Diagnostic analysis of cTTE for patent foramen ovale and the value of combined NLR monitoring in predicting cryptogenic stroke / 中国医师杂志

Objective:To investigate the diagnostic value of transthoracic echocardiographic contrast-enhanced ultrasound (cTTE) in patent foramen ovale (PFO) and the value of combined neutrophil to lymphocyte ratio (NLR) in predicting cryptogenic stroke.Methods:A total of 120 suspected PFO patients admitted to the Affiliated Hospital of Jining Medical College from January 2021 to December 2021 were selected and examined by cTTE and transesophageal echocardiography (TEE) to analyze the diagnostic value of cTTE in PFO. The clinical data and cTTE parameters of PFO patients with and without cryptogenic stroke were analyzed.Results:A total of 69 patients with PFO were confirmed. Among the 69 patients, 23 patients with cryptogenic stroke and 46 patients without cryptogenic stroke were confirmed by magnetic resonance imaging (MRI). The value of cTTE in the diagnosis of PFO was high: the sensitivity, accuracy and negative predictive value of cTTE under Valsalva motion in the diagnosis of PFO were 95.65%, 91.67% and 93.62%, respectively, which were significantly higher than that of cTTE at rest (all P<0.05). The NLR, the proportion of large shunt of PFO right to left shunt (PFO-RLS), the inlet width of patent foramen ovale (PFO) and the outlet width of PFO in patients with PFO complicated with cryptogenic stroke were (3.01±0.89), 43.48%(10/23), (2.54±0.65)mm and (1.51±0.35)mm, respectively, which were significantly higher than those in patients without cryptogenic stroke (all P<0.05). Logistic regression analysis showed that NLR and the degree of PFO-RLS shunt were the influencing factors of patients with PFO complicated with cryptogenic stroke (both P<0.05). The area under the Receiver operating characteristic (ROC) curve predicted by NLR combined with PFO-RLS shunt was 0.905, which was significantly higher than that predicted by NLR and PFO-RLS shunt alone (all P<0.05). Conclusions:cTTE has a good value in the diagnosis of PFO, and cTTE combined with NLR has a certain application value in predicting PFO complicated with cryptogenic stroke.

Scanning of paroxysmal atrial fibrillation as an etiological risk factor in patients with acute ischemic stroke: prospective study

Abstract BACKGROUND: Prevention of recurrence of stroke depends on recognition of the underlying mechanism of ischemia. OBJECTIVE: To screen patients who were hospitalized with diagnosis of acute ischemic stroke in terms of atrial fibrillation (AF) with repeated Holter electrocardiography recordings. DESIGN AND SETTING: Prospective study conducted at Konya Education and Research Hospital, Turkey. METHODS: Patients with a diagnosis of acute ischemic stroke, without atrial fibrillation on electrocardiography (ECG), were evaluated. Their age, gender, histories of previous ischemic attack, occurrences of paroxysmal atrial fibrillation (PAF) and other risks were assessed during the first week after acute ischemic stroke and one month thereafter. ECG recordings were obtained from 130 patients through 24-hour ambulatory Holter. Patients without PAF attack during the first Holter were re-evaluated. RESULTS: PAF was detected through the first Holter in 33 (25.4%) out of 130 acute ischemic stroke patients. A second Holter was planned for 97 patients: 53 (54.6%) of them could not attend due to COVID-19 pandemic; while 44 (45.3%) patients had the second Holter and, among these, 4 (9.1%) had PAF. The only parameter associated with PAF was older age. Four (10.8%) of the 37 patients with PAF had also symptomatic carotid stenosis. CONCLUSIONS: Detecting the presence of PAF by screening patients with no AF in the ECG through Holter ECG examinations is valuable in terms of changing the course of the treatment. It should be kept in mind that the possibility of accompanying PAF cannot be ruled out in the presence of other factors that pose a risk of stroke.

