Analysis of 5 ischemic stroke patients caused by pulmonary arteriovenous fistula / 中华神经科杂志

Objective:To investigate the correlation between pulmonary arteriovenous fistula (PAVF) and ischemic stroke, and to improve the diagnosis and treatment of embolic strokes of undetermined source.Methods:Five patients with ischemic stroke caused by PAVF admitted to Xiangya Hospital of Central South University from January 2017 to December 2020 were collected. The diagnosis, treatment and prognosis of stroke caused by PAVF were summarized based on literature review.Results:Among the 5 patients, 1 is male and 4 are females, with age of (34.4±9.3) years. Weakness of unilateral limb, slurred speech, vision changes, drooping eyelids, etc., were the first manifestations of stroke. The location of cerebral infarction was indefinite. In this study, 5 patients were all isolated PAVF, including 3 cases of left lower lung, 1 case of left upper lung and 1 case of right lower lung. All 5 patients underwent interventional therapy, were followed-up for 6 months and 12 months after surgery, and none of them had a new stroke attack, and only 1 case had recanalization of PAVF.Conclusions:PAVF is a rare vascular lesion, stroke caused by which is even rarer, with a lack of specificity in clinical manifestations. For young patients with unexplained embolic stroke, if the stroke has a sudden onset, the anterior and posterior circulation can be involved, and multiple vascular distribution regions are often involved, and it is difficult to find a clear emboli basis, with manifestations such as hypoxemia, PAVF should be considered. Percutaneous catheter intervention for PAVF is safe and effective, and is the preferred method for the treatment of PAVF.

Application value of inferior vena cava compression combined with modified Valsalva maneuver in patent foramen ovale / 中华超声影像学杂志

Objective:To comparatively analyze the diagnostic value of patent foramen ovale and the degree of right-to-left shunt among the traditional Valsalva maneuver (VM), the modified Valsalva maneuver (mVM) and the compression of the inferior vena cava combined with modified Valsalva maneuver (CM).Methods:A total of 132 patients with migraine, dizziness, chest pain and other symptoms in Longgang District People′s Hospital of Shenzhen from January 2021 to December 2021 were prospectively enrolled. The detection rate of patent foramen ovale and the degree of right-to-left shunt were assessed among the rest state and after performing the auxiliary maneuvers including VM, mVM and CM respectively.Results:After performing the auxiliary maneuvers, the detection rate of patent foramen ovale was significantly increased (88.6% vs 59.8%) with statistical significance (χ 2=36.026, P<0.001). There was a significant difference in the degree of right-to-left shunt among the three auxiliary maneuvers (χ 2=25.581, P<0.001). CM was the most effective for the detection of the large right-to-left shunt, and the difference was statistically significant compared with VM and mVM ( P<0.001, P=0.002). Conclusions:Auxiliary maneuvers is crucial for the diagnosis of patent foramen ovale. Compared with VM and mVM, performing CM can further improve the detection rate of patent foramen ovale and increase the degree of right-to-left shunt.

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.

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.

Beneficial effects of position on patent foramen ovale-induced right-to-left shunt by contrast transcranial Doppler ultrasonography / 中华超声影像学杂志

Objective To investigate the influence on right-to-left shunt (RLS) of patent foramen ovale with contrast transcranial Dopple (cTCD) in different positions.Methods 276 consecutive patients included ischemic cerebrovascular disease (ICVD),migraine,episodic vertigo and syncope.They underwent cTCD at rest and after Valsalva maneuver in 4 positions:upright sitting,supine,left lateral decubitus and right lateral decubitus,in random order.RLS was graded 0 (no microbubbles detected),1 (1-10microbubbles),2 (＞ 10 microbubbles but no curtain),and 3 (curtain,shower of microbubbles).Meanwhile,each patients was examined by contrast transthoracic echocardiography(cTTE),contrast transesophageal echocardiography (cTEE) or right heart catheterization.Results RLS detection rate was 48.2％ (133/276)through cTCD.They were also confirmed patent foramen ovale by 82 cases in cTTE,28 cases in cTEE,and 23 patients in right heart catheterization.At rest,RLS detection rate and microbubbles of 4 positions had no significant difference (P ＞0.05).After the Valsalva maneuver,RLS detection rate and microbubbles of each position were significantly higher than at rest (P ＜0.001),and the RLS detection rate and microbubbles in upright sitting were higher than that at rest(P ＜0.05).Conclusions RLS is best detected in the upright sitting position with Valsalva maneuver with cTCD.Upright sitting detection helps to improve the detection rate and microbubbles of RLS.

