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1.
Medicine (Baltimore) ; 98(45): e17940, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702683

RESUMO

Venous air embolism (VAE) can be observed in the right heart system on contrast-enhanced computed tomography (CT), following injection of contrast media with a power injector system. Although most VAEs are mostly asymptomatic, they may result in paradoxical air embolism (PAE).To evaluate whether the incidence of VAE on coronary CT angiography is associated with the process of preparation of the intravenous access route.We retrospectively evaluated 692 coronary CT examinations at 3 institutions. Trained CT nurses placed an intravenous cannula in the forearm. Tubes connected to the cannula were prepared in the following ways: A, using an interposed three-way cock and a 20-mL syringe filled with normal saline to collect air contamination in the tube; B, through direct connection to the power injector system without the interposed 3-way cock; and C, using an interposed three-way cock and a 100-mL normal saline drip infusion bottle system to keep the tube patent. The incidence and location of VAE and preparation of intravenous injection were assessed.The overall incidence of VAE was 55.3% (383/692), most frequently observed in the right atrium (81.5%, 312/383). Its incidence varied significantly across the 3 techniques (A: 21.6% (35/162), B: 63.2% (237/375) and C: 71.6% (111/155); P < .001). No patient demonstrated any symptom associated with VAE.Using a 3-way cock with syringe demonstrated the lowest incidence of VAE on coronary CT angiography. It is thus recommended to reduce potential complication risks related to intravenous contrast media injection.


Assuntos
Angiografia por Tomografia Computadorizada/efeitos adversos , Embolia Aérea/etiologia , Embolia Paradoxal/etiologia , Átrios do Coração/diagnóstico por imagem , Idoso , Meios de Contraste/administração & dosagem , Embolia Aérea/complicações , Embolia Aérea/epidemiologia , Embolia Paradoxal/epidemiologia , Humanos , Injeções Intravenosas/efeitos adversos , Injeções Intravenosas/instrumentação , Injeções Intravenosas/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
3.
J Stroke Cerebrovasc Dis ; 27(7): e125-e127, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29628339

RESUMO

Paradoxical embolism due to isolated pulmonary arteriovenous malformation (AVM) is an uncommon cause of ischemic stroke, with the majority occurring in patients who have not yet been diagnosed with their malformation. We report a 32-year-old man who presented with an abrupt onset of right facial weakness and expressive aphasia. Brain magnetic resonance imaging revealed an acute infarct in the left middle cerebral artery territory and chronic infarcts in the bilateral cerebellar hemispheres. A cardioembolic mechanism was initially considered in the setting of perimyocarditis diagnosed a few months earlier. Transthoracic and transesophageal echocardiograms revealed high volume right to left shunting, but no septal defects. A pulmonary AVM was confirmed with computed tomography angiography and fistualization was successfully treated with embolization. This report highlights a case of undiagnosed pulmonary AVM leading to recurrent paradoxical emboli to the brain. We review the epidemiology, pathophysiology, and management of pulmonary AVMs in relation to stroke risk.


Assuntos
Malformações Arteriovenosas/complicações , Isquemia Encefálica/etiologia , Embolia Paradoxal/complicações , Embolia Intracraniana/complicações , Acidente Vascular Cerebral/etiologia , Adulto , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/epidemiologia , Malformações Arteriovenosas/terapia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/terapia , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/epidemiologia , Embolia Paradoxal/terapia , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/epidemiologia , Embolia Intracraniana/terapia , Masculino , Artéria Pulmonar/anormalidades , Artéria Pulmonar/diagnóstico por imagem , Veias Pulmonares/anormalidades , Veias Pulmonares/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia
4.
World Neurosurg ; 115: 196-200, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29704690

