scholarly journals Right-to-left shunt and the hypercoagulable state: does paradoxical embolism play a role in patients with antiphospholipid syndrome and stroke?

2012 ◽  
Vol 70 (8) ◽  
pp. 578-582 ◽  
Author(s):  
Laura Nicoleti Zamproni ◽  
Viviane Flumignan Zétola ◽  
Marcos Christiano Lange
Keyword(s):  
Antiphospholipid Syndrome ◽  
Transcranial Doppler ◽  
High Intensity ◽  
Patent Foramen Ovale ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Contrast Enhanced ◽  
Significant Difference ◽  
Stroke Group ◽  
History Of

OBJECTIVE: Patent foramen ovale is associated with paradoxical embolism (PE) and stroke. Hypercoagulable states, such as antiphospholipid syndrome (APS), can exacerbate PE by increasing clot formation. The aim of this study was to verify whether patients with APS and stroke present a right-to-left shunt (RLS) with greater frequency than patients with APS but without stroke. METHODS: Fifty-three patients with APS were tested for RLS using contrast-enhanced transcranial Doppler (cTCD): 23 patients had a history of stroke (Stroke Group) and 30 had no history of stroke (No-stroke Group). RESULTS: cTCD was positive in 15 patients (65%) from the Stroke Group and in 16 patients (53%) in the No-stroke Group (p=0.56). The proportion of patients with a small RLS (<10 high-intensity transient sign or HITS) and a large RLS (>10 HITS) was similar between the groups without significant difference. CONCLUSIONS: Our data do not support the theory that paradoxical embolism may play an important role in stroke in APS patients.

Abstract WP214: Transcranial Color Coded Sonography versus Transcranial Doppler for the Detection of Right-to-left Shunt and Patent Foramen Ovale in Young Patients With Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Milena C Libardi ◽  
Millene R Camilo ◽  
Soraia R Fabio ◽  
Rui Kleber V Martins Filho ◽  
Letícia J Rocha ◽  
...  
Keyword(s):  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Young Patients ◽  
Positive Likelihood Ratio ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Contrast Enhanced ◽  
Hospital Patients ◽  
Bubble Test ◽  
Kappa Agreement

Introduction: Patent Foramen Ovale (PFO) is the most common right-to-left shunt (RLS) and is often found in young patients with stroke related to paradoxical embolism. Contrast-Enhanced Transesophageal Echocardiography (TEE) is considered a gold standard to visualize PFO. Transcranial Doppler (TCD) with bubble test is often used to detect RLS with good correlation to TEE for the diagnostic of PFO. More recently, Transcranial Color Coded Sonography (TCCS) which included B-mode and color coded imaging has overcome TCD in many clinical applications but the accuracy of TCCS for detection of RLS and PFO has not been systematically evaluated. Hypothesis: To determine if the TCCS is an accurate tool to identify both PFO and RLS. Methods: We investigate 106 patients with ischemic stroke under 55 years-old admitted from 2012 to 2014 in a tertiary academic hospital. Patients were evaluated with TEE, TCD and TCCS, and all exams included a saline bubble test. The examiners were blinded for the other tests results. Kappa agreement was calculated inter-examiners for TCCS and TCD. Accuracy of TCCS was calculated in comparison to TEE. Results: We detected a RLS in 54 (50.9%) patients (age mean 43.9 ± 8.2) with kappa agreement 0.92 (95%CI 0.78-1.0) when performed TCCS and TCD. TEE and TCSS were positive in 23/98 (23.4%) and TEE did not reveal contrast in 20/98 (20.4%). In 30 (28.3%) patients only TEE revealed a PFO. TCSS had a sensitivity of 88.4% (95%CI 0.68-0.97), specificity of 72.2% (95%CI 0.60-0.81) and positive likelihood ratio of 3.18 (2.14-4.73) of the diagnosis of PFO. Conclusion: TCCS and TCD had an excellent agreement. TCCS has a good accuracy for the detection of PFO and RLS in young patients with stroke.