Clinical characteristics and outcomes of patients with COVID-19 infection and acute ischemic stroke at Eka Kotebe general hospital in Addis Ababa, Ethiopia

BACKGROUND: Acute ischemic stroke has been reported to occur in a significantly higher number of COVID-19 patients as compared to healthy controls with variable proposed pathophysiologic mechanisms. To our knowledge, sufficient data regarding this subject is lacking in Ethiopia and the African continent at large. In this case series, we report the clinical characteristics and management of 5 cases with COVID-19 infection and acute ischemic stroke to shed light on the diagnostic and therapeutic challenges in resource-limited setups. METHODS: This is a case series including data collected from the medical records of 5 participants with confirmed RT-PCR positive COVID-19 infection and radiologically confirmed acute ischemic stroke, admitted at Eka Kotebe General Hospital Intensive Care Unit (ICU) in Addis Ababa, Ethiopia from June 10, 2020, to November 04, 2020. RESULTS: Cryptogenic stroke was documented in 4/5 participants included in this series with the most common vascular risk factors identified for stroke being hypertension and diabetes mellitus. The median time from onset of COVID-19 symptoms to the identification of stroke was 07 days. Two fifth of the participants in this series died during their ICU admission with the immediate cause of deaths reported to be related to the severe COVID-19 infection but not stroke. CONCLUSION: Cryptogenic stroke was documented in 4/5 patients in this series despite the presence of vascular risk factors for other stroke subtypes. The overall prevalence, subtypes, and outcomes of stroke in COVID-19 patients in Ethiopia and the African continent as a whole needs additional research to elucidate the local burden of the disease and define the predominant pathophysiologic mechanisms for stroke in COVID-19 in the region

Latest diagnosis and treatment strategy for patent foramen ovale and cryptogenic stroke / 中国实用内科杂志

The diagnosis and treatment of cryptogenic stroke(CS) has always been the direction of clinical researchers, and its relationship with patent foramen ovale(PFO) has become a research hotspot in recent years. It is essential to correctly understand its cause and carry out targeted treatment. This article discusses the relationship between PFO and CS and the latest diagnosis and treatment strategies, aiming to standardize and guide PFO closure, so that the true CS patients with PFO can benefit from the closure treatment.

Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: Single operator experience in 110 consecutive patients

Objective Percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) is routinely performed under general anesthesia or deep sedation and use of transesophageal (TEE) or intracardiac echocardiography, incurring longer duration and higher cost. We have used a simplified, economical, fluoroscopy-only guided approach with local anesthesia, and herein report our data. Methods The study includes 112 procedures in 110 patients with PFO (n = 75) or ASD (n = 35), with use of an Amplatzer occluder, heparin and prophylactic antibiotics. Balloon sizing guided ASD-device selection. All patients received aspirin and clopidogrel for 6 months, when they all underwent TEE. Results All PFOs but one (98.7%) and all (100%) ASDs were successfully closed with only one complication (local pseudoaneurysm). At the 6-month TEE, there was no residual shunt in PFO patients, but 2 ASD patients had residual shunts. During long-term (4.3-year) follow-up, no stroke recurrence in PFO patients, and no other problems were encountered. Among 54 patients suffering from migraine, symptom relief or resolution was reported by 45 (83.3%) patients. Conclusion Percutaneous placement of an Amplatzer occluder was safe and effective with use of local anesthesia and fluoroscopy alone. There were no recurrent strokes over >4 years. Migraine relief was reported by >80% of patients.