Juxtacortical Spots on Fluid-Attenuated Inversion Recovery Images in Cryptogenic Transient Ischemic Attack

BACKGROUND AND PURPOSE: Juxtacortical spots are detected frequently on fluid-attenuated inversion recovery (FLAIR) images, but have not been extensively researched in patients with transient ischemic attack (TIA). We hypothesized that juxtacortical spots on FLAIR images are partly associated with right-to-left shunt (RLS) in TIA without clear etiology. The possibility of an association between the presence of RLS and juxtacortical spots on FLAIR images in patients with TIA without clear etiology was investigated, and the imaging findings of patients with and without RLS were compared. METHODS: This was a retrospective study of TIA patients who visited our tertiary stroke center consecutively within 72 hours of TIA onset. Cryptogenic TIA was defined as no clear etiology despite a routine diagnostic workup. The presence of RLS was examined by transcranial Doppler with an agitated saline test or transesophageal echocardiography. Juxtacortical spots were defined as small and round hyperintensities in the juxtacortex on FLAIR images, excluding white-matter hyperintensities. RESULTS: Of the 132 patients with cryptogenic TIA examined for this study, 70 (53.0%) had RLS. Juxtacortical spots on FLAIR images were detected more frequently in patients with RLS than in those without. The independent factors for the presence of juxtacortical spots were RLS [odds ratio (OR)=3.802, 95% confidence interval (95% CI)=1.74-8.2; p=0.001] and age (OR=1.058, 95% CI=1.01-1.10; p=0.004) by multivariate analysis. The number of juxtacortical spots was significantly higher among patients with a moderate-to-large RLS than in those with a small or no RLS. CONCLUSIONS: The findings of the present study demonstrate a significant association between the presence of RLS and the occurrence of juxtacortical spots on FLAIR images in patients with cryptogenic TIA.

Right-to-left shunt and the hypercoagulable state: does paradoxical embolism play a role in patients with antiphospholipid syndrome and stroke? / Shunt direita-esquerda e hipercoagulabilidade: embolia paradoxal pode ser responsável pelo AVC na síndrome antifosfolipídica?

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.

OBJETIVO: O forame oval patente está associado com embolia paradoxal e acidente vascular cerebral isquêmico (AVCi). Estados de hipercoagulabilidade, como a síndrome antifosfolipídica (SAF), podem facilitar esse processo, aumentando a formação de coágulos. O objetivo deste estudo foi verificar se pacientes com SAF e AVCi apresentam maior frequência de shunt direita-esquerda (SDE), comparados a pacientes com SAF sem AVCi. MÉTODOS: Cinquenta e três pacientes com SAF foram testados para SDE usando Doppler transcraniano contrastado (DTCc): 23 com AVCi (Grupo AVC) e 30 sem história de AVCi (Grupo Controle). RESULTADOS: DTCc foi positivo em 15 pacientes (65%) do Grupo AVC e em 16 pacientes (53%) no Grupo Controle (p=0,56). A proporção de pacientes com pequeno SDE (<10 HITS) e grande SDE (>10 HITS) foi semelhante nos dois grupos. Não houve diferença significativa entre os grupos. CONCLUSÕES: Nossos dados não sugerem que embolia paradoxal seja causa importante de AVCi em pacientes com SAF.

Patent foramen ovale in trigeminal autonomic cephalalgias and hemicrania continua: a non-specific pathophysiological occurrence? / Foramen oval patente em cefaleias trigêmino-autonômicas e hemicrania contínua: uma ocorrência fisiopatológica não específica?

Patent foramen ovale (PFO), a relatively common abnormality in adults, has been associated with migraine. Few studies also linked PFO with cluster headache (CH). To verify whether right-to-left shunt (RLS) is related to headaches other than migraine and CH, we used transcranial Doppler following microbubbles injection to detect shunts in 24 CH, 7 paroxysmal hemicrania (PH), one SUNCT, two hemicrania continua (HC) patients; and 34 matched controls. RLS was significantly more frequent in CH than in controls (54 percent vs. 25 percent, p=0.03), particularly above the age of 50. In the HC+PH+SUNCT group, RLS was found in 6 patients and in 2 controls (p=0.08). Smoking as well as the Epworth Sleepiness Scale correlated significantly with CH, smoking being more frequent in patients with RLS. PFO may be non-specifically related to trigeminal autonomic cephalalgias and HC. The headache phenotype in PFO patients probably depends on individual susceptibility to circulating trigger factors.

O forame oval patente (FOP), uma anormalidade cardíaca relativamente comum em adultos, tem sido associado à enxaqueca, mas raramente às cefaléias trigêmino-autonômicas (TACs). Utilizamos o Doppler transcraniano (DTC) para detecção de shunt direito-esquerdo (SDE) em 24 pacientes com cefaléia em salvas (CS), sete com hemicrania paroxística (HP), dois com hemicrania continua (HC) e um com SUNCT; alem de 34 controles. O SDE foi mais frequente nos pacientes com CS do que nos controles (54 por cento vs. 25 por cento p=0,03), particularmente acima de 50 anos. No grupo HP+HC+SUNCT, o SDE foi encontrado em seis pacientes e dois controles (p=0,08). O hábito de fumar, bem como sonolência excessiva diurna foram mais frequentes em paciente com CS. O FOP pode ter importância inespecífica na fisiopatologia das TACs e HC, na dependência da susceptibilidade individual a fatores desencadeantes.

