Isquemia intestinal, una manifestación inusual de la embolia paradójica. Un reporte de caso / Intestinal ischaemia as a rare manifestation of a paradoxical embolism. A case report

Introducción. La embolia paradójica es un evento trombótico originado en la circulación venosa, que se manifiesta como embolismo arterial por medio de un defecto anatómico a nivel cardíaco o pulmonar. Se asocia principalmente a eventos cerebrovasculares, aunque se han encontrado casos de infarto agudo de miocardio, infarto renal y otros eventos isquémicos. Caso clínico. Paciente de 47 años, quien consultó por cuadro de dolor abdominal, que requirió manejo quirúrgico de urgencia, donde identificaron isquemia intestinal importante. Los estudios adicionales hallaron déficit de proteína S y persistencia de foramen oval permeable. Resultados. La presencia de trombosis arterial se conoce como trombosis de sitios inusuales y requiere de estudios para descartar trombofilias asociadas u otros estados protrombóticos. El déficit de proteína S es una trombofilia infrecuente, la cual se asocia en la vida adulta a eventos trombóticos de origen venoso. En presencia de defectos anatómicos, como un foramen oval permeable, puede progresar a embolia arterial, configurando un cuadro de embolismo paradójico. La estratificación de estos pacientes requiere imágenes que demuestran el defecto mencionado, así como el posible origen de los émbolos. El manejo se basa en anticoagulación plena, manejo de soporte, resolver las manifestaciones trombóticas existentes y un cierre temprano del defecto anatómico. Conclusiones. El embolismo paradójico debe sospecharse en caso de trombosis de sitios inusuales. Requiere de un estudio exhaustivo con imágenes y su manejo debe basarse en anticoagulación y cierre del defecto.

Introduction. Paradoxical embolism is a thrombotic event originating in the venous circulation, which manifests as arterial embolism through an anatomical cardiac or pulmonary defect. It is mainly associated with stroke, also presenting as acute myocardial infarction, renal infarction, and other ischemic events. Clinical case. A 47-year-old patient was admitted due to abdominal pain, which required emergency surgical management, finding significant intestinal ischemia. Additional studies found protein S deficiency and evidence of a patent foramen ovale. Discussion. Arterial thrombosis is known as unusual thrombosis; this situation requires to rule out associated thrombophilia or other prothrombotic diseases. Protein S deficiency is a rare thrombophilia, which in adults causes venous thrombosis. In the presence of anatomical defects, such as a patent foramen ovale, it can progress to arterial embolism, presenting a picture of paradoxical embolism. The study work of these patients requires imaging that demonstrates the aforementioned defect, as well as the possible origin of the emboli. Management is based on full anticoagulation, treatment of existing thrombotic manifestations, and management of the anatomical defect. Conclusions. Paradoxical embolism should be suspected in case of unusual thrombosis. It requires exhaustive studies based on imaging, and management should consist of anticoagulation and closure of the defect.

Migraña poscierre percutáneo de defectos septales auriculares

La migraña es una enfermedad que se ha visto asociada a defectos septales auriculares y a su cierre percutáneo, estipulándose en la literatura que sería una rara complicación, pero la evidencia al respecto es escasa. Se realizó una revisión narrativa sobre definiciones, epidemiología, fisiopatología y tratamiento de la migraña y de la entidad migraña poscierre percutáneo de defectos del septum auricular, incluyendo trabajos observacionales (retrospectivos, prospectivos), estudios randomizados, reportes de casos, artículos de revisión y metaanálisis existentes en PubMed y Cochrane, para aportar al conocimiento de esta entidad.

Migraine is a disease that has been associated with atrial septal defects and its percutaneous closure, stipulating in the literature that it would be a rare complication, but evidence is scarce. A narrative review was conducted on definitions, epidemiology, pathophysiology and treatment of migraine and the migraine entity after percutaneous closure of atrial septum defects, including observational studies (retrospective, prospective), randomized studies, case reports, review articles and meta-analyses existing in PubMed and Cochrane, to contribute to the knowledge of this entity.