Clinical characteristics of patients with cryptogenic stroke and patent foramen ovale / 第二军医大学学报

Objective To investigate the clinical characteristics of patients with cryptogenic stroke and patent foramen ovale (PFO). Methods The clinical features, imaging findings and therapeutic outcomes of 51 patients with cryptogenic stroke and PFO, who received treatment in Stroke Center of Changhai Hospital of Navy Medical University (Second Military Medical University) between Sep. 2013 and Jan. 2018, were retrospectively analyzed. Results Of the 51 cases, 41 were male and 10 were female; and the mean age was (53.92±14.83) years (ranging from 21 to 84 years). Diffusion weighted imaging (DWI) showed that 46 patients developed new infarction including 20 cases (43.5%) of single lesion and 26 cases (56.5%) of multiple lesions, of which 15 cases (57.7%) involved single arterial territory and 11 cases (42.3%) involved two or more arterial territories (4 cases of bilateral anterior circulation, and 7 cases of both the anterior and posterior circulations). Thirty-seven patients underwent contrast-enhanced transcranial Doppler (cTCD) examination, which showed that 31 cases (83.8%) had microbubble sign (air microbubble emboli of 4 cases looked like raindrops or curtains). In 50 patients undergoing transesophageal echocardiography (TEE) examination, 49 cases (98.0%) were accompanied with PFO. Nine patients received intravenous thrombolysis. In secondary prevention, 18 patients received single antiplatelet therapy, 12 dual antiplatelet therapy, 8 anticoagulation therapy, and 13 PFO closure+single antiplatelet therapy. One patient with single antiplatelet therapy had recurrent ischemic stroke, 2 patients with dual antiplatelet therapy had recurrent ischemic stroke, and the patients with percutaneous closure of PFO had no recurrent stroke. Conclusion The infarction of cryptogenic stroke with PFO involves single or multiple arterial territories, cTCD and TEE have high positive diagnosis rate for PFO, and the patients with selective antithrombotic therapy and PFO closure have a low risk of recurrent stroke.

The clinical significance of plasma D-dimer levels in cryptogenic stroke with occult systemic malignancy patients / 中国神经精神疾病杂志

Objective This study aimed to investigate the clinical characteristics of cryptogenic stroke as the first manifestation of occult systemic malignancy (OSM) and to determine whether plasma D-dimer levels and lesions in multiple vascular regions could predict occult systemic malignancy in patients with cryptogenic stroke. Methods Data from 83 patients including 9 patients with OSM and 74 patients without OSM were extracted from the stroke database of Beijing Shijitan Hospital. Clinical variables were analyzed between cryptogenic stroke patients with OSM and without OSM. The relationshiop between plasma D-dimer levels or lesions in multiple vascular regions and OSM were analyzed by multiple logistic regression analysis. Results Compare to patients without OSM, patients with OSM was older (66.8± 7.5 vs.56.4±15.7,P=0.004)and had lower hemoglobin levels (127.9±19.8 vs.143.6±17.7,P=0.015),higher conut score [3(1,3) vs. 1(0,2), P=0.011], higher plasma D-dimer levels (77.7% vs. 13.5%, P<0.001) and more common lesions in multiple vascular regions(100% vs.23.0%, P<0.001).Multiple logistic regression analysis revealed that high plasma D-dimer levels are independent risk factors for OSM (OR=26.250,95%CI:3.041-226.604,P=0.003).Conclusions Patients with OSM are elderly people and have poorer nutritional status, higher plasma D-dimer levels and more common lesions in multiple vascular regions. High plasma D-dimer levels can be useful to predict OSM in patients with cryptogenic stroke at earlier stages.

Correlation between RoPE score and right-to-left shunt severity in patients with cryptogenic stroke / 西安交通大学学报(医学版)