Sinus arrest during valsalva maneuver after pneumonectomy: A case report / 대한마취과학회지

We report a case of cardiac arrest in a 71 year old male during the Valsalva maneuver that had been performed immediately after completing a pneumonectomy. The patient had a subclinical atrial septal defect (1.08 cm sized) and he previously undergone a left upper lobectomy of the lung without complications 11 months earlier. He underwent a left completion pneumonectomy due to recurrent lung cancer. After surgery a Valsalva maneuver was performed with 35 cmH2O to relocate the mediastinum. During this procedure, the patient experienced a cardiac arrest and was resuscitated with difficulty. It is believed that the cardiac arrest was due to pulmonary hypertension, right ventricular failure and right to left shunt caused by several factors, such as the pneumonectomy, subclinical atrial septal defect (1.08 cm sized), and Valsalva maneuver. In addition, the hypovolemia caused by fluid restriction and the epidural injection of local anesthetics might have contributed to this incident. Although it is a rare complication, it is suggested that subclinical ASD can cause severe hypoxemia, dyspnea even cardiac arrest after pneumonectomy. In order to avoid these complications, ASD should be treated with percutaneous closure or surgical intervention. If these are not possible, care must be taken when anesthetizing the patient, and anything that can increase the pulmonary vascular resistance and right to left shunt should be avoided.

The Hepatopulmonary Syndrome

No abstract available.

Correlation between Changes of Intrapulmonary Right to Left Shunt and Improvements in Oxygenation after Exogenous Surfactant Administration in Preterm Respiratory Distress Syndrome

PURPOSE: This study was aimed to investigate the relationship between changes in intrapulmonary right to left shunt(QSP/QT) and improvements in oxygenation during the 2-hr study period after Surfactant-TA(S-TA) administration. METHODS: Umbilical arterial blood gases and corresponding respiratory indexes of 27 preterm neonates with respiratory distress syndrome were studied. The neonates were separated into group A(n=20) and group B(n=7) according to whether their initial QSP/QT was above or below 30 %, respectively. And the patients were studied immediately before and after endotracheal single- dose S-TA administration within 6 hours after birth. RESULTS: In the case of P(a/A)O2, group A showed a significant increase throughout the study period(P<0.01, P<0.001), whereas group B showed an initial significant increase at 2 hr(P<0.05). Significant correlations between changes in QSP/QT and improvements in P(a/A)O2 were seen in both groups(P<0.001, P<0.05). Moreover in the case of PaO2/FIO2, group A showed a significant increase throughout the study period(P<0.01, P<0.001), whereas group B showed an initial significant increase at 30 min(P<0.05). Significant correlations between changes in QSP/QT and improvements in PaO2/FIO2 were also seen in both groups(P<0.01, P<0.05). And at 2 hr, VEI and VA showed a significant increase in both groups(P<0.05, P<0.01), whereas PaCO2 showed a significant decrease in both groups(P<0.001, P<0.05). CONCLUSION: Irrespective of initial QSP/QT, immediate improvements in oxygenation following surfactant replacement were accomplished by recruiting atelectatic alveoli and stablizing underventilated alveoli(namely by decreasing QSP/QT). Moreover, the patients with more severe respiratory failure had a more rapid and sustained improvement in oxygenation.

Influences of the Intrapulmonary R-->L Shunt on PaO2 and PaCO2 after Instillation of Exogenous Pulmonary Surfactant to Premature Neonates with Respiratory Distress Syndrome

PURPOSE: We are inclined to analyze the relationship between the intrapulmonary right-to-left shunt and the PaO2/PaCO2 after endotracheal single-dose surfactant instillation to premature neonates with respiratory distress syndrome within 6 hours after birth. METHODS: From Jan. 1993 to Jun. 1995, we have conducted a clinical trial of surfactant replacement therapy to the premature neonates with respiratory distress syndrome at the neonatal intensive care unit of InHa University Hospital. The surfactant group (n=17) was given Surfactant-TA and mechanical ventilator care, but the control group (n=22) was treated with only mechanical ventilator. We analyzed umbilical arterial blood gases and estimated respiratoy indexes before and after treatment. RESULTS: 1) The QSP/QT decreased initially in the surfactant group, but significantly increased 24 hours after treatment in the control group (40.6+/-4.7%, P0.5) resulted in a decrease in PaO2 and also a significant relationship was found between the QSP/QT and the PaO2. However, there was no significant relationship between the QSP/QT and the PaCO2.