Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 844
Filtrar
1.
Vnitr Lek ; 66(5): 76-79, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32942875

RESUMO

We present a case report of a patient with acute upper and lower limb ischemia due to paradoxical embolism. A 67-year old woman without history of venous thromboembolism suffered dislocated patellar fracture requiring surgery in November 2017. Two months after surgery she presented to the emergency room with bilateral pulmonary embolism, occlusion of the left subclavian artery, left common femoral artery and superior mesenteric artery. Transesophageal echocardiography detected patent foramen ovale. Vascular surgeon decided against embolectomy, interventional radiologist against pharmacomechanical thrombolysis due to the extent of the occlusions. Systemic thrombolysis (alteplase) was administered successfully with resolution of the emboli in the left subclavian artery, left common femoral artery and superior mesenteric artery.


Assuntos
Embolia Paradoxal , Forame Oval Patente , Embolia Pulmonar , Idoso , Embolectomia , Embolia Paradoxal/tratamento farmacológico , Embolia Paradoxal/cirurgia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/tratamento farmacológico , Humanos , Isquemia/tratamento farmacológico , Embolia Pulmonar/cirurgia , Terapia Trombolítica
2.
Arch Cardiovasc Dis ; 113(8-9): 513-524, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32680737

RESUMO

BACKGROUND: Closure of patent foramen ovale is well-managed in adults, but is performed less frequently in children. AIM: To analyse all patent foramen ovale closures performed in the past 20 years in French paediatric centres. METHODS: Retrospective study of patent foramen ovale closures in children without cardiopathy in nine centres between 2000 and 2019. RESULTS: Forty-one procedures were carried out in children (median age: 14.9 years). Thirty-one patent foramen ovales were closed after a transient ischaemic attack or stroke, six for a left-to-right shunt and four for other reasons. Transthoracic echocardiography was used for 72.2% of the diagnoses and transoesophageal echocardiography for 27.8%. A substantial degree of shunting was found in 42.9% of patients and an atrial septal aneurysm in 56.2%. General anaesthesia with transoesophageal echocardiography guidance was performed in 68.3% of the procedures; local anaesthesia and transthoracic echocardiography or intracardiac echocardiography was performed in 31.7%. The success rate was 100%. The median fluoroscopy time was 4.14minutes: 3.55minutes with transoesophageal echocardiography; and 4.38minutes with transthoracic echocardiography (P=0.67). There was only one periprocedural complication (2.4%). Postoperatively, 80,5% of patients were treated with aspirin and 12,2% with an anticoagulant. The rate of complete occlusion was 56.8% immediately after the procedure, 68.6% at 1 year and 92.3% at the last follow-up. There were no delayed complications or cases of recurrent stroke during follow-up (median follow-up: 568 days). CONCLUSION: Closure of patent foramen ovale in children appears to be safe and effective, as we noted a low rate of immediate complications, no delayed complications and no stroke recurrence in this indication.


Assuntos
Cateterismo Cardíaco/instrumentação , Forame Oval Patente/terapia , Dispositivo para Oclusão Septal , Adolescente , Fatores Etários , Cateterismo Cardíaco/efeitos adversos , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , França , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Recidiva , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
3.
Medicine (Baltimore) ; 99(24): e20569, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541485

RESUMO

RATIONALE: Fat embolism syndrome with cerebral fat embolism, rarely observed at our neurology department, is often associated with long bone fractures. Its diagnosis is based on medical history and supportive imaging data and is usually not difficult. However, its pathogenesis remains poorly understood. PATIENT CONCERNS: A 46-year-old woman was urgently presented to a nearby hospital because of a femur fracture caused by an accident. She rapidly developed somnolence and was suspected to have fat embolism syndrome. DIAGNOSES: Due to patients history of trauma and supportive imaging data, she was diagnosed with fat embolism syndrome obviously. However, severe brain damage confused our understanding of the pathogenesis. The subsequent diagnosis of fat embolism syndrome with patent foramen ovale provided a reasonable explanation. INTERVENTIONS: Initially, we did not consider the fact that the patient had developed fat embolism syndrome and thus designed a comprehensive treatment program for fat embolism syndrome. Then the routine cardiac and vascular ultrasound screening were followed up, but patent foramen ovale was diagnosed unexpectedly, which led to a more aggressive treatment of brain injury. OUTCOMES: After relevant symptomatic treatment continued for nearly 3 months, an overall improvement was observed. Patients consciousness was restored but language disorders were left. LESSONS: Clinicians should consider patent foramen ovale as the embolization pathway, particularly in young and middle-aged patients with cerebral embolism because it is often mistaken for a rare situation.