Objective To compare the clinical features between cryptogenic stoke(CS)with and without right-to-left shunt(RLS)so as to determine whether shunt severity determined by control-enhanced transcranial Doppler(c-TCD)is correlated with the risk of paradoxical embolism(RoPE)score.Methods We made a retrospective analysis of clinical characteristics of 138 CS patients with and without RLS admitted to our department between January 2014 and November 2016.For patients documented by c-TCD,we evaluated whether there was a correlation between RLS severity and RoPE score. RLS was diagnosed by c-TCD and contrast-enhanced transthoracic echocardiography(c-TTE).We compared every modality for detecting RLS with and without Valsalva maneuver.For patients found with RLS in c-TCD and c-TTE,we judged whether there was an agreement in grading RLS between two modalities.Results For patients with CS,shunt severity by c-TCD was positively correlated with RoPE score(r= 0.26,P= 0.05).The clinical features were different between CS patients with RLS and without RLS.Compared with the positive results of c-TCD and c-TTE at rest,the positive rate was higher in Valsalva maneuver,respectively(P＜0.01).There was a moderate agreement between shunt grades identified by the two techniques(Kappa=0.428).Conclusion There is a positive correlation between RoPE score and RLS severity determined by c-TCD in CS patients.Valsalva maneuver can significantly increase the positive rate of RLS detected by c-TCD and c-TTE.

Research progress in treatment of cryptogenic stroke associated with patent foramen ovale / 解放军医学杂志

Patent foramen ovale (PFO) is a common congenital heart disease that can cause cryptogenic stroke through paradoxical embolization.For patients with PFO combined with cryptogenic stroke,whether anticoagulant therapy is superior to antiplatelet therapy in the prevention of recurrent stroke? And whether PFO closure can significantly reduce the risk of stroke recurrence compared with medical therapy alone? All those raised the clinical problems to be solved urgently.The advances in treatment of cryptogenic stroke associated with PFO are herewith summarized in present paper by reviewing randomized trials,meta-analyses and the guidelines or expert consensus about PFO and cryptogenic stroke.

Foramen oval permeable, un diagnóstico posible en manos del neurólogo. Descripción de caso / Patent Foramen Ovale, A Possible Diagnosis From The Neurologist. Case Report

Resumen Introducción: En pacientes con ictus isquémico criptogénico se ha descrito una alta prevalencia de alteraciones del septum auricular relacionadas con un riesgo aumentado de presentar recurrencia. Objetivo: Presentar la historia clínica de un paciente joven con antecedente de diabetes mellitus e ictus isquémico en el que no se demuestran alteraciones arteriales. A partir de la realización de un estudio de Doppler trasncraneal con test de burbujas se diagnostica un foramen oval permeable. Conclusión: En el paciente que describimos, la realización de un estudio de DTC como parte de la evaluación inicial ayudó a precisar la etiología. La demostración de un foramen ovale permeable tiene implicaciones en la prevención secundaria del ictus.

Abstract Introduction: A high prevalence of atrial septal defects is reported in patients with cryptogenic ischemic stroke, also related to an increase of the risk of recurrence. Objective: To report case of a young patient with a history of diabetes mellitus and ischemic stroke without arterial changes proven. A transcraneal Doppler study with a bubble test helped to diagnose a patent foramen ovale. Conclusion: As part of the initial evaluation of this patient, a TCD study has helped to clarify the stroke etiology. The demonstration of a patent foramen ovale has implications for the secondary prevention of stroke.

Síndrome de May Thurner con accidente cerebrovascular isquémico y foramen oval permeable / May Thurner syndrome with ischemic cerebrovascular accident and permeable oval foramen

La asociación de accidente cerebral isquémico con foramen oval permeable, no ha sido extensamente estudiada, y frecuentemente el sitio de origen de la embolia no se detecta a pesar de los estudios de rutina. Se presenta el caso de un paciente joven con accidente cerebral vascular isquémico y foramen oval permeable en el contexto de síndrome de May Thurner. El síndrome de May Thurner es una entidad poco estudiada en la literatura médica y además se lo ha relacionado poco con accidente cerebral vascular isquémico, pero en pacientes con foramen oval permeable sin evidencia de la fuente embolígena, es interesante descartarlo como causa de embolia paradojal.