Is Migraine Associated with Right-to-Left Shunt a Separate Disease? Results of the SAM Study

Cephalalgia ◽  
2008 ◽  
Vol 28 (4) ◽  
pp. 360-366 ◽  
Author(s):  
GP Anzola ◽  
G Meneghetti ◽  
C Zanferrari ◽  
A Adami ◽  
L Dinia ◽  
...  
Keyword(s):  
Family History ◽  
Observational Study ◽  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Genetic Linkage ◽  
Personal History ◽  
Coagulation Disorders ◽  
Foramen Ovale ◽  
History Of ◽  
Pfo Closure

Migraine with aura (MA) is associated with the persistence of patent foramen ovale (PFO) in about 50% of cases, and migraineurs tend to have larger shunts than controls, suggesting that right-to-left shunt (RILES) determined by PFO could play a role in triggering migraine attacks. Moreover, some preliminary reports have suggested that PFO closure may give relief to both migraine and aura attacks. The aim of this study was to clarify if shunt-associated migraine (SAM) has clinical features that allow a distinction from shunt-unrelated migraine (SUM), in a prospective, multicentre, observational study (SAM study). We enrolled consecutive MA patients, who underwent a structured, standardized questionnaire for family and personal history and for detailed migraine features. All were systematically screened for RILES with transcranial Doppler, and for coagulation disorders. Overall, 460 patients were included; the SUM and SAM classes comprised 58% and 42% of patients, respectively. SAM patients were significantly younger (34.1 ± 10 vs. 37.1 ± 11 years), had a more frequent family history of migraine (76% vs. 66%) and a higher frequency of sensory symptoms of aura (51% vs. 41%); by contrast, there was a lesser association of SAM with other cardiac abnormalities and with coagulation disorders. The SAM study suggests that the effect of RILES on migraine features is not relevant. The higher family history of migraine in SAM suggests a possible genetic linkage between migraine and RILES.

scholarly journals Transcranial Doppler for patent foramen ovale screening: is there a good correlation with transesophageal echocardiography?

2008 ◽  
Vol 66 (4) ◽  
pp. 785-789 ◽  
Author(s):  
Marcos Christiano Lange ◽  
Viviane Flumignan Zétola ◽  
Admar Moraes de Souza ◽  
Élcio Juliato Piovesan ◽  
Juliano André Muzzio ◽  
...  
Keyword(s):  
Positive Predictive Value ◽  
Transcranial Doppler ◽  
Predictive Value ◽  
Screening Test ◽  
Patent Foramen Ovale ◽  
Foramen Ovale ◽  
Negative Results ◽  
Contrast Enhanced ◽  
Group 2 ◽  
Group 1

Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in patent foramen ovale (PFO) patients. AIM: To evaluate cTCD for PFO screening comparing it to cTEE. METHOD: 45 previous cTCD performed for PFO diagnosis and correlated its findings with cTEE. Patients were submitted to a cTCD standardized technique and were divided in two groups according to RLS: Group 1, patients with a positive RLS and Group 2 when RLS was negative. RESULTS: 29 (65%) patients were included in group 1 and 16 (35%) in group 2. PFO confirmation by cTEE was performed in 28 (62%) patients. cTCD had a 92.85% sensitivity, 82.35% specificity, 89.65% positive predictive value and 87.5% negative predictive value when compared to cTEE for PFO diagnosis. CONCLUSION: Standardized technique cTCD allows for RLS visualization in PFO patients with a good correlation with cTEE and can be used as a screening test before cTEE.

Abstract 2922: Patent Foramen Ovale Is A Cause Of Ischemic Stroke In Patients With Antiphospholipid Syndrome

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Yoshiaki Shimada
Keyword(s):  
Ischemic Stroke ◽  
Antiphospholipid Syndrome ◽  
Patent Foramen Ovale ◽  
Multiple Logistic Regression Analysis ◽  
Cryptogenic Stroke ◽  
Control Group ◽  
Atrial Septal Aneurysm ◽  
Foramen Ovale ◽  
Stroke Patients ◽  
Significant Difference