Assuntos
Embolia Gordurosa/etiologia , Fraturas do Fêmur/complicações , Forame Oval Patente/complicações , Embolia Intracraniana/etiologia , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Pessoa de Meia-Idade
4.
Ann Intern Med ; 172(11): 717-725, 2020 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-32422058

RESUMO

BACKGROUND: Residual shunt is observed in up to 25% of patients after patent foramen ovale (PFO) closure, but its long-term influence on stroke recurrence currently is unknown. OBJECTIVE: To investigate the association of residual shunt after PFO closure with the incidence of recurrent stroke and transient ischemic attack (TIA). DESIGN: Prospective cohort study comparing stroke or TIA recurrence in patients with and without residual shunt after PFO closure. SETTING: Single hospital center. PARTICIPANTS: 1078 consecutive patients (mean age, 49.3 years) with PFO-attributable cryptogenic stroke who were undergoing percutaneous PFO closure were followed for up to 11 years. MEASUREMENTS: Residual shunt was evaluated by transthoracic echocardiography with saline contrast. Primary outcome was a composite of the first recurrent ischemic stroke or TIA after PFO closure. RESULTS: Compared with complete closure, the presence of residual shunt after PFO closure was associated with an increased incidence of recurrent stroke or TIA: 2.32 versus 0.75 events per 100 patient-years (hazard ratio [HR], 3.05 [95% CI, 1.65 to 5.62]; P < 0.001). This result remained robust after adjustment for important covariates, namely age; study period; device; presence of atrial septal aneurysm, hypertension, hyperlipidemia, diabetes, hypercoagulability, or hypermobile septum; and medication use (HR, 3.01 [CI, 1.59 to 5.69]; P < 0.001). Further stratification based on shunt size revealed that moderate or large residual shunts were associated with a higher risk for stroke or TIA recurrence (HR, 4.50 [CI, 2.20 to 9.20]; P < 0.001); the result for small residual shunts was indeterminate (HR, 2.02 [CI, 0.87 to 4.69]; P = 0.102). LIMITATION: Nonrandomized study with potential unmeasured confounding. CONCLUSION: Among patients undergoing PFO closure to prevent future stroke, the presence of residual shunt, particularly a moderate or large residual shunt, was associated with an increased risk for stroke or TIA recurrence. PRIMARY FUNDING SOURCE: National Institutes of Health.


Assuntos
Forame Oval Patente/complicações , Acidente Vascular Cerebral/etiologia , Ecocardiografia , Feminino , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Acidente Vascular Cerebral/epidemiologia
5.
Rinsho Shinkeigaku ; 60(6): 414-419, 2020 Jun 06.
Artigo em Japonês | MEDLINE | ID: mdl-32435046

RESUMO

A small centrum ovale infarct in the territory of the white matter medullary artery can be caused not only by embolism but also small-vessel disease. In our study, thorough screening for emboligenic diseases was performed, including the modality of transesophageal echocardiography (TEE), in patients with an acute, isolated, small (less than 1.5 cm) infarct in the centrum ovale. Of 79 patients enrolled in this study, 45 had emboligenic diseases, in whom a patent foramen ovale was detected in 29 patients, complicated aortic arch lesion in 15, atrial fibrillation in 6, occlusive carotid disease in 2, and others in 2. The majority (80%) of the emboligenic diseases were diagnosed by TEE. Therefore, TEE may be mandatory for the etiologic diagnosis of centrum ovale infarcts.


Assuntos
Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Ecocardiografia Transesofagiana , Embolia/complicações , Embolia/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/etiologia , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/complicações , Placa Aterosclerótica/diagnóstico por imagem
6.
J Stroke Cerebrovasc Dis ; 29(8): 104860, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32430239