The association of cerebral ischemic attack with patent foramen ovale has not been extensively studied, and frequently the site of origin of embolism is not detected despite routine studies. We present the case of a young patient with ischemic stroke and permeable oval foramen in the context of May Thurner syndrome. The May Thurner syndrome is an entity scarcely studied in the medical literature and it has also been infrequently related to ischemic vascular cerebral accident, but in patients with permeable oval foramen without evidence of the emboligen source, it is interesting to rule it out as a cause of paradoxical embolism.

Mutaciones heterocigóticas en el gen de la α -galactosidasa A en dos pacientes con ACV criptogénico / α -galactosidase A Heterozygous mutations gene in two patients with cryptogenic stroke

RESUMEN La enfermedad de Fabry es una enfermedad genética con herencia ligada al cromosoma X recesiva, en la que se encuentra afectada la actividad de la enzima lisosomal a-galactosidasa A (GLA), con acumulación de diferentes metabolitos como la globotriaosilceramida (GL 3) y la globotriaosilceramida deacilada (liso GL 3), responsables de la disfunción multiorgánica y de las diversas manifestaciones fenotípicas, comprometiendo principalmente: sistema nervioso, piel tracto gastrointestinal, corazón y riñón. La manifestación neurológica más temprana es el dolor neuropático, sin embargo se pueden encontrar síntomas gastrointestinales, en piel y ojo, mientras que el daño renal y cardiaco se presentan como manifestaciones tardías al igual que el ataque cerebrovascular (ACV) que se presenta en la adultez. A continuación presentamos dos casos clínicos de pacientes con ACV criptogénico con mutaciones hetero-cigotas en el gen de la a-galactosidasa A

SUMMARY Fabry's disease is a recessive X linked genetic disorder in which lysosomal enzyme alpha-galactosidase A activity is affected, with accumulation of different kind of metabolites such as globotriaosylceramide and the deacylated globotriaosylceramide which are responsible for the multi-organ dysfunction that is seen in this disease, and also of the several phenotypic manifestations, mainly in nervous system, skin, gastrointestinal tract, heart and kidney. Earlier neurological manifestation is neuropathic pain could finding also gastrointestinal tract, skin and eye complaints while Cardiac and renal damage present later like as cerebrovascular disease which presents in adulthood. Two clinical cases of young patients with cryptogenic stroke with heterozygous mutations for Fabry's disease are presenting below.

Clinical and imaging characteristics in cryptogenic ischaemic stroke with right-to-left shunt / 中国神经精神疾病杂志

Objective To investigate the clinical and imaging characteristics in cryptogenic stroke with right-to-left shunt (RLS). Methods Fifty-two patients with cryptogenic ischaemic stroke were included in the study and divided into two groups according to transcranial Doppler (TCD) bubble test: RLS group (twenty-five patients) and non-RLS group (twenty-seven patients). The demographic data, traditional risk factors of stroke and characteristics of le?sion patterns were compared between two subgroups. Results There was no significant difference between the groups in age or sex ratio. The percentage of patients with no risk factors was significantly higher in RLS group than non-RLS group (44%vs. 14.8%, P=0.015). The lesion was more frequently observed in the vertebrobasilar artery territory in RLS group (56%vs. 14.8%, P0.05). Conclusions Vertebrobasilar Stroke without traditional cerebrovascular risk factors is more likely to be RLS-associated, which requires an advanced TCD bubble test to find the potential cause of stroke.