A enxaqueca é uma doença que tem sido associada a defeitos do septo atrial e seu fechamento percutâneo, estipulando na literatura que seria uma complicação rara, mas as evidências são escassas. Foi realizada uma revisão narrativa sobre definições, epidemiologia, fisiopatologia e tratamento da enxaqueca e da entidade migranosa após fechamento percutâneo de defeitos do septo atrial, incluindo estudos observacionais (retrospectivos, prospectivos), estudos randomizados, relatos de caso, artigos de revisão e metanálises existentes no PubMed e Cochrane, para contribuir com o conhecimento dessa entidade.

Unveiling Complexity: A Case Report of Catastrophic Antiphospholipid Syndrome With Coronary Occlusion and a Concomitant Patent Foramen Ovale Shunt.

Antiphospholipid syndrome (APLS) and systemic lupus erythematosus (SLE) are rare autoimmune disorders that afflict a small percentage of the global female population. The complexity of these conditions is further exacerbated by their propensity to give rise to recurrent thrombosis and obstetric morbidity, thereby posing intricate challenges for clinicians and patients alike. One of the most concerning aspects of these diseases is the heightened risk they confer for accelerated atherosclerosis, which can ultimately culminate in the development of acute coronary syndrome (ACS). This case report describes a 27-year-old female with APLS, SLE, and lupus nephritis. She suffered from a catastrophic antiphospholipid syndrome (CAPS) episode and simultaneously developed ACS. She also had a patent foramen ovale (PFO) shunt.

Angle Evaluation of Possible Routes that Can Be Used to Reach the Foramen Ovale in the Anterior Approach / Evaluación Angular de Posibles Rutas que se Pueden Utilizar para Alcanzar el Foramen Oval en el Abordaje Anterior

SUMMARY: For the treatment of trigeminal neuralgia, the foramen ovale is reached by entering the cheek with a needle. Thermocoagulation is performed with balloon compression, administration of alcohol or radiofrequency. Apart from the classical method, it is theoretically possible to reach the foramen ovale through the mouth with the anterior approach. In our study, it was aimed to examine horizontally and vertically the angular values that must be given to the needle to reach the foramen ovale in the anterior approach. Three landmark points were determined on both right and left sides of 25 dry skulls. A rod was inserted starting from these landmark points and passing through the center of the foramen ovale. The vertical and horizontal angular values of this bar were measured. For each foramen ovale, 3 vertical angles, 3 horizontal angles and 4 distance measurements were made. There was a significant difference between the right and left sides in terms of horizontal angular values. Average values of horizontal angles (in degrees); on the right, 7.29 for H1, 12.15 for H2, 32.29 for H3; 1.26 for H1, 9.46 for H2, and 30.56 for H3 on the left side (p<0.005). The angle value was measured as 0 or negative value in 5 (20 %) of the H1 angle measurements made on the right side and 14 (56 %) on the left side. The H2 angle value was found to be smaller than the H1 angle in the skull 2 (8 %) on the right and 3 (12 %) on the left. There was no difference between the right and left sides in terms of vertical angular values. A significant difference was found between the right and left sides in the D1, D2, D4 distances (p<0.005). Six important anatomical features affecting angular values were encountered.

Para el tratamiento de la neuralgia del trigémino, se alcanza el foramen oval introduciendo una aguja en la mejilla. La termocoagulación se realiza con compresión con balón, administración de alcohol o radiofrecuencia. Aparte del método clásico, en teoría es posible alcanzar el foramen oval a través de la cavidad oral mediante el abordaje anterior. En nuestro estudio se tuvo como objetivo examinar horizontal y verticalmente los valores angulares que se deben dar a la aguja para alcanzar el foramen oval en el abordaje anterior. Se determinaron tres puntos de referencia en los lados derecho e izquierdo de 25 cráneos secos. Se insertó una varilla comenzando desde estos puntos de referencia y pasando por el centro del foramen oval. Se midieron los valores angulares verticales y horizontales de esta barra. Para cada foramen oval se realizaron mediciones de 3 ángulos verticales, 3 ángulos horizontales y 4 distancias. Hubo una diferencia significativa entre los lados derecho e izquierdo en términos de valores angulares horizontales. Valores medios de ángulos horizontales (en grados); a la derecha, 7,29 para H1, 12,15 para H2, 32,29 para H3; 1,26 para H1, 9,46 para H2 y 30,56 para H3 en el lado izquierdo (p<0,005). El valor del ángulo se midió como 0 o valor negativo en 5 (20 %) de las mediciones del ángulo H1 realizadas en el lado derecho y 14 (56 %) en el lado izquierdo. Se encontró que el valor del ángulo H2 era menor que el ángulo H1 en el cráneo 2 (8 %) a la derecha y 3 (12 %) a la izquierda. No hubo diferencia entre los lados derecho e izquierdo en términos de valores angulares verticales. Se encontró diferencia significativa entre el lado derecho e izquierdo en las distancias D1, D2, D4 (p<0,005). Se encontraron seis características anatómicas importantes que afectan los valores angulares.

