scholarly journals Recurrent Stroke in a Young Woman with a Single Pulmonary Arteriovenous Fistula: An Unusual Association

2017 ◽  
Vol 9 (3) ◽  
pp. 293-298 ◽  
Author(s):  
Sandra Sousa ◽  
Nuno Vasco Costa ◽  
Cátia Carmona ◽  
Élia Coimbra ◽  
Fernando Pita
Keyword(s):  
Arteriovenous Fistula ◽  
Young Woman ◽  
Brain Mri ◽  
Cryptogenic Stroke ◽  
Stroke Recurrence ◽  
Pulmonary Arteriovenous Fistula ◽  
Ischemic Lesion ◽  
Pulmonary Angiogram ◽  
Therapeutic Decisions ◽  
History Of

Introduction: Cryptogenic stroke is present in about 40% of ischemic stroke patients. Extracardiac shunt related to pulmonary arteriovenous fistula (PAVF) could be a rare potential risk factor for embolic stroke. Most PAVFs are multiple, congenital, and associated with hereditary conditions. On the other hand, isolated PAVFs are rare conditions and an uncommon cause of cryptogenic stoke. Case Report: We describe a case of a young woman without history of respiratory diseases or vascular risk factors, who presented with acute onset of transitory aphasia and right hemiplegia. She had a history of a transient ischemic attack, 3 years before, and migraine headaches. Brain MRI showed an acute cortical ischemic lesion and a chronic ischemic lesion. Diagnostic workup with transcranial Doppler ultrasonography revealed a significant right-to-left shunt with curtain pattern, and echocardiogram did not show structural abnormalities. An isolated small PAVF was diagnosed on pulmonary angiogram. Despite the rare association between isolated small PAVF and stroke, we decided to treat it with coil embolization because of recurrence of stroke, cortical lesions suggestive of embolic source, significant right-left shunt, and risk of future complications. Conclusions: This case highlights the importance of search, identification, and interpretation of causes of cryptogenic strokes to better choose therapy to reduce the stroke recurrence risk. Although unusual, PAVF detection is a treatable cause of stroke and the therapeutic decisions should take into account the characteristics of the PAVF and the degree of suspicion regarding the cause-effect relationship between PAVF and stroke.

scholarly journals P916 RoPE score in causal association between patent foramen ovale and cryptogenic stoke, is it enough?

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
L Carnero Montoro ◽  
M Ruiz Ortiz ◽  
M Delgado Ortega ◽  
A M Rodriguez Almodovar ◽  
N Paredes Hurtado ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Incidental Finding ◽  
Cryptogenic Stroke ◽  
Imaging Study ◽  
Interatrial Septum ◽  
Percutaneous Closure ◽  
Stroke Recurrence ◽  
Foramen Ovale ◽  
Complex Anatomy ◽  
History Of

