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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Patent foramen ovale (PFO) is a remnant of the normal fetal circulation consisting in a communication between septum primum and septum secundum. Postnatally, the two septa fuse completing separation of the atria. In 25% of normal individuals incomplete fusion leads to the persistence of the flap valve leaving a PFO. In the recent years a variety of clinical conditions has been associated with or attributed to PFO. In particular, PFO has been implicated in the pathogenesis of cryptogenic stroke/transient ischemic attack due to paradoxical embolism and to the pathogenesis of migraine headache. PFO has also been associated with decompression illness in divers and to minor diseases such as platypnea-orthodeoxia syndrome and high-altitude pulmonary edema. Meta-analyses and observational studies indicate that the prevalence of PFO is approximately 3-fold higher in patients with cryptogenic stroke and migraineurs compared controls. Conversely, observational evidences indicate a 2-3-fold increased prevalence of migraine and cerebrovascular events in PFO carriers. Observational studies and meta-analyses suggest that, compared to optimal medical treatment, transcatheter closure of PFO might significantly reduce the recurrence of ischemic cerebrovascular events in patients with previous stroke/transient ischemic attack; however, albeit mechanical closure of PFO is an attractive alternative to medical therapy, randomized trials supporting the efficacy of this approach have not been completed. Furthermore, about 80% of patients undergoing PFO closure for nonmigraine indications reported improvement in their migraine symptoms. However, these studies were predominantly retrospective, nonrandomized and conducted in highly selected populations. The recently published MIST trial, the only randomized study available, failed to demonstrate a significant favorable effect of PFO closure for migraine resolution and/or migraine improvement. At present, as insufficient evidence exists to support transcatheter PFO closure for prevention of cryptogenic stroke recurrence as well as for migraine therapy, and considering that the procedure is not riskless (major complications occurring in 1.5-2% of patients whose PFO was closed), a very prudent and wise approach is imperative in individual patients when this therapeutic strategy is carried out.
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PMID:[Percutaneous closure of patent foramen ovale: a wise approach]. 1878 80

Economy class stroke syndrome consists of ischemic stroke due to paradoxical embolism through patent foramen ovale after a long flight. Few cases have been described in the literature to date. The treatment choice could be tricky. We present the case of a 65-year-old woman, admitted for submassive pulmonary embolism after a long flight, that presented a paradoxical embolic stroke through patent foramen ovale shortly after. The patient was treated with intravenous thrombolysis within 1 h of stroke onset with a definite symptoms improvement. Afterwards, intravenous unfractioned heparin was started with strict partial thromboplastin time monitoring. Cerebral computed tomography scan, obtained after 24 and 72 h, ruled out hemorrhage. Warfarin was started after 72 h. Patent foramen ovale was percutaneously closed 3 months after. In the reported case, the treatment with thrombolysis and subsequent heparin infusion was effective and safe. We discuss the rationale for this treatment in the light of literature data.
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PMID:Concomitant submassive pulmonary embolism and paradoxical embolic stroke after a long flight: which is the optimal treatment? 1879 74

Patent foramen ovale (PFO) is associated with high prevalence of stroke and systemic embolisation. A 53-year-old man had mitral valve thrombus and PFO diagnosed by echocardiography, in addition to carotid artery stenosis and embolic events including transient ischemia attack, retinal artery occlusion and left kidney infarct. Surgical removal of the mitral valve thrombus and concomitant coronary artery bypass were performed under cardiopulmonary bypass. We believe this is the sole reported case of mitral valve thrombus associated with a PFO. Due to their embolic potential, concomitant PFOs should be closed during heart operations, and independent ones deserve interventional management in high-risk patients.
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PMID:Mitral valve thrombus, embolic events, carotid artery stenosis and patent foramen ovale. 1881 Jul 24