Cardiac Platypnea-Orthodeoxia Syndrome: A Rare Case of Flow-Directed, Right-to-Left Shunt via a Patent Foramen Ovale Exacerbated by Aortic Root Enlargement.

Cardiac platypnea-orthodeoxia is a unique clinical syndrome characterized by dyspnea and deoxygenation when moving from a supine to an upright position. In this case report, we detail the experience of a 78-year-old male with persistent hypoxemia following a paradoxical embolic ischemic stroke. Despite proper management of his respiratory symptoms, the patient continued to be affected by marked dyspnea and hypoxemia, particularly when upright or in a right-sided decubitus position. Subsequent investigation revealed that his hypoxemia was a result of cardiac platypnea-orthodeoxia syndrome (POS). This condition was attributed to the enlargement of his aortic root and ascending aorta, coupled with a counterclockwise rotation of the heart axis. These factors facilitated a flow-directed, right-to-left interatrial shunt through a patent foramen ovale, even in the absence of elevated right heart pressures.

Diffuse Bi-hemispheric Cortical Infarction Secondary to Cerebral Air Embolism After Elective Esophagogastroduodenoscopy: A Case Report and Review of Literature.

Cerebral air embolism (CAE) is a rare entity and is more often secondary to iatrogenic causes. We present a rare case of CAE post esophagogastroduodenoscopy (EGD) with a shower of emboli resulting in diffuse cortical infarction. An 80-year-old man with gastroesophageal reflux disease underwent an elective EGD for esophageal dilatation. During the procedure, there was significant arterial and venous bleeding which subsided with treatment. After the procedure, the patient became comatose with the decerebrate extensor posturing to painful stimulation. Computed tomography without contrast revealed multiple foci of CAE. Diffusion-weighted magnetic resonance images performed at the same time showed numerous areas of acute ischemic lesions affecting primarily the Gray Matter, demonstrating both cortical micro air emboli and bi-hemispheric, global hypoperfusion leading to cortical ribboning pattern.  There have been less than 22 cases of CAE after EGD in the literature, most of which were middle cerebral arterial territory infarctions. Our clinical images represent one of the extremely rare cases showing a shower of emboli and global hypoperfusion-induced gray matter infarction due to CAE-causing brain herniation.

A new era in patent foramen ovale closure - a percutaneous suture-based 'deviceless' technique (NobleStitch®): Experience of a Portuguese center.

INTRODUCTION: In patients with cryptogenic stroke, one of the most frequently found abnormalities is patent foramen ovale (PFO). Percutaneous 'deviceless' systems based on surgical suture-mediated PFO closure have recently been introduced and show a favorable efficacy and safety profile with clear advantages. OBJECTIVES: To present procedural details of the technique and baseline characteristics of patients who underwent the procedure in our center. METHODS: A single-center prospective observational registry was established between February 2020 and February 2021, to assess the safety, efficacy and possible advantages of a novel percutaneous PFO closure system (NobleStitch® EL). Patient and PFO characteristics as well as technical features were collected for analysis. RESULTS: Twenty-three patients were considered suitable for this technique after transesophageal echocardiography. Their mean age was 51 years and 69.5% were women. Most patients (91.3%) had a history of cryptogenic stroke. PFO closure with the NobleStitch® system was successfully performed in all patients. All procedures were performed under local anesthesia and fluoroscopic monitoring. The mean duration of the procedure was 52 min and median contrast dose used was 187 ml. Median radiation dose absorbed per patient was 61.5 Gy cm2. All patients were discharged asymptomatic 24 hours after the procedure with no peri- or postprocedural complications recorded. CONCLUSION: Suture-mediated PFO closure represents a valid and safe alternative to traditional umbrella-like devices, and is feasible in the majority of PFO anatomies. Follow-up information, results of larger series and clinical trials may possibly validate this technique as the first choice for PFO closure.

Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry.

INTRODUCTION: There is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. METHOD: A prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischaemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. RESULTS: In the group ≤ 60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4.11; IC 2.6-6.5, P < .001), criteria for paradoxical embolism (OR 2.61; IC 1.28-5.28; P = .008) and previous use of antithrombotics (OR 2.67; IC 1.38-5.18; P = .009). In the > 60 years group (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria, and high-risk PFO. CONCLUSIONS: The detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.

Disseminated Intravascular Coagulation With Excessive Fibrinolysis Following Diagnostic Prostatic Biopsy for Prostate Cancer.

The most common hematological disorder associated with prostate cancer is disseminated intravascular coagulation (DIC). In most cases, cancer patients with DIC have compensated fibrinolysis with a low incidence of bleeding. However, DIC with excessive fibrinolysis is a rare albeit life-threatening variant that can present with massive bleeding and is thought to occur due to the unique properties of neoplastic cells of prostate cancer that activate both procoagulant and anticoagulant pathways simultaneously. Depending on the shift of the intricate balance between the two forces, the net result can be either systemic micro- (DIC) or macro-thrombi, deep venous thrombosis (DVT) or pulmonary embolism, or a bleeding syndrome from excessive vicious activation of fibrinolysis. Here, we present a unique case of suspected prostate cancer who underwent a diagnostic prostatic biopsy. Subsequently, he developed massive hematuria requiring intensive care unit admission with multiple supportive blood products. Additionally, he was administered epsilon-aminocaproic acid with a prophylactic dose of heparin, with prompt resolution of bleeding. After stabilization, he was discharged with planned outpatient chemotherapy. However, he subsequently presented with lower extremity DVT within a week, which led to a stroke in the setting of a patent foramen ovale. This unique case report highlights how a change in the intricate balance of the coagulation cascade causes a polar shift in clinical presentation and complications.

Heart Failure Associated With Ventricular Septal Defect, Mitral Valve Prolapse, Non-stenotic Bicuspid Aortic Valve, and Patent Foramen Ovale.

Ventricular septal defect (VSD) and bicuspid aortic valve (BAV) are the two most common congenital heart defects. BAV may occur sporadically or in association with other cardiac malformations. VSDs have decreased incidence in the adult population due to spontaneous closure. Mitral valve prolapse (MVP) and patent foramen ovale (PFO) can be associated with these conditions but the simultaneous association of these defects has never been reported in the literature. We report the case of a 35-year-old male patient with persistent VSD, BAV, and PFO associated with new-onset heart failure and MVP. We aim to study the association between the coexistence of structural heart malformations and the increased risk of heart failure.

Tromboembolia pulmonar e infarto de miocardio embólico en paciente con trombo en tránsito a través de foramen oval permeable / Pulmonary embolism and embolic myocardial infarction in a patient with thrombi in transit through a patent foramen ovale

Resumen Se presenta el caso de una paciente ingresada por cuadro clínico de infarto agudo de miocardio con elevación del segmento ST. Tras la realización de una coronariografía emergente en la que se evidencia un trombo en la arteria coronaria derecha, sin objetivar lesiones ateroscleróticas, es diagnosticada de infarto de probable origen embólico. Tras realizar un ecocardiograma transtorácico, se detecta la presencia de trombos en las cavidades derechas e izquierdas del corazón. Por ello se realiza angiografía por tomografía computarizada con protocolo de embolia pulmonar, que confirma la presencia de embolia pulmonar bilateral masiva. Tras esto, se repitió el ecocardiograma transtorácico, hallándose un aneurisma del septo interauricular, con aparente protrusión de una masa trombótica a través de él. Se inició terapia anticoagulante con buena evolución por parte de la paciente, habiendo desaparecido los trombos en el ecocardiograma con test de burbujas que se realizó días después, en el que se demostró la presencia de un foramen oval permeable. Con la presentación de este caso se pretende, en primer lugar, ilustrar una afección que en contadas ocasiones se puede objetivar mediante prueba de imagen, y en segundo lugar, hacer una breve revisión del diagnóstico y el manejo del foramen oval permeable como parte del estudio de fuente embólica.

