scholarly journals Prevalence of Pelvic Vein Pathology in Patients with Cryptogenic Stroke and Patent Foramen Ovale Undergoing MRV Pelvis

2015 ◽  
Vol 39 (3-4) ◽  
pp. 216-223 ◽  
Author(s):  
Marcey Osgood ◽  
Elizabeth Budman ◽  
Raphael Carandang ◽  
Richard P. Goddeau, Jr. ◽  
Nils Henninger
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Foramen Ovale ◽  
Pelvic Vein ◽  
Vein Thrombosis ◽  
Potential Source ◽  
Vein Imaging ◽  
Paradoxical Emboli

Background: A substantial proportion of ischemic strokes has no any identified underlying cause. Notably, the prevalence of a patent foramen ovale (PFO) is increased in cryptogenic stroke (CS) populations, which may serve as a conduit for paradoxical emboli originating from deep vein thrombosis (DVT) including the pelvic veins. Yet, there are no published guidelines for the assessment of pelvic veins as part of the stroke workup and few studies have systematically investigated pelvic veins as a potential source for paradoxical emboli in CS patients. Further, there is a relative paucity of data regarding pelvic DVT in CS and results have been conflicting. Hence, we sought to determine the prevalence of pelvic DVT in select CS patients with PFO who underwent magnetic resonance venography (MRV). Methods: We retrospectively identified patients (n = 50) who underwent contrast-enhanced pelvic MRV at the discretion of the treating physician for the evaluation of CS in the presence of a PFO during hospitalization at a single academic stroke center between January 2011 through December 2013. Multivariable logistic regression analyses were used to assess for factors independently associated with the presence of an abnormal MRV pelvis. Results: Patients (47 ± 13 years of age) had MRV performed 4 ± 3 days after their incident stroke. Nine patients had an abnormal MRV (18%). Of these, four (8%) had pelvic vein thrombosis and 5 (10%) a May-Thurner anatomic variant. All patients with pelvic DVT were subsequently anticoagulated with warfarin (none had abnormal hypercoagulability testing). Clinical clues suggesting paradoxical embolism were present in as many as 40% of patients. On multivariable logistic regression, a history of any risk factors predisposing to DVT (OR 6.7; coefficient 1.9; BCa 95% CI 0.08-20.2; p = 0.014) as well as the number of predisposing risk factors (OR 3.9; coefficient 1.4; BCa 95% CI 0.25-4.2; p = 0.005) predicted the presence of pelvic vein pathology on MRV. Conclusion: We demonstrate a relatively high prevalence of pelvic DVT among select CS patients emphasizing the importance of considering the pelvic veins as a potential source for emboli particularly in the presence of risk factors known to predispose DVT. Because patients were included at the treating physician's discretion, our results reflect ‘real-life' practice. Our results may be of clinical importance as inclusion of pelvic vein imaging in CS patients with PFO had impactful therapeutic and nosologic implications. Further study is needed to define patients most likely to benefit from pelvic vein imaging.

Patent Foramen Ovale Channel Morphometric Characteristics as Risk Factors for Cryptogenic Stroke

2020 ◽  
Vol 34 (S1) ◽  
pp. 1-1
Author(s):  
Jakub Piotr Holda ◽  
Kamil Bugala ◽  
Agata Krawczyk-Ozog ◽  
Mateusz Koziej ◽  
Danuta Sorysz ◽  
...  
Keyword(s):  
Risk Factors ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Foramen Ovale ◽  
Morphometric Characteristics

scholarly journals Cryptogenic stroke over 60 years of age: should patent foramen ovale be closed?

2020 ◽  
Vol 22 (Supplement_E) ◽  
pp. E82-E86
Author(s):  
Achille Gaspardone ◽  
Gregory A Sgueglia
Keyword(s):  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Careful Consideration ◽  
Percutaneous Closure ◽  
Foramen Ovale ◽  
Antithrombotic Treatment ◽  
Vein Thrombosis ◽  
Technical Advances ◽  
The Right ◽  
Deep Vein

Abstract Patent foramen ovale (PFO) is an anatomical communication between the left and the right atrium due to the lack of completed sealing of the fossa ovalis. Epidemiologic data, for the most part derived from young populations studies, suggested that PFO, allowing paradoxical embolization of thrombotic material from the venous to the arterial district, could play a significant role in the pathogenesis of cryptogenic ischaemic cerebral events. Recently, three randomized studies in patients ≤60 years of age demonstrated the superiority of percutaneous closure of PFO over medical antithrombotic treatment. Several studies, on the other hand, indicated that also in older patients with cryptogenic cerebral ischaemia, there was an higher prevalence of PFO in patients at low atherosclerosis and cardioembolic risk, and increased incidence of adverse cerebral events (mostly cryptogenic in patients treated medically, but likely due to a new cause in patients who had percutaneous closure of PFO). Advanced age is associated with more risk factors for deep vein thrombosis, and consequent paradoxical embolization through the PFO, so much so that careful consideration should be given to patients over the age of 60 years with cryptogenic stroke, as to not forgo the benefit of percutaneous closure of PFO, merely for anagraphic consideration. This consideration is particularly poignant in light of the more recent technical advances now available, such as direct percutaneous suture, mostly appealing for elderly patients, for its better tolerability and high safety both peri-procedural and during the follow-up, as well as the lack of necessity for antithrombotic treatment.