Relation between Left Atrial Remodeling in Young Patients with Cryptogenic Stroke and Normal Inter-atrial Anatomy / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: To investigate an association between left atrial (LA) structural and P wave dispersion (PWD) during sinus rhythm, and electrical remodeling in cryptogenic stroke (CS) patients. METHODS: Forty CS patients and 40 age- and sex-matched healthy controls were enrolled. P wave calculations were based on 12-lead electrocardiography (ECG) at a 50-mm/s-paper speed with an amplitude of 10 mm/mV. Difference between the maximum and minimum P wave duration was the P wave dispersion (PWD=Pmax-Pmin). LA deformation was evaluated by speckle tracking echocardiography within 3 days of the acute event. RESULTS: PWD was 30.1+/-7.0 ms and 27.4+/-3.5 ms in CS and control group (P=0.02), whereas LA maximum volume index [LAVImax] was 20.4+/-4.5 mL/m2 and 19.9+/-2.4 mL/m2 in CS and control group, respectively (P = 0.04). While global peak LA strain was [pLA-S] (LA reservoir function) 41.4 +/- 6.3% and 44.5 +/- 7.1% in CS and control group, (P = 0.04), global peak late diastolic strain rate values [pLA-SRa] (LA pump function) were 2.5 +/- 0.4% and 2.9 +/- 0.5% in CS and control group, respectively (P = 0.001). A mild and a strong negative correlation between global pLA-S and LAVImax (r=-0.49; P<0.01), and between PWD and global pLA-S (r = -0.52; P < 0.01), respectively, was observed in CS. CONCLUSIONS: Increased PWD is associated with impaired LA mechanical functions and enlargement, and involved in the pathophysiology of AF or an AF-like physiology in CS.

Telemonitoring Boosts Atrial Fibrillation Detection in Cryptogenic Stroke Patients – Preliminary Findings.

Background: Approximately 25% of strokes are cryptogenic in origin and identifying atrial fibrillation (AF) as an etiologic factor in this situation has major therapeutic implication. Standard Holter ECG has a low sensitivity for AF detection in this patient group. Aim: To assess the diagnostic yield of prolonged ambulatory noninvasive ECG telemonitoring for AF detection in cryptogenic stroke or transitory ischemic attack (TIA) patients. Methods and Results: We prospectively included 36 patients (mean age 53 ± 15 years, 17% women) with cryptogenic stroke or TIA in the previous 3 months and without previously documented episodes of AF. We employed a validated ECG telemonitoring system (TEMEO). The median monitoring period was 22 days, ranging from 13 to 36 days. AF was detected in 10 patients (27%): in 7 patients (70%) AF episodes lasted <30 sec and in the other 3 episodes of absolute arrhythmia were longer. AF runs were asymptomatic in 6 of the patients with arrhythmia detection (60%). The mean time from initiation of telemonitoring to AF detection was 10 days, ranging from 2 to 29 days. Anticoagulation therapy for secondary prevention of stroke and systemic embolism was initiated in all of the patients with AF detected during telemonitoring. Conclusion: ECG telemonitoring after cryptogenic stroke or TIA results in AF detection in at least one in every four patients. Considering the important therapeutic implication of this finding we believe that prolonged ECG monitoring should become the standard of care in this patient group.

Análisis de costo-efectividad de estrategias alternativas en el manejo de pacientes con accidente cerebrovascular criptogénico y foramen oval permeable / Cost-Effectiveness Analysis of Alternative Strategies for the Management of Patients with Cryptogenic Stroke and Patent Foramen Ovale / Cost-Effectiveness Analysis of Alternative Strategies for the Management of Patients with Cryptogenic Stroke and Patent Foramen Ovale