The presence of right-to-left shunt (RLS), which can result in paradoxical brain embolism, is an important etiology of ischemic stroke especially in young adults. However, the characteristic features of RLS and paradoxical brain embolism have not been recognized in detail, especially in Japan. Patent foramen ovale (PFO) and pulmonary arterio-venous fistula are the most important causes of RLS. According to the registered clinical data of 7,245 acute stroke patients obtained by the Strategies Against Stroke Study for Young Adults in Japan (SASSY-Japan), PFO is more frequent in young patients (n = 1,584) than in old patients (n = 5,661) (1.2% vs. 0.7%, p = 0.07). However, the prevalence of PFO in the study was considerably lower than that in previous studies. The low prevalence of PFO in this study was probably due to the limited number of subjects who underwent transesophageal echocardiography (TEE) or other examinations for the detection of RLS. Currently, the golden standard for detecting RLS is contrast-enhanced TEE. Developing a standard method of TEE is very important for the accurate diagnosis of RLS. In recent years, transcranial Doppler ultrasound has been reported to be a noninvasive and useful method for detecting RLS. Ultrasonography is considered to be a most useful method for evaluating venous thrombi, as the source of the embolism. It is recommended that these examinations be carried out immediately after the onset of the stroke. In order to prevent ischemic strokes in patients with RLS, treatment should be provided based on coexisting factors. Patients with other risk factors, such as venous thrombus and a cardiac source of embolism, should be administered anticoagulation therapy and the prothrombin time--international normalized ratio should be closely monitored. The PICCS confirmed that there was no difference in the recurrence rate of embolism between patients who were administered anticoagulation therapy and these administered aspirin therapy, in patients with no other risk factors. Therefore, patients with no other risk factors may be administered antiplatelet therapy.
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PMID:[Paradoxical brain embolism]. 1897 1

Patent foramen ovale (PFO) is thought to be associated with cryptogenic stroke and migraine headache. Saline contrast echocardiography (SCE) is the gold standard for identifying the presence of right-to-left shunt, whether from PFO or pulmonary arteriovenous malformation (PAVM). The timing of left heart contrast entry during SCE is used to distinguish a PFO from a PAVM, a method that is not as specific as previously thought. In this report, we describe a patient with a SCE demonstrating the early appearance of left heart bubbles during good effort Valsalva injections that is ultimately proven to be due to a PAVM. The case illustrates the limited specificity of left heart contrast timing during SCE as the sole criteria for differentiating intracardiac and extracardiac shunts.
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PMID:Use of saline contrast echo timing to distinguish intracardiac and extracardiac shunts: failure of the 3- to 5-beat rule. 1898 96

Patent foramen ovale (PFO) is a remnant of the foetal circulation, found in about a quarter of the population. PFO is an asymptomatic condition and the high prevalence infers that it is in most cases of no or only limited clinical significance. However, recent research has found an increased prevalence of PFO in cryptogenic stroke, decompression illness and migraine. The presence of a PFO has also been associated with oxygen desaturation in conditions such as obstructive pulmonary disease and obstructive sleep apnoea. The rapid evolution and widespread availability of catheter-based closing techniques have further stimulated interest. The seemingly growing significance of PFO will be discussed in this review.
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PMID:The significance of patent foramen ovale: a current review of associated conditions and treatment. 1923 60

Patent foramen ovale (PFO) is reported in up to 50% of patients with cryptogenic stroke. However, the role of PFO in acute myocardial infarction is less reported. In this case report, the relationship between PFO, myocardial infarction, and an interatrial paradoxical thromboembolism (aka thrombus-in-transit) was diagnosed with the use of non-invasive technique, percutaneous procedures, as well as gross surgical specimen.
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PMID:Interatrial thrombus-in-transit resulting in paradoxical thromboembolism. 1929 35