scholarly journals Cryptogenic Stroke: A Challenge in Diagnosis and Management

2021 ◽  
Vol 42 (3) ◽  
Author(s):  
Sidhi Laksono Purwowiyoto ◽  
Budhi Setianto ◽  
Gea Panindhita ◽  
Reynaldo Halomoan ◽  
I Nyoman Wiryawan
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Stroke Recurrence ◽  
Clinical Settings ◽  
Cardiac Structure ◽  
Foramen Ovale ◽  
Advanced Knowledge ◽  
Pfo Closure

Ischemic stroke is responsible for 85% of all stroke globally. However, the etiology of around a quarter of ischemic stroke are undetermined, this is called cryptogenic stroke. This kind of stroke affects younger population. Several mechanism are associated with the incidence of cryptogenic stroke such as paroxysmal atrial fibrillation, patent foramen ovale, atherosclerosis, and atrial cardiopathy. Despite many advanced knowledge on stroke generally, cryptogenic stroke is still a challenge in clinical settings. To understand more about cryptogenic stroke, a new term of embolic strokes of undetermined source (ESUS) is proposed and may need a specific workup. Specific workup aims to detect any silent risk factors and also to evaluate the cardiac structure. The term of ESUS also leads to the understanding that cryptogenic stroke is highly related to embolic mechanism and anticoagulation administration might benefit the patients. However, the result of several recent studies showed that anticoagulant was not superior to antiplatelet, and antiplatelet is still the preferred treatment. Studies on PFO closure also shows different result, but the majority of the trials showed benefit of PFO closure in reducing the risk of stroke recurrence.

scholarly journals Ischemic Stroke in the Young

2021 ◽  
Vol 27 ◽  
pp. 107602962110022
Author(s):  
Samuel A. Berkman ◽  
Shlee S. Song
Keyword(s):  
Ischemic Stroke ◽  
Patent Foramen Ovale ◽  
Anticoagulation Therapy ◽  
Cryptogenic Stroke ◽  
Artery Dissection ◽  
Cerebral Vein ◽  
Antiphospholipid Antibody ◽  
Foramen Ovale ◽  
Cerebral Vein Thrombosis ◽  
Vein Thrombosis

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.

Abstract WP362: Over-Utilization of Studies to Detect Deep Venous Thrombosis in Stroke Patients With Patent Foramen Ovale

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sophie Samuel ◽  
Thuy Nguyen ◽  
Sujan T Reddy ◽  
Kaushik N Parsha ◽  
Sean I Savitz
Keyword(s):  
Ischemic Stroke ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Young Group ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Old Patients ◽  
Vein Thrombosis ◽  
Multivariable Regression ◽  
Deep Vein

Introduction: Cryptogenic stroke may result from paradoxical embolism through a patent foramen ovale (PFO). However, the association between deep vein thrombosis (DVT) and cryptogenic stroke has not been proven. The objective of our study is to compare the incidence of DVT in young and old patients who presented with acute ischemic stroke and were found to have a PFO. Method: We conducted a single-centre retrospective study from January 2014-December 2018. Patients over the age of 18 with ischemic stroke and PFO, who underwent magnetic resonance venography (MRV) of the pelvis and venous doppler ultrasonography (VDU) for assessment of DVT were included. Primary endpoint was the incidence of DVT in patients that were age ≤ 60 (young group) compared to those age > 60 (old group). We further analyzed the incidence of DVT in cryptogenic stroke vs determined origin; and based on the Risk of Paradoxical Embolism (ROPE) score. Results: We included 327 patients: 200 were young (Y) and 127 were old (O). Incidence of DVT was similar for patients in Y versus those in O group (7% vs 8%). A significantly higher ROPE score ≥ 6 was seen in the Y group (71% vs 9%; p<0.001). However, there was no difference in the incidence of DVT in patients with high (9%) or low ROPE scores (8%); OR 0.75, 95% CI (0.32-1.76) p=0.517. Among cryptogenic stroke with high ROPE score and young, incidence of DVT was (7% vs 9%) in determined origin; OR 0.74, 95% CI (0.28-1.96) p=0.557. MRV pelvis detected a clot in 5% of all patients. In a multivariable regression analysis; age, gender, and presence of PFO was not associated with the incidence of DVT. Length of stay and mRS at day 7 were the same between Y and O groups. Conclusions: Detection of DVT was not associated with PFO, high ROPE scores or cryptogenic strokes. Our data indicate an over-reliance of testing for DVT, particularly MRV pelvis with contrast, in patients with PFO. Clinical studies are needed to identify other factors predictive of DVT in patients with ischemic stroke and PFO.