Antecedentes El foramen oval permeable (FOP) se ha asociado con el accidente cerebrovascular criptogénico (ACVC). El mejor tratamiento para evitar la recidiva en pacientes con ACVC y FOP es controversial. No existen datos de costo-utilidad en nuestra región para el manejo de estos pacientes. Objetivos Construir un modelo de decisión para el manejo de pacientes con ACVC y FOP y establecer la relación costo-utilidad de tres estrategias alternativas. Material y métodos Se realizó un análisis de costo-utilidad basado en un árbol de decisión con un horizonte temporal de 4 años considerando tres estrategias: aspirina (AAS), anticoagulación (ACO) o cierre percutáneo del FOP con dispositivo. Los beneficios se expresaron en QALYs. Se fijó un umbral de pago de $28.000 argentinos y se realizó un análisis de sensibilidad. Resultados En comparación con la AAS, la anticoagulación fue más costosa ($1.315 adicionales) y generó menos beneficios (QALY incremental -0,063). El cierre con dispositivo comparado con el tratamiento con AAS costaría $89.876 adicionales por QALY ganado. Dicho monto supera el umbral de pago predeterminado. Luego del análisis de sensibilidad, la AAS se mantuvo como la estrategia con mejor relación costo-utilidad, salvo cuando la probabilidad de recidiva con esta droga aumenta al 35%, en donde la anticoagulación presenta una tasa de costo-utilidad incremental de $1.356/QALY. Conclusión De acuerdo con este modelo, para pacientes con ACVC y FOP, la AAS sería la estrategia con mejor relación costo-utilidad en nuestro medio, salvo cuando la probabilidad de eventos se eleva sustancialmente, en cuyo caso sería apropiado el uso de anticoagulantes.

Background Patent foramen ovale (PFO) has been associated with cryp-togenic stroke (CS). There are still some controversies about the best treatment to prevent recurrences in patients with CS and PFO. Our region lacks cost-utility analysis of the management of these patients. Objectives To construct a decision model for the management of patients with CS and PFO and to establish the cost-utility ratio of three alternative strategies. Material and Methods We conducted a cost-utility analysis based on a decision tree with a time horizon of 4 years considering three strategies: aspirin (ASA), anticoagulants (AC) or percutaneous device closure of the PFO. The benefits were expressed in QALYs. A payment threshold of ARS $28,000 was established and a sensitivity analysis was performed. Results Anticoagulants were more expensive compared to ASA (additional cost of ARS $1,315) and produced less benefits (incremental (QALY -0.063). Percutaneous device closure had an additional cost of ARS $89,876 per QALY gained compared to ASA. This cost exceeds the predetermined payment threshold. After performing the sensitivity analysis, ASA remained as the strategy with the best cost-utility ratio; however, when the probability of recurrences with this drug increases to 35%, anticoagulants present an incremental cost-utility ratio of ARS $1.356/QALY. Conclusion According to this model, in patients with CS and PFO, ASA would be the strategy with the best cost-utility ratio in our environment unless recurrences develop; in this case the use of anticoagulants would be more appropriate.

Acidente vascular encefálico isquêmico em paciente portadora de forâmen oval patente: relato de caso / Ischemic stroke in patient carrier of patent foramen oval: case report

JUSTIFICATIVA E OBJETIVOS: O embolismo através do forâmen oval patente (FOP) é bem conhecido e parece ser o principal mecanismo envolvido em pacientes jovens com acidente vascular encefálico isquêmico (AVEi). Este estudo teve como objetivo demonstrar que o diagnóstico precoce e o tratamento adequado a cada caso são essenciais na redução de possíveis morbidades relacionadas à presença do FOP. RELATO DO CASO: Paciente do sexo feminino, 26 anos, branca, jornalista, natural de Colatina, ES. Sem antecedentes patológicos significativos, iniciou em maio de 2005 quadro de hiperestesia na face flexora do antebraço e da mão esquerda, associada à hemiparesia desproporcionada incompleta esquerda de predomínio braquial, de caráter progressivo. A investigação final firmou o diagnóstico de AVEi correlacionado com a presença de FOP. A paciente foi submetida ao fechamento percutâneo do FOP com prótese Amplatzer Cribifrom n35 e orientada a utilizar ácido acetilsalisílico (AAS) e clopidogrel de forma contínua. CONCLUSÃO: O diagnóstico pôde ser feito através de exames capazes de evidenciar a patência do forâmen oval, como o ecocardiograma transesofágico e o Doppler transcraniano, associados aos métodos diagnósticos de eventos isquêmicos cerebrais. O tratamento ainda é controverso sem evidência na literatura da melhor terapêutica clínica - se anticoagulante ou antiagregante - nem sobre o melhor tratamento invasivo, se cirúrgico ou fechamento percutâneo.