Since the foundations laid by Sacco and Mohr in 1989, from the Stroke data bank, cryptogenic infarctions have had a predominant place among the causes of ischemic strokes. In that study, they accounted for approximately 40% of the stroke causes. Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up; they differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. The size of this group will probably shrink as knowledge advances. Patent foramen ovale (PFO), with or without a septal aneurysm, is more frequent in patients with a cryptogenic infarction. Transesophageal echocardiography is the reference examination for screening for these abnormalities. A meta-analysis of several case-control studies showed a significant association between PFO and stroke in subjects younger than 55 years. For now, these septal abnormalities constitute a risk factor but not a cause. Complex aortic atheroma affecting area upstream of the left subclavian artery may be a source of cerebral embolisms in some conditions. The prevalence of this disease increases with age. It is identified most frequently in patients older than 60 years with a cryptogenic infarction. The thickness of the atheromatous plaque determines whether it is a risk factor or a cause. Recent stroke classifications do not consider carotid atheromatous lesions less than 50% to be a source of ischemic stroke. Nonetheless some studies identify moderate stenosis of the carotid artery more frequently in infarctions of unknown causes than in other categories. The increased risk of cerebral infarction when parents and homozygous twins have a history of stroke suggests that there may be genetic causes that have not yet been detected. An unknown genetic cause would thus be included in the infarctions of unknown causes. A recent study tested for Fabry disease in young patients with a cryptogenic infarction: 4.9% of the men and 2.4% of the women had a functional mutation of the alpha-galactosidase gene. These findings must be confirmed. Some studies suggest an association between cryptogenic infarction and hereditary thrombophilias. Nonetheless the risk attributable to these thrombophilic disorders is slight and the discovery may be only a coincidence. The work described above shows the importance of stratification in the identification of stroke causes: age older or younger than 55/60 years, type of interatrial abnormality (PFO and aneurysms of the interatrial septum), type of atheroma of the aortic arch (more or less than 4mm). They also show the difficulty involved in attributing cause to an identified abnormality: is carotid stenosis of less than 50% a marker of atherosclerosis or also a cause of stroke? To continue improving our understanding of the mechanisms of strokes, new investigational techniques are under evaluation. They include magnetic resonance imaging (MRI), computed tomographic angiography (CT), positron emission tomography (PET) of carotid plaque and of the aortic arch, transcranial Doppler, cardiac recording by telemetry, and even new biological assays.
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PMID:[Cryptogenic cerebral infarction: from classification to concept]. 1939 32

Migraine with aura (MA) is associated with an increased risk of ischemic stroke, especially in young women with vascular risk factors (smoke, contraceptive pill). Patent foramen ovale (PFO) has also been associated with MA. We describe a 41-year-old man, in good health, with MA since 16, familiar history of diabetes, heavy smoker (30 cigarettes/day). Frequency (1-2 attacks/year) and clinical features of migraine have been unchanged since the onset. A few days before our examination he suffered a typical migraine attack. In the following hours, however, the headache became more and more throbbing and the aura symptoms (regressed as usual in 30 min) reappeared and persisted, so he went to an Emergency Department. The CT-scan (without contrast) was normal. The following days he had visual disturbances and spatial disorientation. We found a normal neurological examination and fundus oculi. He referred persisting visual troubles. We prescribed MR + angioMR which confirmed a migrainous infarction and ruled out others pathological conditions. Further tests found out dyslipidemia, hyperhomocysteinemia, impaired glucose tolerance. Transcranial Doppler showed right to left shunting. We also prescribed the screening tests for vasculitis (normal). In our opinion this case highlights the relevance of vascular risk factors in MA complications also in male subjects.
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PMID:Migrainous infarction: association with vascular risk factors in a male subject. 1941 47

Patent Foramen Ovale (PFO) is present in 20 - 25% of the population, and is known to be associated with a number of clinical syndromes. However, it is less clear that there is a causal (or contributory) role for the PFO in the development of thromboembolic stroke, systemic thromboembolization, decompression illness in divers, hypoxemia with obstructive sleep apnea, or migraine headaches. On-going and new randomized prospective trials are testing these relationships and are attempting to prove therapeutic benefit to closing the defects. This paper will review the existing literature on PFO, and will attempt to clarify some of the outstanding clinical management issues.
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PMID:Patent foramen ovale: where are we in 2009? 1941 92


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