Abstract The authors describe a case of a patient admitted with ST elevation myocardial infarction. An emergent coronariography was done, showing a thrombus in the right coronary artery, without evidence of atherosclerotic lesions in the coronary bed. Due to this, she is diagnosed with probable embolic myocardial infarction. When she was performed a transthoracic echocardiography, the presence of free thrombi was detected in right and left chambers of the heart. Due to this, a CT angiography with pulmonary embolism protocol was done, confirming the presence of a massive bilateral pulmonary embolism. After that, a new trans-thoracic echocardiography was done, finding an aneurism at interatrial septum, with an apparent protrusion of thrombotic mass through it. The decision taken was initiating therapeutic anticoagulation, having the patient a positive evolution with disappearance of thrombi in the bubble test performed days later, and showing the presence of a patent foramen ovale. The purpose of the presentation of this case report is, firstly, illustrating an entity which in very few occasions can be demonstrated by imaging tests, and secondly, making a brief review of the diagnosis and management of the patent foramen ovale as a part of the study of embolic sources.

Foramen oval restrictivo intraútero: causa de hidrops fetal / Intrauterine restrictive oval foramen: cause of fetal hydrops

Introducción: El cierre prematuro del foramen oval o foramen oval restrictivo intraútero es una entidad clínica rara pero seria, de etiología desconocida. Puede ocasionar diversos defectos cardíacos, hipertensión pulmonar, insuficiencia cardiaca congestiva, hidrops fetal y muerte. El diagnóstico puede realizarse mediante ecocardiografía fetal, aunque en la mayoría de los casos sucede en autopsia posmortem. Objetivo: Describir un caso de hidrops fetal secundario al cierre prematuro del foramen oval intraútero. Presentación del caso: Recién nacido pretérmino de 34 semanas en el que, en ecografía y ecocardiografía prenatal se visualizó un aumento de las cavidades cardíacas asociado a cierre intrauterino de foramen oval e hidrops, hallazgos confirmados al nacimiento. Tras una prolongada estancia en unidad de cuidados intensivos neonatal y tratamiento con inotrópicos y diuréticos, se otorgó el alta hospitalaria con diagnóstico de cardiomiopatía dilatada secundaria a foramen oval restrictivo. Conclusiones: La asociación de cierre prematuro de foramen oval con hidrops fetal ha sido descripta en escasas publicaciones y es frecuente en estas la relación con muerte perinatal y con anomalías extracardíacas. En este caso se describe hidrops secundario al cierre temprano del foramen oval intraútero que condicionó a la dilatación global de cavidades cardíacas y a la disfunción ventricular severa persistentes más allá del periodo neonatal sin otras anomalías asociadas. A pesar de la severidad del compromiso cardiovascular, la evolución clínica fue favorable y permitió el egreso hospitalario. Es importante el reconocimiento temprano mediante ecografía y ecocardiografía fetal de estas entidades para guiar un diagnóstico y tratamiento oportunos(AU)