RESUMO

BACKGROUND: The semi-sitting position is preferred in some surgeries of the posterior fossa and the cervical spine. At the same time, it is associated with a risk of air embolism. In the presence of a patent foramen ovale (PFO) with an intracardial right-to-left shunt, an air embolism can result in a paradoxical embolism to the heart or brain. It is unclear whether the risk-benefit ratio favors the semi-sitting position in this scenario. METHODS: We conducted a systematic review of the relevant studies published after 2007 by searching the PubMed, Science Direct, and Cochrane Database of Systematic Reviews databases. Studies in which the presence of PFO was stated and the occurrence of paradoxical embolism was evaluated in patients who underwent neurosurgical procedures in the semi-sitting position were included in our analysis. RESULTS: We identified 4 observational studies with a total of 977 patients who underwent surgery of the posterior fossa or cervical spine in the semi-sitting position; among these, 82 had a PFO. Air embolism occurred in 33 of these 82 patients (40.2%). No paradoxical embolisms were detected. CONCLUSIONS: In experienced medical centers, neurosurgery in the semi-sitting position is feasible with acceptable risk even in patients with PFO. If the PFO is large, or if a permanent right-to-left shunt is present in a patient with a history of paradoxical embolism, it may be reasonable to repair the PFO before surgery if the semi-sitting position is strongly preferred. The risk analysis must be done on a case-by-case basis.


Assuntos
Embolia Paradoxal/epidemiologia , Forame Oval Patente/epidemiologia , Forame Oval Patente/cirurgia , Procedimentos Neurocirúrgicos/métodos , Postura , Embolia Paradoxal/diagnóstico , Forame Oval Patente/diagnóstico , Humanos , Procedimentos Neurocirúrgicos/efeitos adversos , Estudos Observacionais como Assunto/métodos , Postura/fisiologia
5.
Ann Cardiol Angeiol (Paris) ; 66(6): 433-440, 2017 Dec.
Artigo em Francês | MEDLINE | ID: mdl-29096902

RESUMO

Paradoxical embolism should be suspected in front of a clinical phenomenon of thromboembolism associated with an anatomical right-to-left shunt. Others potential cardiac sources of thromboembolism must be ruled out. Strokes constitute the most frequent clinical manifestations of paradoxical embolism. Right-to-left left shunts are in connection with intracardiac defects (atrial septal defect and patent foramen ovale) or pulmonary arteriovenous malformations. The probability that a discovered PFO is stroke-related can be evaluated by a score. Therapeutic approaches for secondary prevention of recurrent stroke include antithrombotic and/or percutaneous treatments. The choice strategy begins to be clearer with the recent results of randomized controlled studies.


Assuntos
Embolia Paradoxal/diagnóstico , Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Comunicação Interatrial/complicações , Comunicação Interatrial/diagnóstico por imagem , Acidente Vascular Cerebral/prevenção & controle , Diagnóstico Diferencial , Ecocardiografia Transesofagiana/métodos , Embolia Paradoxal/epidemiologia , França/epidemiologia , Humanos , Incidência
6.
Rev Neurol ; 64(12): 543-548, 2017 Jun 16.
Artigo em Espanhol | MEDLINE | ID: mdl-28608354

RESUMO

INTRODUCTION: Presumed perinatal ischemic stroke is a frequent cause of neurological sequelae. We aimed to describe the different clinical findings and risk factors and to analyse the differences according the vascular origin. PATIENTS AND METHODS: Retrospective, descriptive study of patients diagnosed with presumed perinatal ischemic stroke attended at a tertiary pediatric hospital from 1990 to 2015. RESULTS: 44 patients were included. A total of 24 patients (55%) had arterial ischemic stroke and 20 (45%) had periventricular venous infarction. Delay in diagnosis was significantly higher in patients with periventricular venous infarction compared to those with arterial ischemic stroke (14 and 8 months respectively; p = 0.025). Most patients presented with asymmetrical motor development (90%), only < 5% with seizures or non motor delays. Subsequent epilepsy at follow-up was significantly more prevalent in arterial ischemic stroke group (p = 0.020). We determined risk factors theoretically involved in the pathogenesis of presumed perinatal ischemic stroke: prenatal, obstetrical, perinatal, prothrombotic and cardiac. No significant differences between risk factors and vascular origin were found. Prothrombotic abnormalities were common (48.3%). CONCLUSIONS: Investigation in risk factors implicated in presumed perinatal ischemic stroke is required to develop prevention strategies. Delay in diagnosis is higher in periventricular venous infarction group.