Abstract Introduction The prevalence of patent foramen ovale (PFO) in the general population is high (25%). In patients with cryptogenic stroke (CS) and PFO, determining whether it is causally related to stroke or is an incidental finding is a controversial issue. The RoPE score was described in 2013 to predict the likelihood that the stroke was related to the PFO. The higher the score, the greater the risk of attributable causality, considering 6 as the cut-off point. This scale includes clinical variables, but does not consider the echocardiographic characteristics of PFO that were used as inclusion criteria in studies that have shown benefit with percutaneous closure, such as the complex anatomy of PFO (extensive passage of microbubbles across the PFO at rest and/or interatrial septum aneurysm). Purpose Our aim was to investigate the association of the RoPE score with recurrence of stroke in a series of patients with CS and percutaneously closed PFO in a period of time prior to the current recommendations, as well as to describe the presence of complex anatomy of PFO and its relationship with the value of that score. Methods A series of 172 consecutive patients with CS and percutaneous closure of PFO, included from January 2001 to November 2014 in a single center was analyzed, and the RoPE score was calculated retrospectively in each patient. The presence of complex anatomy of the PFO was estimated by echocardiography, and the rate of recurrence of stroke and the relationship of both variables with the value of the RoPE score was investigated. Results Of the 172 patients in the series, it was possible to calculate the RoPE score in 150 (87%) of them, which constitute the study sample. The mean age was 46 years (range 17-78), 60% were male, 21% were hypertense, 6% diabetic and 27% smokers. A history of previous stroke was present in 3% of patients and 11% had an imaging study with cortical infarction. RoPE score was ≥6 in 69% of the sample, and 66% of the patients presented complex anatomy of PFO, without significant differences between those with RoPE score ≥6 and <6 (65% versus 70%, p = 0.62). Acute complications (mortality, cardiac tamponade, stroke, device embolism) related to closure of the PFO were not observed. After 17.5 years of maximum follow-up (mean 9.6 ± 3.7 years, no patients lost, with a total of 1441 patients-years of observation), 6 patients presented a stroke. The recurrence rate of stroke was very low in both groups of patients, either with RoPE score ≥6 or <6 (0.4 versus 0.5 per 100 patients/year, p = 0.87). Conclusions In our center, before the current recommendations of PFO closure associated with CS, most of the patients had a RoPE score≥6. The majority of patients presented a complex anatomy of the PFO and the incidence of stroke recurrence was very low, independently of the value of the RoPE score.

scholarly journals Patent Foramen Ovale and Cryptogenic Stroke or Transient Ischemic Attack: To Close or Not to Close? A Systematic Review and Meta-Analysis

2018 ◽  
Vol 45 (5-6) ◽  
pp. 193-203 ◽  
Author(s):  
Simona Lattanzi ◽  
Francesco Brigo ◽  
Claudia Cagnetti ◽  
Mario Di Napoli ◽  
Mauro Silvestrini
Keyword(s):  
Transient Ischemic Attack ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Bleeding Complications ◽  
Stroke Recurrence ◽  
Foramen Ovale ◽  
History Of ◽  
Ischemic Attack ◽  
Pfo Closure ◽  
New Onset

Background: The optimal strategy of secondary stroke prevention in patients with patent foramen ovale (PFO) is controversial. This study was performed to evaluate the efficacy and safety of the device closure (DC) versus the medical therapy (MT) in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO. Summary: Randomized controlled trials with active and control groups receiving the DC plus MT and MT alone in patients with history of cryptogenic stroke/TIA and diagnosis of PFO were systematically searched. The main efficacy outcome was stroke recurrence. Subgroup-analyses were performed according to age, shunt size, and presence of atrial septal aneurysm (ASA). Safety endpoints included any serious adverse event (SAE), atrial fibrillation (AF), and major bleeding complications. Risk ratios (RRs) and hazard ratios (HRs) with 95% CIs were estimated. Five trials were included, involving 3,440 participants (DC = 1,829, MT = 1,611). There was a protective effect of closure in the risk of recurrent stroke (RR 0.43 [0.21–0.90]; p = 0.024; HR = 0.39 [0.19–0.83]; p = 0.014). The benefit of PFO closure was significant in patients with PFO associated with substantial right-to-left shunt or ASA. There were no differences in the risks of SAEs and major bleedings between the groups. The rate of new-onset AF was higher in the DC than in the MT arm (RR 4.46 [2.35–8.41]; p < 0.001). Successful device implantation and effective PFO closure were achieved in 96 and 91% of the patients respectively. Key Messages: In selected adult patients with PFO and history of cryptogenic stroke, the DC plus MT is more effective to prevent stroke recurrence and is associated with an increased risk of new-onset AF compared to the MT alone.

scholarly journals Characteristics and analysis of right-to-left shunt-related dizziness in patients without hypoxemia

2019 ◽  
Vol 47 (7) ◽  
pp. 2921-2928
Author(s):  
Liming Cao
Keyword(s):  
Cerebral Infarction ◽  
Acute Stroke ◽  
Arteriovenous Fistula ◽  
Patent Foramen Ovale ◽  
Pulmonary Arteriovenous Fistula ◽  
Foramen Ovale ◽  
History Of