Background: The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, and can be an independent risk factor for a first-ever ischemic stroke especially in young female patients. Patent foramen ovale (PFO) has been established as a cause of cryptogenic stroke. Atrial septal aneurysm (ASA) is associated with PFO. Until recently, the precise pathophysiology of APS as causing ischemic stroke has been essentially unknown. In the present study, we investigated the relationship between APS and potential embolic sources including PFO and ASA using transesophageal echocardiography (TEE). Methods: This study was a retrospective case series design. From July 2006 to June 2008, 120 patients with ischemic stroke who admitted to Juntendo University Hospital underwent TEE. In this study period, consecutive ischemic stoke patients diagnosed as APS based on the modified Sapporo criteria were enrolled and classified into APS group. Controls were selected among age- and gender-matched stroke patients without APS who also underwent TEE. We assessed clinical characteristics and presence of embolic sources including PFO and atrial septal aneurysm (ASA) between APS and Control groups. Results: Nine of ischemic stroke patients with APS and 41 controls were included. Primary APS was present in one patient (11.1%) of the APS group, and APS with SLE were found in eight patients (88.9%). There is no significant difference in age, risk factors for ischemic stroke, and MRI findings between two groups. The prevalence of PFO and ASA were significantly higher in APS group compared to Control group (89% vs 41%, P=0.027; 67% vs 20%, P=0.015, respectively). C reactive protein was relatively higher in APS group. Multiple logistic regression analysis showed that PFO (OR: 13.71; 95% CI: 1.01 to 185.62; P=0.049) and ASA (OR: 8.06; 95% CI: 1.17 to 55.59; P=0.034) were independently associated with the APS group. Conclusion: Atrial septal abnormalities including PFO and ASA are strongly associated with APS group, and could be potential embolic sources in ischemic stroke patients with APS.

Abstract TMP13: Baseline DWMRI Characteristics In Patients With Cryptogenic Stroke And Patent Foramen Ovale: Results From The Closure I Trial

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Richard Jung ◽  
Benny Kim ◽  
Joseph Massaro ◽  
Anthony J Furlan
Keyword(s):  
Patent Foramen Ovale ◽  
Cox Regression ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Patient Characteristics ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Anterior Circulation ◽  
Significant Difference ◽  
Multivariate Proportional Hazard

Background: Cryptogenic stroke may have several etiologies including paradoxical embolism through a patent foramen ovale (PFO). A cardiac source of embolism may be suggested by multiple infarcts, sometimes hemorrhagic, in different vascular distributions or a cortical wedge shaped infarct. We report the baseline diffusion weighted MRI (DWMRI) characteristics in patients with cryptogenic stroke and a patent foramen ovale (PFO) from the CLOSURE I trial. Methods: CLOSURE I compared device closure versus medical therapy for secondary prevention in patients with cryptogenic TIA or stroke and a PFO. Of 909 patients randomized, 562 patients demonstrated acute infarcts on baseline DWMRI and are included in this analysis. Multivariate proportional hazard Cox regression compared imaging subgroups with remaining randomized patients Results: Single infarcts were found in 62% of patients. Of these, 61% were anterior circulation, 30% posterior, and 8.5% were of uncertain territory. Of the anterior circulation infarcts, 40% were cortical, 36% subcortical, and 24% affected both the cortical and subcortical regions. Of the posterior circulation infarcts, 45% were thalamic or cerebellar. Of 562 patients, 18.5% had a single subcortical lesion <1.5cm in diameter and met the radiological definition of an acute lacunar infarct. Multiple infarcts were found in 38%. Infarcts in a single vascular territory were found in 23%, often in the anterior circulation (66%). Infarcts in multiple vascular territories were found in 15%. Hemorrhagic infarction was present in 9%. Adjusting for patient characteristics, no significant difference in 2 year rate of TIA, stroke or death was found compared to remaining randomized patients. Discussion: The specificity of infarct patterns for embolism in patients with cryptogenic stroke and a PFO is uncertain. We found no significant relationship between lacunar or subcortical infarction and the risk of recurrent TIA or stroke. Baseline infarct patterns on DWMRI in patients with cryptogenic stroke and PFO may not be useful in predicting recurrent stroke risk or determining best prevention therapy.

scholarly journals A Study on the Relationship Between Patent Foramen Ovale and White Matter Lesions in Migraine Patients