Assuntos
Isquemia Encefálica/epidemiologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/embriologia , Isquemia Encefálica/etiologia , Artérias Cerebrais/diagnóstico por imagem , Veias Cerebrais/diagnóstico por imagem , Diagnóstico Tardio , Parto Obstétrico , Embolia Paradoxal/epidemiologia , Epilepsia/etiologia , Feminino , Doenças Fetais/diagnóstico por imagem , Doenças Fetais/epidemiologia , Doenças Fetais/etiologia , Humanos , Lactente , Recém-Nascido , Deficiência Intelectual/etiologia , Imagem por Ressonância Magnética , Masculino , Transtornos dos Movimentos/etiologia , Neuroimagem , Assistência Perinatal , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Centros de Atenção Terciária/estatística & dados numéricos , Trombofilia/complicações , Trombofilia/diagnóstico , Trombofilia/epidemiologia , Tomografia Computadorizada por Raios X
7.
Cardiol Clin ; 34(2): 247-54, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27150173

RESUMO

The absolute separation of the right and left circulations and the filtration of blood by the pulmonary circulation are essential to prevent the passage of thrombotic material from the venous system into the systemic arterial circulation. Any breach of the intracardiac septae or circumvention of the pulmonary capillary network may cause a paradoxical embolus. The most common causes are atrial septal defects and pulmonary arteriovenous malformations. This article discusses unusual connections and pathways related to congenital malformations. Although anticoagulation is necessary to prevent paradoxical emboli, the hematologic disturbances and the most appropriate therapy in these patients warrant further investigation.


Assuntos
Anormalidades Congênitas/epidemiologia , Embolia Paradoxal/etiologia , Embolia Paradoxal/epidemiologia , Saúde Global , Humanos , Incidência , Fatores de Risco
8.
Nat Rev Dis Primers ; 2: 15086, 2016 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-27188965

RESUMO

Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.


Assuntos
Septo Interatrial/fisiopatologia , Forame Oval Patente/complicações , Forame Oval Patente/fisiopatologia , Septo Interatrial/patologia , Procedimentos Cirúrgicos Cardíacos/instrumentação , Procedimentos Cirúrgicos Cardíacos/métodos , Anormalidades Congênitas/epidemiologia , Ecocardiografia/métodos , Embolia Paradoxal/epidemiologia , Embolia Paradoxal/etiologia , Embolia Paradoxal/fisiopatologia , Forame Oval Patente/cirurgia , Humanos , Prevalência , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
9.
Eur J Paediatr Neurol ; 20(4): 500-11, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27169856

RESUMO

BACKGROUND: Stroke in association with a patent foramen ovale (PFO) may be due to paradoxical embolization via a right to left intracardiac shunt but the exact contribution of PFO to stroke or stroke recurrence in childhood remains unclear. METHODS: To review the relationship of a PFO with stroke, and evaluate associated co-morbidities. An electronic database literature search of Pubmed, Cochrane and EMBASE was performed from January 2000-December 2014. RESULTS: 149 articles were retrieved, with overlap for diagnosis, management, treatment and outcome. 65 reports were utilized for the comprehensive review. Majority of childhood arterial ischemic stroke and transient ischemic attacks are associated with prothrombotic disorders or arteriopathy. Transthoracic echocardiography with a Valsalva maneuver is highly sensitive as a screening tool but may be falsely positive. Transthoracic echocardiography with color Doppler and a concurrent bubble contrast study are excellent for visualizing the atrial septum and PFO and identifying a right to left shunt. Current literature does not support PFO closure for cryptogenic stroke in young adults without an associated risk of thromboembolism. CONCLUSIONS: High quality research in the pediatric population is lacking and most of the data is extrapolated from adults. Paradoxical embolism from a PFO as a cause of transient ischemic attack or stroke is a diagnosis of exclusion. PFO closure should be individualized based on significant shunting and risk factors such that maximum benefit is derived from the procedure. A young person with a PFO and stroke should be thoroughly investigated to rule out other etiologies.