RESUMO

BACKGROUND: Recent published trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) for preventing recurrent cryptogenic cerebrovascular events. However, the risk of recurrent cerebrovascular events (rCVEs) is up to 5.7%, and the etiology is unclear. OBJECTIVE: This study aimed to investigate the risk factors for rCVEs after closure of PFO during long-term follow-up. METHODS: In our center, 282 consecutive patients underwent PFO closure because of a cryptogenic cerebrovascular event between 2006 and 2014. Their Risk of Paradoxical Embolism (RoPE) score was calculated retrospectively. We followed up with the patients by telephone, using hospital records to identify those who suffered from rCVEs. Patients with rCVEs were matched with two control patients of the same sex and RoPE score without rCVEs who underwent PFO closure at approximately the same time. The patients with rCVEs and controls participated in a clinical examination, including contrast transthoracic echocardiography (TTE) and Holter electrocardiography, to investigate the possible cause of rCVEs compared with controls. RESULTS: Fourteen (5%) out of the 282 consecutive patients who underwent PFO closure suffered from rCVEs during a mean follow-up of 8.4 years (1.7 rCVEs per 100 patient-years). The median RoPE score of the patients was 7. Recurrent CVE occurred in 3.2 patients per 100 patient-years in patients with residual shunting compared with 0.8 patients per 100 patient-years in those without residual shunt. These patients were on antiplatelet treatment or without any effective anticoagulant treatment at the time rCVE occurred. The risk ratio of rCVEs in patients with residual shunting was 2.9-times higher than in patients without residual shunting (95% CI: 1.4-6.1) at follow-up visit. Four patients who had the BioSTAR device implanted suffered from an rCVE despite lack of residual shunting. CONCLUSIONS: This study indicates that residual shunting and choice of the device may be the major reasons for rCVEs.


Assuntos
Cateterismo Cardíaco/efeitos adversos , Transtornos Cerebrovasculares/etiologia , Forame Oval Patente/terapia , Adulto , Idoso , Anticoagulantes/uso terapêutico , Cateterismo Cardíaco/instrumentação , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/fisiopatologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Desenho de Prótese , Recidiva , Estudos Retrospectivos , Fatores de Risco , Dispositivo para Oclusão Septal , Fatores de Tempo , Resultado do Tratamento
8.
Open Heart ; 7(1): e001176, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32257245

RESUMO

Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.


Assuntos
Isquemia Encefálica/etiologia , Ecocardiografia Transesofagiana , Embolia/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Idoso , Antibacterianos/administração & dosagem , Anticoagulantes/administração & dosagem , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/prevenção & controle , Tomada de Decisão Clínica , Bases de Dados Factuais , Embolia/complicações , Embolia/terapia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/terapia , Cardiopatias/complicações , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/prevenção & controle
9.
Cerebrovasc Dis ; 49(2): 124-134, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32289794

RESUMO

BACKGROUND: Randomized-controlled trials (RCTs) reported a finding on the safety and efficacy of percutaneous patent foramen ovale (PFO) closure to prevent stroke recurrence. It showed that the Amplatzer (AMP) device appears to be superior to medical therapy (MT) in preventing strokes and episodes of atrial fibrillation (AF), than other devices. We performed a network meta-analysis (NMA) to evaluate the closure of PFO in preventing subsequent neurological events while investigating the results obtained by specific devices. METHODS: We searched 3 databases (MEDLINE, EMBASE, CENTRAL/CCTR) and identified 6 RCTs until March 2019. We performed an NMA and used pooled ORs. Analyses were done in NetMetaXL1.6-WinBUGS1.4. RESULTS: Six RCTs with 3,560 patients (mean age 45.2-46.2 years) were included in the present NMA. Depending on the device, 4 groups of patients were compared with MT: 1,889 patients undergoing PFO closure were significantly less likely to experience a stroke than 1,671 patients treated with MT (ORs 0.41; 95% Cr.I. 0.27-0.60 with fixed-effects model and ORs 0.22; 95% Cr.I. 0.05-0.70 with random-effects model). The patients with AMP showed a similar risk than those treated with Helex/Cardioform (HLX/CF) or with a group of 11 multiple devices. This suggests the equality between the 2 most currently used devices. When assessing TIA and, for the safety analysis, major bleeding, both models confirm no significant difference between any devices and MT. PFO closure increased the risk of new-onset AF: MT induces AF significantly less than all the devices. In favor of the AMP, there is a reduced number of cases of AF versus MT; however, no device superiority has been established in comparing HLX/CF and other devices in a random effect model. CONCLUSIONS: Our NMA provides evidence in favor of PFO closure with all the devices currently in use. We can conclude that these devices are better than MT, but not that 1 device is better than the rest in reducing stroke recurrences and AF episodes in the follow-up.