Introduction: Premature closure of the oval foramen or intrauterine restrictive oval foramen is a rare but serious clinical entity of unknown etiology. It can cause various heart defects, pulmonary hypertension, congestive heart failure, fetal hydrops and death. Diagnosis can be made by fetal echocardiography, although in most cases it occurs in postmortem autopsy. Objective: Describe the presentation of a case of fetal hydrops secondary to premature closure of the intrauterine oval foramen. Case presentation: A 34-week preterm newborn in which, in ultrasound and prenatal echocardiography, an increase in the cardiac chambers associated with intrauterine closure of oval foramen and hydrops was visualized; these findings were confirmed at birth. After a prolonged stay in the neonatal intensive care unit and treatment with inotropic and diuretic drugs, hospital discharge was granted with diagnosis of dilated cardiomyopathy secondary to restrictive oval foramen. Conclusions: The association of premature closure of oval foramen with fetal hydrops has been described in few publications and it is common in these the relation with perinatal death and extracardiac abnormalities. In this case, it is described hydrops secondary to the early closure of the intrauterine oval foramen that conditioned the overall dilation of heart chambers, and persistent severe ventricular dysfunction beyond the neonatal period without other associated abnormalities. Despite the severity of cardiovascular compromising, clinical evolution was favorable and allowed hospital discharge. Early recognition using ultrasound and fetal echocardiography of these entities is important to guide timely diagnosis and treatment(AU)

Patent foramen oval: A rare case of acute ischemia of the upper limb: A case with 2 year follow-up.

INTRODUCTION AND IMPORTANCE: Paradoxical emboli (PDE) represent less than 2% of all arterial emboli, that is why they are considered as a rare event. We notice that the upper limb ischemia is very exceptional as part of a paradoxical embolism. This case presentation can help in considering the diagnosis the PFO as one of the most important risk factors of paradoxical embolism. CASE PRESENTATION: Here, we present a rare case of a 69-year-old woman with paradoxical systemic arterial embolism, presented by an acute ischemia of the upper limb, secondary to deep venous thrombosis and pulmonary embolism in the presence of patent foramen ovale, treated with long-term anticoagulation with rivaroxiban 20 mg/day, because of the mutation of the Factor II whish indicate already the anticoagulation. DISCUSSION: Echocardiographic techniques such as transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), or transcranial echocardiography (TCE) are the principal tools used to detect PFO. There are no clear consensus on the treatment of PDE. Presenting symptoms largely depend upon the location of the embolus, necessitating a different approach for each patient, but There is essentially three therapeutic options: surgical embolectomy, thrombolysis, and anticoagulation. CONCLUSION: PFO closure is, today, a standardized and safe intervention, but the indication stay individualized to each patient.

The pterygospinous foramen (Civinini) and the pterygoalar (crotaphitico-buccinatorius): laboratory findings / El foramen pterigoespinoso (Civinini) y el pterigoalar (crotafítico-buccinatorius): hallazgos de laboratorio

SUMMARY: The Pterygospinous foramen and pterygoalar foramen (crotaphitico-buccinatorius) are variant and atavic formations of the skull base and arise respectively from complete or incomplete idiopathic ossifications of the pterygospinous and pterygoalar ligaments. By proximity with areas of relevance for diagnosis and surgery, such as access pathways to the parapharyngeal and retropharyngeal spaces, it is necessary to be aware of these conditions due to the difficulties generated in surgical maneuvers and the promotion of compressive syndromes of mandibular nerve branches. This study was conducted on 45 samples of dry skulls and disarticulated sphenoid bones belonging to the collection of the Federal University of Juiz de Fora, Governador Valadares campus, Minas Gerais, Brazil. Our results indicated a total incidence of complete and incomplete pterygospinous and pterygoalar foramen (crotaphitico- buccinatorius) in 15, 5 % (7 skulls), with a higher incidence for the incomplete form of pterygospinous foramen (Civinini foramen) in 4 skulls (8.8 %), with 3 presenting unilaterally and 3 presenting bilaterally. The pterygoalar foramen (crotaphitico-buccinatorius or Hyrtl) was noted bilaterally in 1 of the skulls (2.2 %). The pterygospinous foramen and pterygoalar foramen are important findings, sometimes incidental, of an area of great anatomical expressiveness and pathological occurrences, besides the indispensable and unclear studies of phylogenetic order.