Assuntos
Embolia Paradoxal/complicações , Forame Oval Patente/complicações , Acidente Vascular Cerebral/etiologia , Comorbidade , Embolia Paradoxal/epidemiologia , Forame Oval Patente/diagnóstico , Forame Oval Patente/epidemiologia , Humanos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia
10.
Acta Clin Belg ; 71(3): 149-53, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27075798

RESUMO

OBJECTIVE: Patent foramen ovale (PFO) is a common developmental anomaly and is well associated with paradoxical embolism and cryptogenic stroke. The aim of this study was to investigate the relationship of PFO location with severity of cryptogenic stroke. MATERIALS AND METHODS: Fifty patients with cryptogenic stroke and echocardiographically proven PFO were classified according to the severity of stroke. In order to define the location of PFOs, an imaginary line dividing the length of interatrial septum vertically into two equal parts was drawn manually at axial plane on cardiac multidetector computed tomography. PFOs located at superior part of this imaginary line was defined as superiorly located PFO, while PFOs located at inferior part of this imaginary line was defined as inferiorly located PFO. RESULTS: Fourteen patients (28%) revealed mild, 20 patients (40%) revealed moderate and 16 patients (32%) had severe stroke. Based on PFO location, there were 34 patients (68%) with superiorly (group 1), and 16 patients (32%) with inferiorly (group 2) located PFO. It was found that patients of group 1 had significantly higher frequency of moderate or severe stroke compared to those of group 2 (p < 0.005) CONCLUSION: In conclusion, the patients with superiorly located PFO had higher frequency of severe stroke compared to the patients with inferiorly located PFO. Since this is a preliminary study, clinical application and importance of this finding necessitates further large-scale interventional studies.


Assuntos
Embolia Paradoxal/epidemiologia , Forame Oval Patente/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Embolia Paradoxal/complicações , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/patologia , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/patologia
11.
Eur J Clin Invest ; 45(8): 875-82, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26017145

RESUMO

Patent foramen ovale (PFO) is an embryologic remnant with incomplete postnatal adhesion of the cardiac atrial septum primum and secundum. After birth, the prevalence of PFO decreases from about 35% at young to approximately 20% at old age. PFO has been associated with numerous conditions such as decompression illness in divers, migraine, high-altitude pulmonary oedema, cerebrovascular and coronary ischaemia, and obstructive sleep apnoea syndrome. PFO is the cause of intermittent atrial right-to-left shunt, and it can be the source of cardiac paradoxical embolism. So far, randomized controlled trials have not documented a reduced rate of cerebrovascular recurrent events in patients receiving PFO device closure as compared to those on medical treatment. The purpose of this article was to critically evaluate evidence on the pathophysiologic, clinical as well as prognostic relevance of PFO.


Assuntos
Doença da Altitude/fisiopatologia , Doença da Descompressão/fisiopatologia , Embolia Paradoxal/fisiopatologia , Forame Oval Patente/fisiopatologia , Transtornos de Enxaqueca/fisiopatologia , Edema Pulmonar/fisiopatologia , Apneia Obstrutiva do Sono/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Doença da Altitude/epidemiologia , Doença da Descompressão/epidemiologia , Embolia Paradoxal/epidemiologia , Terapias Fetais , Forame Oval Patente/epidemiologia , Forame Oval Patente/cirurgia , Humanos , Transtornos de Enxaqueca/epidemiologia , Edema Pulmonar/epidemiologia , Recidiva , Apneia Obstrutiva do Sono/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle
12.
Cerebrovasc Dis ; 39(3-4): 216-23, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25791718

RESUMO

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.


Assuntos
Embolia Paradoxal/epidemiologia , Forame Oval Patente/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Trombofilia/epidemiologia , Trombose Venosa/epidemiologia , Adulto , Idoso , Embolia Paradoxal/complicações , Embolia Paradoxal/diagnóstico , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Trombofilia/diagnóstico , Trombose Venosa/complicações
13.
J Am Coll Cardiol ; 64(4): 403-15, 2014 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-25060377

RESUMO

Paradoxical embolism is an important clinical entity among patients with venous thromboembolism in the presence of intracardiac or pulmonary shunts. The clinical presentation is diverse and potentially life-threatening. Although the serious nature and complications of paradoxical embolism are recognized, the disease entity is still rarely considered and remains under-reported. This paper provides an overview on the different clinical manifestations of paradoxical embolism, describes the diagnostic tools for the detection of intracardiac and pulmonary shunts, reviews therapeutic options, and summarizes guideline recommendations for the secondary prevention of paradoxical embolism.