BACKGROUND AND OBJECTIVES: The embolism through the patent foramen oval (FOP) is well known and seems to be the main mechanism involved in young patients with AVEI. This paper aims to demonstrate that early diagnosis and more appropriate treatment in each case are essential in the morbidity reduction related to the possible presence of the FOP. CASE REPORT: Patient female, 26 years-old, white, journalist, a native of Colatina - ES. Without significant previously healthy, began in May 2005 featuring flexor hyperesthesia in the forearm and left hand, associated with left arm incomplete disproportionate dominance progressive hemiparesis. The research has the final diagnosis of ischemic stroke correlated with the presence of FOP. The patient was submitted to FOP percutaneous closure with Amplatzer Cribifrom n35 prosthetic and directed to use aspirin and clopidogrel continuously. CONCLUSION: The diagnosis can be done through examinations capable of demonstrating the foramen oval patency, as the transesophageal echocardiography and transcranial Doppler sonography, associated with ischemic stroke brain diagnostic methods. The treatment is still controversial, no evidence in the literature of better medical therapy - if anticoagulant or antiplatelet - not on the best invasive treatment, whether surgical or percutaneous closure.

Arotic Atherosclerotic Plaques as a Potential Embolic Sources in Patients with Cryptogenic Stoke

BACKGROUND: The atherosclerotic plaque in the thoracic aorta has been considered as a potential source of cerebral or peripheral embolization. Especially, complex type of atherosclerotic plaques in the thoracic aorta have strongly been associated with cerebral embolism in ischemic stroke and transesophageal echocardiography(TEE) is a useful diagnostic tool for evaluation of thoracic aorta atherosclerosis. The aim of this study was to evaluate the prevalence and significance of complex type of thoracic atherosclerotic plaques in the patients with cryptogenic stroke who have neither cardiac source nor significant carotid atherosclerosis. METHOD: From 1993 to 1998, TEE and carotid Doppler sonography were performed in 58 consecutive patients with ischemic stroke and in 30 control patients without ischemic stroke. We divided the former into two groups. One is known-cause stroke(n=37) group and the other is Cryptogenic stroke group(n=21). We evaluated cardiogenic source of embolism, thoracic aorta atherosclerotic plaques as well as carotid atherosclerosis by carotid Doppler sonography and TEE. Aortic atherosclerosis was classified as grade 1: normal-appearing aortic intima, grade 2: extensive intimal thickening, grade 3: sessile atheroma protruding 5mm, and grade 5: mobile atheroma. Carotid atherosclerosis was categorized as significant if luminal stenosis of either common carotid artery or internal carotid artery is greater than 50%. RESULTS: 1) There was no statistically significant difference among the three groups in age, gender, diabetes mellitus, hyperlipidemia and smoking. 2) Hypertension was more common in the cryptogenic stroke group(p<0.05). Atrial fibrillation was more common in the known-cause and control group than in the cryptogenic group(p<0.005). 3) The carotid atherosclerosis was found in 7(12%) out of 58 consecutive patients with ischemic stroke. 4) The thoracic aortic atherosclerotic plaque was located primarily on descending aorta. The complex type of plaque was found in 8(38%) out of 21 patients with cryptogenic stroke. The complex type of plaque was found in 10(27%) out of 37 patients with known-cause stroke. The complex type of plaque was found in 3(10%) out of 30 patients with known-cause stroke. CONCLUSION: These results suggest that complex type of thoracic atherosclerotic plaques in cryptogenic stoke can be considered as potential source of ischemic stroke and we suggest that a patient with cerebral embolism without a source identified by the routine transthoracic echocardiograpy or carotid sonography shoud undergo transesophageal echocardiography to evaluate the thoracic aorta atheroma.