RESUMEN: El foramen pterigoespinoso y el foramen pterigoalar (crotafítico-buccinatorius) son formaciones variantes y atávicas de la base del cráneo y surgen respectivamente de osificaciones idiopáticas completas o incompletas, de los ligamentos pterigoespinoso y pterigoalar. Debido a la proximidad con áreas de relevancia para el diagnóstico y la cirugía, como las vías de acceso a los espacios parafaríngeo y retrofaríngeo, es necesario conocer estas condiciones por las dificultades que se generan en las maniobras quirúrgicas. Este estudio se realizó en 45 muestras de cráneos secos y huesos esfenoides desarticulados pertenecientes a la colección de la Universidad Federal de Juiz de Fora, campus Governador Valadares, Minas Gerais, Brasil. Nuestros resultados indicaron una incidencia total de foramen pterigoespinoso y pterigoalar completo e incompleto (crotafítico-buccinatorius) en el 15,5 % (7 cráneos), con una mayor incidencia de la forma incompleta de foramen pterigoespinoso (agujero de Civinini) en 4 cráneos (8,8 %), con 3 de presentación unilateral y 3 de presentación bilateral. El foramen pterigoalar (crotaphitico-buccinatorius o Hyrtl) se observó bilateralmente en 1 de los cráneos (2,2 %). El foramen pterigoespinoso y pterigoalar son hallazgos importantes, a veces incidentales, de un área de gran expresividad anatómica y ocurrencias patológicas, además de los estudios indispensables y poco claros de orden filogenético.

Rare Association of Patent Foramen Ovale and Atrial Septal Aneurysm Leading to Branch Retinal Artery Occlusion in a Young Healthy Man.

Retinal artery occlusion (RAO) occurs in the elderly population above the age of 60 years due to carotid atherosclerosis as a consequence of long-standing hypertension, diabetes mellitus, smoking, and hyperlipidemia. It can also develop due to paradoxical emboli from patent foramen ovale (PFO), which can happen in a relatively younger population. Early diagnosis mandates prompt management; otherwise, it may lead to vision loss. We present a rare case of branch RAO (BRAO) in a healthy young gentleman with concurrent PFO and large atrial septal aneurysm, which has not been reported much in the literature. Our patient presented with sudden left-sided blurriness of vision, which was diagnosed as BRAO on ophthalmoscope examination. Multidisciplinary teams were involved in reaching the underlying etiology of such a presentation in a young, healthy person. Urgent head CT with cerebral angiography and head MRI was unremarkable for any acute insult. The autoimmune screen and thrombophilia workup were unremarkable. After thorough investigations, a small PFO with a large atrial septal aneurysm was found to be correlating with his clinical picture. We aim to highlight the importance of timely diagnosis and further management in such clinical scenarios, where permanent vision loss can compromise someone's quality of life.

Historia natural del cierre percutáneo de foramen oval permeable / Natural history of patent foramen ovales closure

INTRODUCCIÓN: El cierre percutáneo del foramen oval permeable (FOP) se ha posicionado como el tratamiento de elección para la prevención secundaria de pacientes con infartos encefálicos (IE) criptogénicos asociados a FOP. OBJETIVO: Revisar los cierres de FOP realizados en nuestra institución, evaluando las características clínicas y del procedimiento, los resultados a mediano plazo luego del procedimiento y la tendencia en el número de intervenciones durante el período estudiado. MÉTODOS: Se incluyeron 101 pacientes consecutivos en que se realizó cierre de FOP, con una mediana de seguimiento de 4,6 años. Se analizaron las características basales de los pacientes, la indicación del cierre de FOP, el éxito del procedimiento y la presencia de shunt residual en ecocardiografía al año. Se realizó una encuesta telefónica estructurada a todos los pacientes, en la cual se preguntó por nuevo IE o crisis isquémica transitoria (CIT), otros eventos cardiovasculares y la presencia de sangrados. El seguimiento fue completado en el 95%. Se calculó el puntaje RoPE ("Risk of Paradoxical Embolism") el cual provee una estimación de la posibilidad de que ese IE se haya debido al FOP y del riesgo de repetir un nuevo IE en caso de no cerrar el FOP para cada paciente. RESULTADOS: La edad promedio fue de 49,1±13,7 años, con 53% mujeres. Sólo en 3 pacientes se diagnosticó una trombofilia. En 96 pacientes la indicación fue para prevención de embolía paradojal e IE (74% IE, 17% CIT y 4% embolía periférica), mientras que en 5% por síndrome de ortodeoxia/platipnea. El cierre de FOP fue exitoso en todos los pacientes. Shunt residual en ecocardiograma al año se observó en 5% - ninguno de estos pacientes presentó un nuevo evento encefálico durante el seguimiento. Se registraron 2 nuevos IE (4 IE por 1000 pacientes/año) y 1 nueva CIT (2 CIT por 1000 pacientes/año) en el seguimiento, con un promedio de presentación de 3,6 años post procedimiento. Esta tasa de eventos fue significativamente menor a lo predicho por el puntaje RoPE en nuestra cohorte. Se observó un marcado aumento en el número de procedimientos desde el año 2017 en adelante. CONCLUSIONES: En nuestra cohorte, el cierre de FOP fue un procedimiento exitoso y seguro. Se asoció a una baja tasa de nuevos eventos cerebrales, marcadamente menor a lo estimado por el puntaje de riesgo actualmente disponible (RoPE).