Assuntos
Isquemia Encefálica , Diagnóstico por Imagem/métodos , Embolia Paradoxal , Cardiopatias Congênitas , Infarto do Miocárdio , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Embolia Paradoxal/complicações , Embolia Paradoxal/diagnóstico , Embolia Paradoxal/epidemiologia , Saúde Global , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/epidemiologia , Humanos , Morbidade/tendências , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Fatores de Risco
15.
Neurology ; 83(3): 221-6, 2014 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-24928123

RESUMO

OBJECTIVE: To examine predictors of stroke recurrence in patients with a high vs a low likelihood of having an incidental patent foramen ovale (PFO) as defined by the Risk of Paradoxical Embolism (RoPE) score. METHODS: Patients in the RoPE database with cryptogenic stroke (CS) and PFO were classified as having a probable PFO-related stroke (RoPE score of >6, n = 647) and others (RoPE score of ≤6 points, n = 677). We tested 15 clinical, 5 radiologic, and 3 echocardiographic variables for associations with stroke recurrence using Cox survival models with component database as a stratification factor. An interaction with RoPE score was checked for the variables that were significant. RESULTS: Follow-up was available for 92%, 79%, and 57% at 1, 2, and 3 years. Overall, a higher recurrence risk was associated with an index TIA. For all other predictors, effects were significantly different in the 2 RoPE score categories. For the low RoPE score group, but not the high RoPE score group, older age and antiplatelet (vs warfarin) treatment predicted recurrence. Conversely, echocardiographic features (septal hypermobility and a small shunt) and a prior (clinical) stroke/TIA were significant predictors in the high but not low RoPE score group. CONCLUSION: Predictors of recurrence differ when PFO relatedness is classified by the RoPE score, suggesting that patients with CS and PFO form a heterogeneous group with different stroke mechanisms. Echocardiographic features were only associated with recurrence in the high RoPE score group.


Assuntos
Embolia Paradoxal/epidemiologia , Forame Oval Patente/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Comorbidade , Bases de Dados Factuais , Feminino , Seguimentos , Forame Oval Patente/classificação , Forame Oval Patente/diagnóstico , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Recidiva , Medição de Risco , Acidente Vascular Cerebral/tratamento farmacológico
16.
Circ Cardiovasc Imaging ; 7(1): 125-31, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24214884

RESUMO

BACKGROUND: Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS), although the pathogenicity of a discovered PFO in the setting of CS is typically unclear. Transesophageal echocardiography features such as PFO size, associated hypermobile septum, and presence of a right-to-left shunt at rest have all been proposed as markers of risk. The association of these transesophageal echocardiography features with other markers of pathogenicity has not been examined. METHODS AND RESULTS: We used a recently derived score based on clinical and neuroimaging features to stratify patients with PFO and CS by the probability that their stroke is PFO-attributable. We examined whether high-risk transesophageal echocardiography features are seen more frequently in patients more likely to have had a PFO-attributable stroke (n=637) compared with those less likely to have a PFO-attributable stroke (n=657). Large physiologic shunt size was not more frequently seen among those with probable PFO-attributable strokes (odds ratio [OR], 0.92; P=0.53). The presence of neither a hypermobile septum nor a right-to-left shunt at rest was detected more often in those with a probable PFO-attributable stroke (OR, 0.80; P=0.45; OR, 1.15; P=0.11, respectively). CONCLUSIONS: We found no evidence that the proposed transesophageal echocardiography risk markers of large PFO size, hypermobile septum, and presence of right-to-left shunt at rest are associated with clinical features suggesting that a CS is PFO-attributable. Additional tools to describe PFOs may be useful in helping to determine whether an observed PFO is incidental or pathogenically related to CS.