Assuntos
Cateterismo Cardíaco/instrumentação , Embolia Paradoxal/prevenção & controle , Forame Oval Patente/terapia , Embolia Intracraniana/prevenção & controle , Ataque Isquêmico Transitório/prevenção & controle , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Teorema de Bayes , Cateterismo Cardíaco/efeitos adversos , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Metanálise em Rede , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Adulto Jovem
10.
J Cardiovasc Med (Hagerstown) ; 21(4): 292-298, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32068573

RESUMO

INTRODUCTION: Atrial fibrillation ablation has historically been guided by fluoroscopy, with the related enhanced risk deriving from radiation. Fluoroscopy exposure may be confined to guide the transseptal puncture. Small sample size study presented a new methodology to perform a totally fluoroless atrial fibrillation ablation in the case of a patent foramen ovale (PFO). We evaluated this methodology in a large sample size of patients and a multicentre experience. METHODS AND RESULTS: Two hundred and fifty paroxysmal atrial fibrillation patients referred for first atrial fibrillation ablation with a CARTO3 electroanatomic mapping system were enrolled. In 58 out of 250 patients, a PFO allowed crossing of the interatrial septum, and a completely fluoroless ablation was performed applying the new method (Group A). In the remaining patients, a standard transseptal puncture was performed (Group B). Pulmonary vein isolation was achieved in all patients with comparable procedural and clinical outcomes at short- and long-term follow-up. CONCLUSION: The presence of a PFO may allow a completely fluoroless well tolerated and effective atrial fibrillation ablation. Probing the fossa ovalis looking for the PFO during the procedure is desirable, as it is not time-consuming and can potentially be done in every patient undergoing atrial fibrillation ablation.


Assuntos
Potenciais de Ação , Fibrilação Atrial/cirurgia , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Forame Oval Patente , Veias Pulmonares/cirurgia , Cirurgia Assistida por Computador , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Feminino , Forame Oval Patente/diagnóstico por imagem , Frequência Cardíaca , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Veias Pulmonares/fisiopatologia , Cirurgia Assistida por Computador/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 29(4): 104632, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32037269

RESUMO

AIMS: The REDUCE study demonstrated a reduction in the risk of recurrent stroke with patent foramen ovale closure and antiplatelet therapy compared to antiplatelet therapy alone. The clinicians were allowed to choose among aspirin, clopidogrel, or aspirin/dipyridamole with the expectation that all antiplatelet therapies would have similar efficacy in this population. We tested that presumption by comparing recurrent stroke rates among antiplatelet agents within the control arm of the trial. METHODS: We evaluated patients in REDUCE study who were randomized to the medical arm. The primary endpoint for this analysis was freedom from clinical ischemic stroke through at least 2 years of follow-up, to a maximum of 5 years. In the primary analysis, antiplatelet treatment was defined as the agent during the week prior to a recurrent stroke or last known contact. RESULTS: Of 223 patients in the medical treatment arm, the initial agent was aspirin 52%, clopidogrel 30%, and aspirin/dipyridamole 12%. Patients treated with aspirin were similar to those treated with alternatives, but were more likely to be enrolled in the United States. The last reported agent was aspirin alone in 55%, clopidogrel alone in 31%, aspirin/dipyridamole in 7%, and other/nothing/missing in 7%. Recurrent stroke rates were similar for all 3 antiplatelet regimens in unadjusted and adjusted analyses, with no overall difference among agents (P= .17). CONCLUSIONS: Among patients with patent foramen ovale-associated stroke who were managed medically, there were no differences among antiplatelet agents in the risk of recurrent stroke, though confidence intervals were wide.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/administração & dosagem , Dipiridamol/administração & dosagem , Forame Oval Patente/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Dipiridamol/efeitos adversos , Quimioterapia Combinada , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Intervalo Livre de Progressão , Estudos Prospectivos , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Adulto Jovem
14.
JACC Cardiovasc Interv ; 13(3): 293-302, 2020 02 10.
Artigo em Inglês | MEDLINE | ID: mdl-32029246