Objective This study aimed to analyze right-to-left shunt-related dizziness in three patients without hypoxemia. Methods Case 1 was a 47-year-old man with a history of cerebral infarction 8 years previously and recurrent dizziness for > 6 months. Patent foramen ovale (PFO) was found with a severe right-to-left shunt. Case 2 was a 50-year-old man with acute stroke. He had a history of repeated dizziness for > 4 years. He was diagnosed with PFO with a severe right-to-left shunt after admission. Case 3 was a 73-year-old woman with recurrent dizziness for > 10 months. Pulmonary arteriovenous fistula was diagnosed upon admission. No patients had hypoxemia. Results After percutaneous PFO occlusion in Cases 1 and 2, the patients were followed up for 6 months and 1 year, respectively. Two patients had relief of dizziness without recurrence. In Case 3, the pallor improved and the dizziness was relieved after pulmonary arteriovenous fistula embolization and did not recur over a 6-month follow-up. Conclusions There was a possible association between a severe right-to-left shunt and dizziness, although hypoxemia was absent in the cases. Intervention to eliminate a left-to-right shunt can improve dizziness in patients without hypoxemia with a severe right-to-left shunt.

scholarly journals The Value of Contrast-Enhanced Transesophageal Echocardiography in the Detection of Cardiac Right-to-Left Shunt Related with Cryptogenic Stroke and Migraine

2020 ◽  
Vol 2020 ◽  
pp. 1-5
Author(s):  
Huiqin Zhang ◽  
Wenyan Huang ◽  
Tingyu Lan ◽  
Meng Zhang ◽  
Jing Yang ◽  
...  
Keyword(s):  
Transesophageal Echocardiography ◽  
Arteriovenous Fistula ◽  
Left Atrium ◽  
Cryptogenic Stroke ◽  
Pulmonary Arteriovenous Fistula ◽  
Contrast Enhanced ◽  
Significant Difference ◽  
Stroke Group ◽  
Migraine Group ◽  
Grade 3

Purpose. To analyze the characteristics of right-to-left shunt (RLS) in patients with cryptogenic stroke and migraine by contrast-enhanced transesophageal echocardiography (c-TEE). Methods. The study population consisted of 330 patients with cryptogenic stroke and 330 patients with migraine who suspected PFO. All of them received c-TEE examination successfully. In terms of c-TEE analyses, RLS could be diagnosed when microbubbles were visualized in the transition from the right atrium to the left atrium. For semiquantitative analysis, a small amount of RLS was grade 1, indicating 1-10 microvesicles per frame could be seen in the left atrium, a moderate amount of RLS was grade 2, indicating 11-30 microvesicles per frame could be seen in the left atrium, and a large amount of RLS was grade 3, indicating more than 30 microvesicles per frame, or the left atrium is filled with microvesicles. Results. A total of 660 patients were analyzed in the study. PFO-RLS was detected in 348 (348/660, 52.7%) cases by TEE, while in 392 (392/660, 59.3%) cases by c-TEE. Simultaneously, P-RLS was detected in 239 (239/660, 36.2%) cases by c-TEE. Among 330 patients with cryptogenic stroke, PFO-RLS was detected in 198 cases; according to the c-TTE method (198/330, 60.0%), concurrently, 83 participants suffered from PFO-RLS and P-RSL (83/330, 25.1%), including 1 case with PFO and pulmonary arteriovenous fistula. Among 330 patients with migraine, PFO-RLS was detected in 194 cases; according to the c-TTE method (194/330, 58.7%), specifically, 90 participants suffered from PFO-RLS and P-RSL (90/330, 27.2%). There was no statistical significance between the two groups. P-RLS singly was detected in 28 cases with cryptogenic stroke, while in 38 cases with migraine, excluding from pulmonary arteriovenous fistula by CTA examination. In addition, semiquantitative results on c-TTE grading of RLS were compared between the two groups: grade 1 RLS in the migraine group (144/322) was significantly higher than that in the cryptogenic stroke group (71/309) ( P < 0.05 ). Grade 3 RLS in the cryptogenic stroke group (113/309) was significantly higher than that in the migraine group (67/322) ( P < 0.05 ). For grade 2 RLS, there was no statistical difference between the two groups ( P = 0.12 ). Conclusions. c-TEE can increase the positive rate of PFO diagnosis compared with TEE color Doppler. There is no significant difference in the incidence of PFO-PLS and P-RLS between the cryptogenic stroke group and the migraine group. The grades 2-3 RLS are mainly detected in the cryptogenic stroke group, while grades 1-2 RLS are mostly detected in the migraine group.