Assuntos
Ecocardiografia Transesofagiana , Embolia Paradoxal/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Adulto , Idoso , Distribuição de Qui-Quadrado , Circulação Coronária , Bases de Dados Factuais , Embolia Paradoxal/epidemiologia , Embolia Paradoxal/fisiopatologia , Feminino , Forame Oval Patente/epidemiologia , Forame Oval Patente/fisiopatologia , Septos Cardíacos/diagnóstico por imagem , Hemodinâmica , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Prevalência , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Ultrassonografia Doppler Transcraniana
17.
Congenit Heart Dis ; 9(1): 30-7, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-23601093

RESUMO

OBJECTIVE: Determine incidence and risk factors for possible paradoxical embolic events in patients who have Ebstein anomaly with severe tricuspid regurgitation. DESIGN: Retrospective study of clinical and imaging data. SETTING: Tertiary care center. PATIENTS: Patients undergoing clinical evaluation and echocardiography prior to cardiac surgery for Ebstein anomaly (1975-2010) performed at age ≥ 40 years. RESULTS: Mean age of 128 patients (81 female) was 53 ± 9 years. All had severe tricuspid regurgitation. Twenty-four (19%) had previous cardiac surgery (at <40 years), including 17 for interatrial shunt closure. Most (112 [88%]) had New York Heart Association functional class III/IV heart failure; 84 (66%) had interatrial shunting (58 had an atrial septal defect and 29 had a patent foramen ovale [3 had both]). During their lifetime, 29 patients (23%) had a history of ≥1 possible paradoxical embolic events (stroke or transient ischemic attack, brain abscess, or myocardial infarction). The best predictors of preoperative possible paradoxical embolic events were an atrial septal defect (P = .002) and older age at surgery (P = .007). There was no association of possible paradoxical embolic events with cardiovascular risk factors (hypertension, dyslipidemia, smoking, or family history of coronary artery disease) (all P ≥ .3) or atrial fibrillation (P = .69). Median age at occurrence of paradoxical embolism was 49 (range, 1.5-74 years). CONCLUSIONS: Possible paradoxical embolic events are common in adults with Ebstein anomaly and severe tricuspid regurgitation and are strongly associated with atrial septal defect. In patients with atrial septal defect or patent foramen ovale, shunt closure should be considered to reduce risk of possible paradoxical embolic events.


Assuntos
Anomalia de Ebstein/epidemiologia , Embolia Paradoxal/epidemiologia , Insuficiência da Valva Tricúspide/epidemiologia , Adulto , Fatores Etários , Transtornos Cerebrovasculares/epidemiologia , Comorbidade , Anomalia de Ebstein/diagnóstico , Anomalia de Ebstein/fisiopatologia , Anomalia de Ebstein/cirurgia , Embolia Paradoxal/diagnóstico , Embolia Paradoxal/fisiopatologia , Feminino , Forame Oval Patente/epidemiologia , Comunicação Interatrial/epidemiologia , Hemodinâmica , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Infarto do Miocárdio/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Centros de Atenção Terciária , Fatores de Tempo , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/fisiopatologia
18.
Catheter Cardiovasc Interv ; 82(4): 541-6, 2013 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-22707325

RESUMO

OBJECTIVES: To determine the incidence of symptomatic recurrent embolic events after patent foramen ovale (PFO) closure and potential causes for these events. BACKGROUND: It is well-known that cerebral or other embolic events may occur after PFO closure. METHODS: This is a retrospective analysis of consecutive patients who underwent PFO closure for secondary prevention of embolic events at a single institution. RESULTS: 1,930 patients (mean age of 50 ± 13.3 years) underwent transcatheter PFO closure. Complete closure occurred in 92%. The annual recurrence rate of embolic events before PFO closure was 22.4% (785 events in 3,497 patient-years). During follow-up (mean 39 months), 63 recurrent events were documented: 25 strokes, 36 transient ischemic attacks (TIAs), and 2 peripheral embolic events. The overall annual recurrence rate after the procedure was 1% per year (63 events in 6,211 patient-years). The majority of events occurred in patients without residual shunts (54/63). There was no significant association between the presence of a residual shunt and recurrent events [hazard ratio (HR) 1.7; 95% confidence interval (CI) 0.8-3.6, P = 0.16]. The most common cause for recurrent events was atherosclerosis. Nine out of 63 events were considered likely or possible paradoxical embolism due to residual shunt [stroke (2), TIA (5), and peripheral embolism (2)]. After PFO closure, the annual rate of events potentially related to paradoxical embolism was 0.14% (9 events in 6,211 patient-years). CONCLUSION: The incidence of symptomatic embolic events after PFO closure is low. Most recurrent events are related to coexistent conditions associated with thromboembolic risk rather than residual shunts.