Abstract 84: An Index to Identify Cryptogenic Stroke Patients whose Stroke is likely Attributable to Patent Foramen Ovale

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
David M Kent ◽  
Robin Ruthazer ◽  
Christian Weimar ◽  
Joaquín Serena ◽  
Jean-Louis Mas ◽  
...  
Keyword(s):  
Risk Factors ◽  
Patent Foramen Ovale ◽  
Risk Model ◽  
Cryptogenic Stroke ◽  
Recurrence Risk ◽  
Bayes Theorem ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Stroke Risk Factor ◽  
Simple Index

Background: A patent foramen ovale (PFO) discovered in the setting of a cryptogenic stroke (CS) may be incidental or pathogenic. Based on Bayes theorem, the proportion of CS that is PFO-attributable among patients found to have a PFO has been shown to be related to PFO prevalence in CS versus control patients. However, the prevalence of PFO in CS patients is itself dependent on the presence or absence of other risk factors. We exploited this relationship to create an index to stratify CS patients with PFO by their likelihood that the CS is PFO-attributable. Methods This project is part of the Risk of Paradoxical Embolism (RoPE) Study, an international, multicenter collaboration that has combined data for patients with CS and cryptogenic TIA who have known PFO status from 12 component studies (n=3665). For this study, we included those subjects within the 7 databases enrolling subjects both with and without PFO (n=3023). We used generalized linear mixed models to identify variables associated with the presence of a PFO, accounting for clustering within study. Based on this model, we created a simple index. Bayes theorem was used to estimate the PFO-attributable fraction in each stratum assuming a PFO prevalence in the general population of ∼25%. Results: Variables negatively associated with the presence of a PFO included: age (odds ratio [OR] = 0.97 per 1 year increase, p <0.0001); diabetes (OR= 0.65, p < 0.001); hypertension (OR =0.68, p < 0.0001); smoking (OR = 0.70, p<0.60); prior stroke or TIA (OR = 0.78, p=0.04). Cortical stroke on neuroimaging (OR = 1.46, p < 0.001) was also associated with PFO. Based on this, a simple index was created in which the absence of each stroke risk factor was assigned a point, with age dichotomized at 50 years. PFO prevalence in each stratum is shown in the table for patients < age 60, i.e. the subset of patients likely to be considered for PFO closure trials. Conclusion: Even among CS patients in the younger age range considered eligible for closure trials, there is considerable heterogeneity in the distribution of risk factors for stroke and other characteristics that identify subgroups of CS patients with variation in PFO prevalence. This reflects substantial and clinically important variation in the probability that a discovered PFO is likely to be pathogenic rather than incidental. This score may be useful in selecting patients for closure trials, or for stratification within trials, particularly if combined with a recurrence risk model.

scholarly journals Characteristics and prognosis of patients with cryptogenic stroke and suggestive of patent foramen ovale

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Jaehuk Choi ◽  
Min-Kyung Kang ◽  
Jin-Sun Jun ◽  
Dong Geum Shin ◽  
Donghoon Han ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Stroke ◽  
Lower Risk ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Good Method ◽  
Cardiac Performance ◽  
Lower Body ◽  
Lower Prevalence ◽  
Foramen Ovale

Abstract Aims The purpose of this study were to identify the usefulness of screening for PFO using agitated saline echocardiography (ASE) and characteristics and prognosis of patients with suggestive of patent foramen ovale (PFO). Methods Three hundred three patients (mean age, 53 ± 9 years; 199 [66%] men) admitted with acute stroke or suspicion of stroke were included. Patients were classified into those with and without right-to-left shunt (RLS) according to the ASE results (positive ASE [n = 92] vs. negative ASE [n = 211]). Fifty-one out of ninety-two patients with positive ASE and twenty-one out of two hundred eleven patients with negative ASE underwent TEE with ASE to confirm PFO. Results Ninety-two were positive for ASE and thirty-six of the fifty-one patients who underwent TEE were confirmed as having PFO. Of the patients with RLS grade 1, 50% were diagnosed with PFO and all patients with RLS grade ≥ 2 were diagnosed with PFO. All patients with negative ASE had no PFO (sensitivity of 100% and specificity of 58%). Patients with positive ASE were younger, had a lower body mass, and a lower prevalence of hypertension. The positive ASE patients had a higher mean Sʹ velocity and better diastolic function. Four of ninety-one patients with positive ASE and thirteen of one hundred seventy-seven showed recurrence of stroke and suspicion of stroke. Conclusion Transthoracic ASE is a good method to screen for PFO. Patients with suggestive of PFO had lower risk factors, less atherosclerosis, and better cardiac performance.

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