A world in the head: Brain abscess caused by Paradoxical embolism due to pulmonary arteriovenous fistula as a debut of hereditary hemorrhagic telangiectasia

2020 ◽  
pp. 184
Author(s):  
Keyword(s):  
Iron Deficiency ◽  
Physical Examination ◽  
Arteriovenous Fistula ◽  
Brain Abscess ◽  
Genetic Study ◽  
Paradoxical Embolism ◽  
Deficiency Anemia ◽  
Pulmonary Arteriovenous Fistula ◽  
History Of ◽  
Etiological Study

66-year-old patient with a history of alcoholism and smoking, chronic iron deficiency anemia treated with oral iron who was admitted for streptococcal brain abscess, during the etiological study we found arteriovenous shunt on echocardiography and pulmonary arteriovenous fistula, undergoing endovascular closure of the same during stay. In the physical examination, perioral teleangiectasis was observed, when meeting the Curaçao criteria, a genetic study of hereditary hemorrhagic teleangiectasia was requested, which was positive.

Abstract P702: How Many Cryptogenic Stroke Patients Should Be Candidates for Patent Foramen Ovale Closure?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Hidetaka Mitsumura ◽  
Tomomichi Kitagawa ◽  
Maki Tanabe ◽  
Takeo Sato ◽  
Hiroki Takatsu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Stroke Recurrence ◽  
Atrial Septal Aneurysm ◽  
Large Artery ◽  
Foramen Ovale ◽  
Stroke Patients ◽  
Ischemic Lesion ◽  
Pfo Closure

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke (CS) and PFO. Our aim of this retrospective study is to survey the frequency of CS, which can be an indication of PFO closure. Methods: Subjects were consecutive stroke patients with symptomatic ischemic lesion detected by magnetic resonance imaging. Of them, CS were extracted according to exclusion of small-vessel collusion, large-artery atherosclerosis, cardioembolism, definite case of aortogenic embolism, and distinctive causeof ischemic stroke such as arterial dissection, hypercoagulable state and so on. After that, we selected patients in accordance with clinical guideline of PFO closure recommended by the Japanese Stroke Association (Figure). We analyzed the prevalence of CS with right-to-left shunt (RLS) as a good and recommended candidates for PFO closure. Results: Among 1,374 ischemic stroke patients from October 2012 to September 2019 , CS were 240 patients (83 females, mean age of 66 years, 17% of subjects). Of them, 100 patients (42%) had RLS (PFO; 65, atrial septal defect; 1, pulmonary arteriovenous fistula; 1, positive on transcranial Doppler (not performed in TEE) including 21 cases of definite of paradoxical embolism. In 65 patients of CS with PFO, 30 patients younger than 60 years (13% of CS) were good candidates for PFO closure. Moreover, 22 of 1,374 (1.6%) patients who were recommended candidates had one or more high risk factors of PFO, for example large shunt, atrial septal aneurysm, and the presence of shunt at rest (Figure). Conclusions: In our preliminary survey, 2% of acute ischemic stroke should be PFO closure candidates.

Pulmonary arteriovenous fistula in a patient with cryptogenic stroke

Heart ◽  
2011 ◽  
Vol 97 (24) ◽  
pp. 2093-2093 ◽  
Author(s):  
K. T. Ahn ◽  
J.-H. Choi ◽  
S. W. Park
Keyword(s):  
Arteriovenous Fistula ◽  
Cryptogenic Stroke ◽  
Pulmonary Arteriovenous Fistula
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