. 2 Recurrent cerebrovascular events are frequent in medically treated patients with a history of paradoxical embolism 3 ; however, in more than one third of these patients concurrent pathogeneses (other than the sole presence of PFO) are identified. 4,5 Thus, it still remains unclear whether PFO is causally related to firstever or recurrent cerebral ischemia or constitutes an incidental finding of diagnostic work-up. 6,7 PFO size and the degree of functional shunting could represent potential risk factors for cerebral ischemia in medically treated patients with PFO. 8 PFOs in patients with cerebral ischemia are thought to be larger 9 and to be more frequently associated with atrial septal aneurysms, compared with the PFOs in asymptomatic patients. 10 Moreover, in transcranial Doppler (TCD) studies, large PFOs were found to be significantly associated with more microembolic signals compared with small PFOs. 11,12 However, data from other studies suggest that the shunt grade assessed with TCD is not associated with the brain infarct volume on computed tomography 13 and that Background and Purpose-Recurrent cerebrovascular events are frequent in medically treated patients with patent foramen ovale (PFO), but it still remains unclear whether PFO is a causal or an incidental finding. Further uncertainty exists on whether the size of functional shunting could represent a potential risk factor. The aim of the present study was to evaluate if the presence of PFO is associated with an increased risk of recurrent stroke or transient ischemic attack and to investigate further if this relationship is related to the shunt size.
Arquivos de Neuro-Psiquiatria, 2021
Background: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. Objective: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. Methods: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. Results: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). Acco...
Journal of interventional cardiology, 2017
This study was sought to evaluate the effectiveness of patent foramen ovale (PFO) closure in selected patients (PFO shunt grade more than moderate) with cryptogenic stroke (CS). Whether closure of PFO is an effective treatment for prevention of CS is still unclear. Consecutive 158 patients (mean age: 49.9 years old, closure group: 67 patients, medication group: 91 patients) were enrolled. The primary end point was a composite of recurrent stroke and transient ischemic attack. Baseline characteristics were similar between the two groups, except age which was younger in the closure group (47.7 ± 10.8 vs 51.9 ± 9.9, P = 0.013), and the presence of shunt at rest was more common in the closure group (35.8% vs 10.4%, P = 0.000). Procedural success was 94.0%. Over a mean follow-up of 27.8 months, a total of six primary end point, all of which were strokes, occurred only in the medication group (6.6% vs 0%, P = 0.039). Stroke-free survival rate was significantly higher in the closure group ...
Stroke and Patent Foramen Ovale in Young Individuals
European Neurology, 2013
The importance of patent foramen ovale (PFO) has long been discussed in the literature in relation to different coexisting medical conditions. Many researchers focused on the occurrence of PFO in ischemic stroke patients, especially in the subgroup of young patients with a recurrent event. Unfortunately, before establishing a clear significance of PFO and right-to-left shunting (RLS) in pathogenesis of cerebrovascular disorders, multiple interventional trials have been launched, aimed at PFO closure in heterogeneous populations of patients. Moreover, some closure devices were granted at least partial approval by regulatory agencies for this indication. There is a need for large and unbiased epidemiological studies assessing the role of RLS through the PFO in ischemic stroke. All patients with recurrent ischemic events and PFO should be assessed by multidisciplinary teams, including a stroke neurologist, and all potential and rare causes of stroke should be considered before any deci...
Management of patients with patent foramen ovale and cryptogenic stroke
Catheterization and Cardiovascular Interventions, 2013
Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.
An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke
Neurology, 2013
Objective: We aimed to create an index to stratify cryptogenic stroke (CS) patients with patent foramen ovale (PFO) by their likelihood that the stroke was related to their PFO. Methods: Using data from 12 component studies, we used generalized linear mixed models to predict the presence of PFO among patients with CS, and derive a simple index to stratify patients with CS. We estimated the stratum-specific PFO-attributable fraction and stratum-specific stroke/TIA recurrence rates. Results: Variables associated with a PFO in CS patients included younger age, the presence of a cortical stroke on neuroimaging, and the absence of these factors: diabetes, hypertension, smoking, and prior stroke or TIA. The 10-point Risk of Paradoxical Embolism score is calculated from these variables so that the youngest patients with superficial strokes and without vascular risk factors have the highest score. PFO prevalence increased from 23% (95% confidence interval [CI]: 19%-26%) in those with 0 to 3 points to 73% (95% CI: 66%-79%) in those with 9 or 10 points, corresponding to attributable fraction estimates of approximately 0% to 90%. Kaplan-Meier estimated stroke/TIA 2-year recurrence rates decreased from 20% (95% CI: 12%-28%) in the lowest Risk of Paradoxical Embolism score stratum to 2% (95% CI: 0%-4%) in the highest. Conclusion: Clinical characteristics identify CS patients who vary markedly in PFO prevalence, reflecting clinically important variation in the probability that a discovered PFO is likely to be stroke-related vs incidental. Patients in strata more likely to have stroke-related PFOs have lower recurrence risk. Neurology â 2013;81:619-625 GLOSSARY auROC 5 area under the receiver operating characteristic curve; CS 5 cryptogenic stroke; PFO 5 patent foramen ovale; RoPE 5 Risk of Paradoxical Embolism. Case-control studies suggest that patent foramen ovale (PFO) is a common cause of cryptogenic stroke (CS), likely through a paradoxical (venous-to-arterial) embolism. 1,2 However, CS has many potential causes, and PFO is a common anatomical variant found in approximately 25% of the general population. 3 Thus, a PFO discovered in the setting of a CS may be incidental or stroke-related. Percutaneous mechanical closure of a PFO is frequently considered in patients with CS and PFO. The recently reported CLOSURE trial, however, found no benefit for this approach over medical therapy. 4 Nonetheless, stroke recurrence rates were low overall (limiting statistical power) and most stroke recurrence in both treatment groups was due to stroke of known mechanism, suggesting that many patients with incidental PFOs may have been enrolled. The premise of the Risk of Paradoxical Embolism (RoPE) Study 3 is that only patients with a high attributable recurrence risk have the opportunity to benefit from PFO closure for secondary
Prevalence of Patent Foramen Ovale in Young Patients with Cryptogenic Ischemic Stroke
Arya Atheroscler, 2009
BACKGROUND: Patent foramen ovale (PFO) is the most commonly persistent abnormality of fetal origin. PFO has long been recognized as a potential risk factor for ischemic stroke. This study has shown the prevalence of PFO among young patients with cryptogenic stroke. METHODS: In our case-control study we had 32 patients, 18 to 55 years old with cryptogenic stroke and 64 participants among normal population with matched age and sex in control group. We studied them for stroke risk factors like hypertension, diabetes mellitus, ischemic heart disease, dyslipidemia and then election of PFO by contrast trans-thoracic echocardiography. Data entered in SPSS 11 and analyzed by chi-Square and logistic regression. P value less than 0.05 was considered statistically significant. RESULTS: We found that 37.5 % of patients in case group and 7.7 % of patients in controls had PFO and this difference was statistically significant (P = 0.001). They had no significant difference in other atherosclerosis risk factors. In control group we saw small shunt but in stroke group large shunt was more prevalence (P < 0.05). CONCLUSION: Our findings supported this idea that PFO is a predisposing factor for stroke and it had a higher prevalence among patients with cryptogenic stroke. Besides, large shunt was more concomitant with ischemic attack. Then we suggest any patient with undefined cause of stroke must be evaluated for PFO.