2021 ◽  
Author(s):  
Junyan Huo ◽  
Mengxia Wan ◽  
Nan Li ◽  
Juan Wang ◽  
Xiao Cai ◽  
...  
Keyword(s):  
White Matter ◽  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
White Matter Lesions ◽  
Primary Headache ◽  
Transcranial Doppler Ultrasound ◽  
Foramen Ovale ◽  
Significant Difference ◽  
The Difference ◽  
The Relationship

Abstract Background Migraine is a common clinical primary headache with unclear aetiology. In recent years, studies have shown that migraine is related to patent foramen ovale, and some patients with migraine have white matter lesions. However, the relationship among the three is unclear.Objective To explore the characteristics of white matter lesions (WMLs) in migraine patients with patent foramen ovale and to predict the occurrence of patent foramen ovale through magnetic resonance imaging (MRI) characteristics in patients with migraine.Methods Seventy-seven patients clinically diagnosed with migraine were examined by transcranial Doppler ultrasound (cTCD) and MRI. The patients were grouped according to the presence of WMLs, with matching by age, sex, hypertension, diabetes, PFO and other characteristic data. We observed the MRI fluid attenuation inversion recovery sequence (FLAIR) image and compared and analysed the difference in WMLs between the PFO-positive group and the PFO-negative group.Results There were 42 cases and 35 cases of migraine with and without WMLs, respectively. A statistically significant difference in near-cortical WMLs with PFO in migraine patients was observed (P=0.001). Logistic regression analysis adjusted by age, sex, hypertension and diabetes identified PFO status as the sole determinant for the presence of near-cortical WMLs (OR = 0.14; 95%CI 0.045–0.421; p < 0.001)Conclusion Near-cortical white matter lesions in migraine patients are related to PFO. Transcranial Doppler ultrasonography may reveal more PFO in patients with migraine and near-cortical WMLs.

scholarly journals Detection of Patent foramen Ovale with Contrast Enhanced Transcranial Doppler at Divers

2019 ◽  
Vol 67 (2) ◽  
pp. 93-102
Author(s):  
Krzysztof Dziewiatowski ◽  
Piotr Siermontowski
Keyword(s):  
Left Atrium ◽  
Sensitivity And Specificity ◽  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Decompression Sickness ◽  
Adult Population ◽  
Venous Blood ◽  
Arterial System ◽  
Foramen Ovale ◽  
Contrast Enhanced

Abstract Patent foramen ovale (PFO) is a condition present in 25% of the adult population. It is a remnant of fetal foramen ovale which allows blood to pass from the right to the left atrium, bypassing the fetal lungs. In majority adults it does not have any clinical significance, but in some people it may allow shunting of venous blood into the left atrium (right – left – shunt or RLS), circumventing the lung filter, especially during sneezing, cough, lifting heavy equipment. Is such case, PFO may be a route for venous emboli or gas bubbles from veins to the arterial system. It is known as a paradoxical embolism and may be cause of ischaemic stroke or neurologic decompression sickness (DCI), inner-ear DCI and cutis marmorata. Transesophageal echocardiography is considered as a reference standard in detection of intracardial shunts. Its sensitivity and specificity ranges between 94%-100%. However, TEE is an invasive examination with potentially serious side effects. An alternative examination in RLS detection is contrast enhanced Transcranial Doppler (the bubble study or c-TCD). In comparison to TEE, Transcranial Doppler is not invasive, relatively not expensive and save technique. With its high sensitivity and specificity in detection of PFO, 97% and 93% respectively, it may improve detection of RLS and allow to conduct screening examination for PFO in divers.

scholarly journals Safety and efficacy of endovascular patent foramen ovale closure: the first results of a Russian multicenter study

2020 ◽  
Vol 12 (6) ◽  
pp. 26-32
Author(s):  
D. V. Ognerubov ◽  
A. S. Tereshchenko ◽  
A. N. Samko ◽  
G. К. Arutyunyan ◽  
O. A. Sivakova ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Young Patients ◽  
Paradoxical Embolism ◽  
Atrial Septal Aneurysm ◽  
Foramen Ovale ◽  
History Of ◽  
Pfo Closure