INTRODUCTION: The percutaneous closure of a patent foramen ovale (PFO) has been established as the preferred treatment for those with an ischemic stroke (IS) and associated PFO. AIMS: To review the PFO closure experience at our institution, characterizing the patients and procedures, mid-term results and the trend in the number of interventions during the study period. METHODS: One hundred and one consecutive patients undergoing PFO closure were included, with a median follow-up of 4.6 years. Baseline demographics, PFO closure indications, procedural success rates and residual shunt at 1-year were recorded. A telephonic survey was performed to complete follow-up, asking for new IS or transient ischemic attacks (TIA), other cardiovascular events and bleeding. Follow-up was completed by 95%. The RoPE score was calculated for each patient, providing an estimate of the chance a given IS being due to a PFO and the risk of a new event when the defect is not closed. RESULTS: Mean age was 49.1±13.7 years and 53% were females. Whereas the indication for PFO closure was paradoxical embolism in 96 patients (74% IS, 17% TIA and 4% peripheral embolism), in 5 it was for platypnea-orthodeoxia syndrome. All patients had a successful PFO closure procedure. Residual shunt at 1 year was found in 5% - yet, none of these patients experienced a new stroke during the study period. During follow-up there were 2 new IS (4 IS per 1,000 patients/year) and 1 new TIA (2 TIA per 1,000 patients/year), with a mean incidence time of 3.6 years after the procedure. This rate of new events was significantly lower than the one predicted by the RoPE score. From 2017 onwards, there was a marked increase in the number of procedures performed at our institution. CONCLUSION: In this cohort, PFO closure was a successful and safe procedure. It was associated to a low rate of new cerebral events during mid-term follow-up, markedly lower than the RoPE predicted rate.

A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence.

Patent foramen ovale (PFO) is a common cardiac anatomic variant that has been increasingly found in young (<60 years) cryptogenic stroke patients. Despite initial neutral randomized-controlled clinical trials (RCTs), there have been four recent RCTs providing consistent data in favor of the efficacy and safety of PFO closure compared to medical therapy for secondary stroke prevention. However, taking into consideration the high prevalence of PFO, the low risk of stroke recurrence under medical treatment and the uncommon yet severe adverse events of the intervention, patient selection is crucial for attaining meaningful clinical benefits. Thorough workup to exclude alternative causes of stroke and identification of high-risk PFOs through clinical, neuroimaging and echocardiographic criteria are essential. Cost effectiveness of the procedure cannot be proven for the time being, since there are no robust data on clinical outcome after PFO-associated stroke but only limited anecdotal data suggesting low risk for long-term disability.

[Isolated atrial septal aneurysm: Exceptional cause of digital ischemia - a case report]. / Anévrysme isolé du septum interauriculaire : cause exceptionnelle d'ischémie digitale.

An atrial septal aneurysm (ASA) is a rare but well recognized entity characterized by saccular deformity of the atrial septum that bulges into the right or left atrium. Diagnosis can be established using transthoracic and transesophageal echocardiography. Although this abnormality is considered clinically benign, it has been independently associated with systemic or cerebral embolism. We present a unique case of isolated atrial septal aneurysm complicated by digital ischemia in a 51 years old woman.