RESUMO

OBJECTIVES: This study sought to evaluate the long-term effect of transcatheter patent foramen ovale (PFO) closure on migraineurs with and without aura and examine the effect of residual right-to-left shunt. BACKGROUND: Many studies reported improvement in migraine symptoms after PFO closure, yet randomized trials failed to reach its clinical endpoints. METHODS: The study retrospectively analyzed data from 474 patients who underwent transcatheter PFO closure at Massachusetts General Hospital. Patients completed a migraine burden questionnaire at baseline and at follow-up. Migraine severity is reported as migraine frequency (days/month), average duration (min), and migraine burden (days × min/month). Improvement following closure was defined as complete abolishment of symptoms or >50% reduction in migraine burden. RESULTS: A total of 110 migraineurs who underwent PFO closure were included; 77.0% had aura and 23.0% were without aura, and 91.0% had a cryptogenic stroke. During long-term median follow-up of 3.2 (interquartile range: 2.1 to 4.9) years, there was a significant improvement in migraine symptoms in migraineurs with or without aura. Migraine burden was reduced by >50% in 87.0% of patients, and symptoms were completely abolished in 48%. Presence of aura was associated with abolishment of migraine (odds ratio: 4.30; 95% confidence interval: 1.50 to 12.30; p = 0.006). At 6 months after PFO closure, residual right-to-left shunt was present in 26% of patients. Absence of right-to-left shunt was associated with improvement in migraine burden by >50% (odds ratio: 4.60; 95% confidence interval: 1.30 to 16.10; p = 0.017). CONCLUSIONS: Long-term follow-up after transcatheter PFO closure was associated with significant improvement in migraine burden. Aura was a predictor of abolishing symptoms. Absence of residual right-to-left shunt was a predictor of significant reduction in migraine burden.


Assuntos
Cateterismo Cardíaco , Circulação Coronária , Forame Oval Patente/terapia , Transtornos de Enxaqueca/prevenção & controle , Adulto , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/etiologia , Transtornos de Enxaqueca/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Dispositivo para Oclusão Septal , Fatores de Tempo , Resultado do Tratamento
15.
Cerebrovasc Dis ; 49(1): 105-109, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32062661

RESUMO

BACKGROUND: In acute infarction patients, small cortical cerebellar infarctions (SCCI) on MRI (assessed on diffusion-weighted imaging, with SCCI often chronic and asymptomatic) are associated with acute cardioembolic infarction. In young cryptogenic stroke patients, patent foramen ovale (PFO) is thought to be a potential source of cardioembolic infarction. We hypothesize that SCCI on MRI would be associated with PFO in young cryptogenic stroke patients. METHODS: A total of 321 consecutive young (≤50 years) stroke patients admitted between January 2015 and July 2019 were screened. Of these patients, 287 patients had diagnostic work-up including early-phase MRI, intra- and extracranial vessel imaging, contrast transoesophageal or contrast transthoracic echocardiography, and ≥24 h ECG-monitoring. We retrospectively analyzed MRI scans of the 112 patients with cryptogenic stroke, including 63 with and 49 without PFO. Between both groups, we compared baseline characteristics (including cardiovascular risk factors and history of stroke), MRI characteristics of acute symptomatic infarction (cortical/subcortical localization, arterial territory, lesion number, and lesion size in case of subcortical infarction), atrial septum aneurysm (ASA) presence, and acute and chronic SCCI and non-SCCI lesions assessed on diffusion-weighted imaging. RESULTS: Groups with and without PFO were comparable in regard to performed vessel imaging and echocardiography modalities, baseline characteristics, and acute infarction characteristics, except for more frequent current smoking (67 vs. 44%, p = 0.022) and multiterritorial infarction (14 vs. 0%, p = 0.0024) and less frequent ASA (10 vs. 48%, p < 0.001) in the group without PFO. Risk of Paradoxal Embolism score was >6 in 76% of patients with PFO. SCCI was more frequent in patients with than without PFO (33 vs. 10%, p = 0.0061; OR 4.4, 95% CI 1.5-12.7), with chronic and asymptomatic SCCI in the vast majority of cases. No difference was observed for non-SCCI lesions. CONCLUSIONS: Chronic SCCI are strongly associated with PFO in young cryptogenic stroke patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04043559.