Assuntos
Cateterismo Cardíaco , Embolia Paradoxal/prevenção & controle , Forame Oval Patente/terapia , Ataque Isquêmico Transitório/prevenção & controle , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Comorbidade , Embolia Paradoxal/epidemiologia , Embolia Paradoxal/fisiopatologia , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/epidemiologia , Forame Oval Patente/fisiopatologia , Alemanha/epidemiologia , Hemodinâmica , Humanos , Incidência , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Int J Stroke ; 8(8): 612-9, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22883936

RESUMO

BACKGROUND: Detecting a benefit from closure of patent foramen ovale in patients with cryptogenic stroke is hampered by low rates of stroke recurrence and uncertainty about the causal role of patent foramen ovale in the index event. A method to predict patent foramen ovale-attributable recurrence risk is needed. However, individual databases generally have too few stroke recurrences to support risk modeling. Prior studies of this population have been limited by low statistical power for examining factors related to recurrence. AIMS: The aim of this study was to develop a database to support modeling of patent foramen ovale-attributable recurrence risk by combining extant data sets. METHODS: We identified investigators with extant databases including subjects with cryptogenic stroke investigated for patent foramen ovale, determined the availability and characteristics of data in each database, collaboratively specified the variables to be included in the Risk of Paradoxical Embolism database, harmonized the variables across databases, and collected new primary data when necessary and feasible. RESULTS: The Risk of Paradoxical Embolism database has individual clinical, radiologic, and echocardiographic data from 12 component databases, including subjects with cryptogenic stroke both with (n = 1925) and without (n = 1749) patent foramen ovale. In the patent foramen ovale subjects, a total of 381 outcomes (stroke, transient ischemic attack, death) occurred (median follow-up 2·2 years). While there were substantial variations in data collection between studies, there was sufficient overlap to define a common set of variables suitable for risk modeling. CONCLUSION: While individual studies are inadequate for modeling patent foramen ovale-attributable recurrence risk, collaboration between investigators has yielded a database with sufficient power to identify those patients at highest risk for a patent foramen ovale-related stroke recurrence who may have the greatest potential benefit from patent foramen ovale closure.


Assuntos
Embolia Paradoxal/epidemiologia , Forame Oval Patente/complicações , Modelos Teóricos , Adulto , Idoso , Bases de Dados como Assunto , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
20.
J Neuroimaging ; 23(4): 523-5, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22928688

RESUMO

BACKGROUND AND PURPOSE: Paradoxical embolism through extracardiac right-to-left shunts (ECRLS) may represent an under-detected stroke mechanism. Stroke patients without evidence of cardiac right-to-left shunt (RLS) on echocardiogram may benefit from transcranial Doppler with bubble study (TCD-b) to aid in recognition of stroke etiology. This study assesses the usefulness of TCD-b in the stroke evaluation. METHODS: Retrospective cohort study of consecutive patients undergoing TCD-b performed in our neurovascular laboratory from February 2005 to August 2009. Echocardiography results were reviewed in patients with positive TCD-b. Detailed medical record review was performed on patients with positive TCD-b and negative echocardiogram findings for RLS. RESULTS: Of 502 patients undergoing TCD-b, 48.4% (n = 243) had a positive study suggesting the presence of RLS. Of these, 59.2% (n = 144) had an echocardiogram demonstrating a cardiac RLS, 26% (n = 63) had echocardiograms without evidence of cardiac RLS, and 14.8% (n = 36) had no echocardiogram. Data on the evaluation to determine source of potential shunting in patients with discrepant findings was available in 11(17.5%). Of these, 63.6% (7/11) had potential mechanisms for positive TCD-b: one pulmonary arteriovenous malformation (AVM), one arteriovenous fistula thrombus, one parietal AVM, and four had malignancy. CONCLUSIONS: TCD-bubble studies may prove useful in uncovering treatable causes of stroke.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/epidemiologia , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/epidemiologia , Microbolhas , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Ultrassonografia Doppler Transcraniana/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Causalidade , Comorbidade , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Prevalência , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade
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