Patent foramen ovale (PFO) is detectable in more than 25% of the adult population and is generally clinically insignificant. However, it can be a cause of paradoxical embolism in some cases. Randomized trials indicate that endovascular PFO closure in patients with a history of cryptogenic stroke is an effective method for the secondary prevention of catastrophic brain damage.Objective: to study the safety and efficiency of endovascular PFO closure in young patients with a history of cryptogenic stroke.Patients and methods. Sixty-two patients, including (22 males and 40 females) women, underwent percutaneous PFO closure in May 2018 to March 2020. The patients' mean age was 37.4±7.6 years. The inclusion criteria were a prior cryptogenic ischemic stroke lasting less than 12 months and PFO with a high risk for paradoxical embolism (PFO concurrent with atrial septal aneurysm or hypermobility; PFO, ≥2 mm size; the presence of the Chiari network and/or the Eustachian valve).Results and discussion. The technical success of the operation was achieved in all cases. In 50 (80.6%) patients, the right chamber of the heart was completely isolated from the left one in the first 3 months. During the first year, the atria were also completely isolated in 10 (16.1%) patients. A left-to-right shunt persisted in 2 (3.2%) patents 12 months later. Two patients were found to have main procedural complications: one had perioperative atrial fibrillation and the other had pseudoaneurysm formation at the puncture site.Conclusion. Endovascular PFO closure is a safe and effective operation for the secondary prevention of recurrent ischemic stroke. In our study, blood shunting through the PFO was stopped in 96.6% of patients at less than 6 months after surgery, which suggests that there is a rapid and effective reduction in the risk of paradoxical embolism.

scholarly journals Detecting a patent foramen ovale by transcranial doppler sonography (tcd)

1996 ◽  
Vol XXVIII (3-4) ◽  
pp. 23-25
Author(s):  
М. Salaschek ◽  
R. Winkel
Keyword(s):  
Cerebral Ischemia ◽  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Doppler Sonography ◽  
Saline Solution ◽  
Transcranial Doppler Sonography ◽  
Unknown Origin ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Insignificant Difference

In patients with cerebral ischemia of unknown origin, paradoxical embolism must be considered as one of the possible causes, if there is an abnormal right-to- left shunt. The most likely site of transmission is a persisting patent foramen ovale (PFO), which is found in approximately 30% of adult persons in autopsy studies. Using transcranial Doppler sonography (TCD) and an agitated saline solution as an inexpensive and readily available contrast medium, probably all clinically important right-to-left shunts can be detected. In our department we examined 215 patients within the last 5 years, 30% of which had an abnormal right-to-left shunt with insignificant difference between 10 and 69 years of age.

scholarly journals Is the patent foramen ovale closure the best option?

2012 ◽  
Vol 70 (12) ◽  
pp. 934-938
Author(s):  
Viviane Flumignan Zetola ◽  
Melissa Castello Branco e Silva ◽  
Marcos Christiano Lange ◽  
Juliano Andre Muzzio ◽  
Edison Matos Novak ◽  
...  
Keyword(s):  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Valsalva Maneuver ◽  
Foramen Ovale ◽  
Contrast Enhanced ◽  
Number Of Patients ◽  
Study Results ◽  
Before And After ◽  
One Year ◽  
Pfo Closure

Patent foramen ovale (PFO) closure is indicated in some cases to protect patients against embolic events. The aim of this study was to certify that the method of PFO closure to prevent microemboli (MES) is reliable, using contrast enhanced transcranial Doppler (cTCD) as a diagnostic and follow-up tool. METHODS: cTCD was performed before and after PFO closure in 20 patients. Results obtained a minimum of 12 months after the procedure were analyzed in this study. RESULTS: After the procedure, 14 patients (82%) showed no microemboli in cTCD at rest, but after provocative Valsalva maneuver (VM) microembolic phenomenon were still detected in 14 (70%): 7 (35%) <10 MES, 3 (15%) 10-20 MES and 4 (20%) had more than 20 MES ("curtain"). Only six of the total patients presented no MES in both resting and VM. CONCLUSION: These results showed a large percentage of patients with MES detection in a bubble study with transcranial Doppler more than one year after the procedure of PFO closure, showing right-to-left residual shunting. Despite the small number of patients, this study provides important data about this therapeutic decision.

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