Assuntos
Infartos do Tronco Encefálico/diagnóstico por imagem , Cerebelo/irrigação sanguínea , Cerebelo/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Embolia Paradoxal/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Adulto , Fatores Etários , Infartos do Tronco Encefálico/etiologia , Doença Crônica , Bases de Dados Factuais , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco
16.
Cerebrovasc Dis ; 49(1): 1-9, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32097931

RESUMO

INTRODUCTION: It is still disputable whether specific morphometric features of the patent foramen ovale (PFO) may stratify patients by the related probability that a discovered PFO is incidental or stroke related. OBJECTIVE: We aimed to determine whether certain morphometrical characteristics of PFO are associated with an increased risk of cerebrovascular accidents, using a meta-analytical approach. METHODS: We performed a systematic review of electronic databases for studies that compared morphometric parameters of PFO assessed by transesophageal echocardiography (TEE) in subjects with cryptogenic cerebrovascular accidents (Group 1) and control (Group 2). Data were extracted and pooled into a meta-analysis. RESULTS: A total of 895 patients with PFO were reported (Group 1: 493, Group 2: 402). No difference was found in the PFO channel length (Group 1: 10.8 [8.6-12.9] mm vs. Group 2: 10.4 [9.1-11.7] mm), as well as in PFO height measured at rest (Group 1: 2.4 [1.5-3.3] mm vs. Group 2: 1.8 [1.4-2.2] mm). The PFO height measured during a Valsalva maneuver was larger in Group 1 (3.5 [2.8-4.1] mm) than in Group 2 (1.7 [1.2-2.2] mm). Also, the septal excursion distance was found to be larger in Group 1 (6.4 [5.1-7.8] mm) than in Group 2 (3.1 [1.8-4.4] mm). The risk of cerebrovascular accident was higher in patients with PFO and concomitant septal aneurysm (OR 4.00; 95% CI 2.63-6.09; p < 0.001) and with large right-to-left shunt PFO (OR 3.81; 95% CI 2.21-6.55; p < 0.001), no such relationship was found for the presence of a Eustachian valve or Chiari's network (OR 1.90; 95% CI 0.90-4.05; p = 0.094). CONCLUSIONS: The TEE may help in identifying PFO that are of high risk of cerebrovascular accident. Greater PFO height during a Valsalva maneuver, larger septal excursion distance, concomitant atrial septal aneurysm, and large right-to-left shunt are associated with stroke-related PFOs.


Assuntos
Ecocardiografia Transesofagiana , Forame Oval Patente/diagnóstico por imagem , Forame Oval/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Feminino , Forame Oval/anormalidades , Forame Oval Patente/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Manobra de Valsalva , Adulto Jovem
19.
Ann Vasc Surg ; 66: 668.e5-668.e10, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31904517

RESUMO

BACKGROUND: Paradoxical embolism is the translocation of a thrombus originating in the systemic venous circulation into the arterial circulation through a cardiac defect, most commonly a patent foramen ovale (PFO). PFO exists in 15-35% of the adult population. The most common manifestation is cerebrovascular accident; acute limb ischemia is much rarer. METHODS: A 67-year-old woman with multiple confounding risk factors for hypercoagulability presented with grade IIb left lower limb ischemia secondary to thromboembolism through a previously silent PFO. Management included urgent embolectomy, prophylactic fasciotomy, postoperative anticoagulation, and PFO closure. A systematic literature review of PFO-mediated acute limb ischemia was performed to identify the patient populations most commonly affected, the anatomic distribution of emboli, and patient management. RESULTS: Forty-three reports including 51 patients with first-time PFO-mediated paradoxical embolism were identified. Fifty-one percent were men, and the average age at presentation was 54 years. Multiple limbs were affected in 14 patients (27.5%), and a propensity for the lower limbs (72%) and left-sided circulation (82%) was noted. Deep venous thromboembolism was identified in 36 patients (71%). Immediate anticoagulation was instituted in 31 patients. Embolectomy and/or fibrinolysis were performed in 45 patients (88%). CONCLUSIONS: Acute limb ischemia is a rare manifestation of PFO-mediated paradoxical embolism that requires a high index of suspicion for diagnosis. Middle-aged individuals appear to be more commonly affected, and acute limb ischemia most often occurs in the lower limbs and left-sided circulation, with the potential to affect multiple extremities simultaneously. Prompt identification and surgical embolectomy with prophylactic fasciotomy can facilitate successful outcomes. Perioperative management should include anticoagulation and may include workup with echocardiography, duplex ultrasound, and hypercoagulability testing.


Assuntos
Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Isquemia/etiologia , Doença Arterial Periférica/etiologia , Doença Aguda , Idoso , Anticoagulantes/uso terapêutico , Embolectomia , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/terapia , Fasciotomia , Feminino , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/terapia , Humanos , Isquemia/diagnóstico por imagem , Isquemia/terapia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/terapia , Terapia Trombolítica , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA