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Chandra M, Chandra A, Chakraborty S, Ghosh J. Midbrain infarction in inherited protein S deficiency: a rare association. BMJ Case Rep 2021; 14:e246073. [PMID: 34667051 PMCID: PMC8527143 DOI: 10.1136/bcr-2021-246073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/04/2022] Open
Abstract
Inherited thrombophilic disorders are well-established predisposing factors for venous thromboembolism, but their role in arterial ischaemic stroke is uncertain. The exact mechanism of arterial thrombosis in thrombophilias remains elusive. Herein, we report a case of a 30-year-old woman who was admitted to our facility with sudden-onset right-sided ptosis and ophthalmoplegia. Detailed clinical features, neuroimaging and laboratory evaluation clinched the diagnosis of ischaemic stroke in midbrain due to microvascular obstruction associated with isolated protein S deficiency. She was treated with oral anticoagulant (warfarin) and physiotherapy; without any improvement of her symptoms at 2 months of follow-up. A high index of clinical suspicion is needed in any case of young ischaemic stroke in absence of common cardiac and vascular risk factors, to recognise the presence of inherited thrombophilia.
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Affiliation(s)
- Manali Chandra
- Internal Medicine, Medical College and Hospital Kolkata, Kolkata, West Bengal, India
| | - Atanu Chandra
- Internal Medicine, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Sayantan Chakraborty
- Internal Medicine, Medical College and Hospital Kolkata, Kolkata, West Bengal, India
| | - Joydeep Ghosh
- Internal Medicine, Medical College and Hospital Kolkata, Kolkata, West Bengal, India
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2
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Rhoades R, Tzeng D, Ruggiero N. Secondary stroke prevention in patients with patent foramen ovale. Curr Opin Hematol 2021; 28:292-300. [PMID: 34261880 DOI: 10.1097/moh.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although a patent foramen ovale (PFO) is an established risk factor for cryptogenic ischemic stroke, strategies for secondary prevention remain controversial. Increasing evidence over the past decade from well designed clinical trials supports transcatheter PFO closure for selected patients whose stroke was likely attributable to the PFO. However, patient selection using imaging findings, clinical scoring systems, and in some cases, thrombophilia testing, is crucial for determining patients most likely to benefit from closure, anticoagulation, or antiplatelet therapy. RECENT FINDINGS Recent studies have found that patients with a high Risk of Paradoxical Embolism (RoPE) score and those with a thrombophilia benefit more from closure than medical therapy (including antiplatelet or anticoagulant therapy) alone. Meta-analyses have demonstrated an increased short-term risk of atrial fibrillation in closure patients, and that residual shunt after closure predicts stroke recurrence. Last, recent data have been inconclusive as to whether patients receiving medical therapy only benefit more from anticoagulation or antiplatelet therapy, so this remains an area of controversy. SUMMARY Transcatheter PFO closure is an evidence-based, guideline-supported therapy for secondary stroke prevention in patients with a PFO and cryptogenic stroke. However, proper patient selection is critical to achieve benefit, and recent studies have helped clarify those patients most likely to benefit from closure.
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Affiliation(s)
| | | | - Nicholas Ruggiero
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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3
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D'Andrea A, Dweck MR, Holte E, Fontes-Carvalho R, Cameli M, Aboumarie HS, Diener HC, Haugaa KH. EACVI survey on the management of patients with patent foramen ovale and cryptogenic stroke. Eur Heart J Cardiovasc Imaging 2021; 22:135-141. [PMID: 33346351 DOI: 10.1093/ehjci/jeaa318] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke. METHODS AND RESULTS In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended. CONCLUSION Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Umberto I_ Hospital, Luigi Vanvitelli University - Nocera Inferiore (ASL Salerno), Viale San Francesco - 84014 Caserta, Italy
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, Department of Cardiology, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Espen Holte
- Department of Cardiology, St. Olavs Hospital, Postboks 3250 Torgarden, 7006 Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, PO Box 8905, 7491 Trondheim, Norway
| | - Ricardo Fontes-Carvalho
- Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico Le Scotte, Viale Bracci 16, 53100 Siena, Italy
| | - Hatem Soliman Aboumarie
- Department of Cardiology - Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, UB9 6JH London, UK
| | - Hans Christoph Diener
- Department of Neurology - Medical Faculty of the University Duisburg-Essen-Institute for Medical Informatics, Biometry and Epidemiology, Hufelandstraße, 26, 45147 Essen, Germany
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.,Department of Cardiology - Institute for Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
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4
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1014] [Impact Index Per Article: 338.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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5
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Ben-Assa E, Herrero-Garibi J, Cruz-Gonzalez I, Elmariah S, Rengifo-Moreno P, Al-Bawardy R, Sakhuja R, Lima FV, Demirjian ZN, Ning M, Buonanno FS, Inglessis I, Palacios IF. Efficacy and safety of percutaneous patent foramen ovale closure in patients with a hypercoagulable disorder. Catheter Cardiovasc Interv 2021; 98:800-807. [PMID: 34132472 DOI: 10.1002/ccd.29835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 05/19/2021] [Accepted: 06/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduces the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from large randomized trials. OBJECTIVES We compared the safety and efficacy of percutaneous PFO closure in patients with and without a hypercoagulable state. METHODS Data from 800 consecutive patients undergoing percutaneous PFO closure in our medical center were analyzed. All patients were independently evaluated by specialists in neurology, cardiology, hematology, and vascular medicine. A post-procedural treatment of at least 3 months of anticoagulation was utilized in patients with thrombophilia. Follow-up events included death, recurrent neurological events, and the need for reintervention for significant residual shunt. RESULTS A hypercoagulable state was found in 239 patients (29.9%). At median follow-up of 41.9 months, there were no differences in the frequencies of stroke or transient ischemic attack between patients with or without thrombophilia (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p = 0.35). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success, or complications between groups. CONCLUSION Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state.
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Affiliation(s)
- Eyal Ben-Assa
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cardiology Division, Assuta Ashdod University Hospital, Ben Gurion University, Ashdod, Israel
| | - Jesús Herrero-Garibi
- Servicio de Cardiología, Hospital Clínico Universitario de Salamanca-IBSAL, CIBERCV, Salamanca, Spain
| | - Ignacio Cruz-Gonzalez
- Servicio de Cardiología, Hospital Clínico Universitario de Salamanca-IBSAL, CIBERCV, Salamanca, Spain
| | - Sammy Elmariah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Rasha Al-Bawardy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rahul Sakhuja
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabio V Lima
- Division of Cardiology, Warren Alpert Medical School of Brown University and Rhode Island Hospital Cardiovascular Institute, Providence, Rhode Island, USA
| | - Zareh N Demirjian
- Hematology Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mingming Ning
- Department of Neurology and Cardio-Neurology Clinic, Clinical Proteomics Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ferdinando S Buonanno
- Department of Neurology and Cardio-Neurology Clinic, Clinical Proteomics Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ignacio Inglessis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Igor F Palacios
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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6
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Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
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7
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He D, Li Q, Xu G, Hu Z, Li X, Guo Y, Xu S, Wang W, Luo X. Clinical and imaging characteristics of PFO-related stroke with different amounts of right-to-left shunt. Brain Behav 2018; 8:e01122. [PMID: 30311435 PMCID: PMC6236234 DOI: 10.1002/brb3.1122] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Right-to-left shunt (RLS) induced by a patent foramen ovale (PFO) is associated with an increased risk of cryptogenic stroke (CS). However, little is known about the relationship between the amount of RLS and the stroke pattern. In this study, we aimed to evaluate the distinct clinical features of PFO-related CS in different RLS degrees resulting from PFO. METHODS This is a cohort study of 222 CS patients admitted to the Tongji Hospital from 1st May 2014 to 31st April 2017. All patients underwent contrast transcranial Doppler examination. And then, 121 (54.5%) were classified as non-RLS group, while 76 (34.2%) were classified as mild RLS group and 25 (11.3%) were large RLS group according to the number of micro-emboli signals. The groups were compared with respect to their clinical and neuroimaging characteristics. RESULTS In terms of risk factors of stroke, the prevalence of hypertension was lower in mild group (p = 0.002). Regarding the infarct patterns in different CS patients, we found that the multiple cortical lesions were more frequently observed (p<0.001) with increasing RLS in DWI. Moreover, there was a rising trend in the proportion of small lesions (≤1 cm) with an increasing RLS (p < 0.01). And as RLS increased, the posterior circulation was more likely to be influenced (p < 0.05). In addition, the serum cholesterol concentration was lower in the large RLS group, compared to the non-RLS group (p = 0.003) and mild RLS group (p = 0.008). While the mean platelet volume (MPV) in mild group was significantly higher than that of non-RLS group (p = 0.013). CONCLUSION Patients with larger RLS show more infarction in posterior circulation, higher frequency of small lesions or multiple cortical lesions. The results of our study indicate that the infarct patterns might be a clue of PFO-related stroke.
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Affiliation(s)
- Dan He
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qian Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Department of Neurology, Shenzhen Shekou People's Hospital, Shenzhen, China
| | - Guangjin Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zheng Hu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xuefei Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yinping Guo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shabei Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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8
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Alhazzani AA, Kumar A, Selim M. Association between Factor V Gene Polymorphism and Risk of Ischemic Stroke: An Updated Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:1252-1261. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/20/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022] Open
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9
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Putaala J, Martinez-Majander N, Saeed S, Yesilot N, Jäkälä P, Nerg O, Tsivgoulis G, Numminen H, Gordin D, von Sarnowski B, Waje-Andreassen U, Ylikotila P, Roine RO, Zedde M, Huhtakangas J, Fonseca C, Redfors P, de Leeuw FE, Pezzini A, Kõrv J, Schneider S, Tanislav C, Enzinger C, Jatuzis D, Siegerink B, Martínez-Sánchez P, Grau AJ, Palm F, Groop PH, Lanthier S, Ten Cate H, Pussinen P, Paju S, Sinisalo J, Lehto M, Lindgren A, Ferro J, Kittner S, Fazekas F, Gerdts E, Tatlisumak T. Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Triggers, Causes, and Outcome (SECRETO): Rationale and design. Eur Stroke J 2017; 2:116-125. [PMID: 31008307 PMCID: PMC6453214 DOI: 10.1177/2396987317703210] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/22/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Worldwide, about 1.3 million annual ischaemic strokes (IS) occur in adults aged <50 years. Of these early-onset strokes, up to 50% can be regarded as cryptogenic or associated with conditions with poorly documented causality like patent foramen ovale and coagulopathies. KEY HYPOTHESES/AIMS (1) Investigate transient triggers and clinical/sub-clinical chronic risk factors associated with cryptogenic IS in the young; (2) use cardiac imaging methods exceeding state-of-the-art to reveal novel sources for embolism; (3) search for covert thrombosis and haemostasis abnormalities; (4) discover new disease pathways using next-generation sequencing and RNA gene expression studies; (5) determine patient prognosis by use of phenotypic and genetic data; and (6) adapt systems medicine approach to investigate complex risk-factor interactions. DESIGN Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is a prospective multi-centre case-control study enrolling patients aged 18-49 years hospitalised due to first-ever imaging-proven IS of undetermined etiology. Patients are examined according to a standardised protocol and followed up for 10 years. Patients are 1:1 age- and sex-matched to stroke-free controls. Key study elements include centralised reading of echocardiography, electrocardiography, and neurovascular imaging, as well as blood samples for genetic, gene-expression, thrombosis and haemostasis and biomarker analysis. We aim to have 600 patient-control pairs enrolled by the end of 2018. SUMMARY SECRETO is aiming to establish novel mechanisms and prognosis of cryptogenic IS in the young and will provide new directions for therapy development for these patients. First results are anticipated in 2019.
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Affiliation(s)
- Jukka Putaala
- Department of Neurology, Helsinki
University Hospital, Finland
| | | | - Sahrai Saeed
- Department of Clinical Science,
University of Bergen, Norway
| | - Nilufer Yesilot
- Department of Neurology, Istanbul
Faculty of Medicine, Istanbul University, Turkey
| | - Pekka Jäkälä
- Neuro Center, Kuopio University
Hospital, Finland
| | - Ossi Nerg
- Neuro Center, Kuopio University
Hospital, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, National
and Kapodistrian University of Athens, Attikon University Hospital, Greece
| | - Heikki Numminen
- Department of Neuroscience and
Rehabilitation, Tampere University Hospital, Finland
| | - Daniel Gordin
- Folkhälsan Institute of Genetics,
Folkhälsan Research Center, Biomedicum Helsinki, University of Helsinki,
Finland
| | | | | | - Pauli Ylikotila
- Division of Clinical Neurosciences,
Turku University Hospital, University of Turku, Finland
| | - Risto O Roine
- Division of Clinical Neurosciences,
Turku University Hospital, University of Turku, Finland
| | | | | | - Catarina Fonseca
- Department of Neurosciences
(Neurology), Hospital de Santa Maria, University of Lisbon, Portugal
| | - Petra Redfors
- Department of Clinical Neuroscience,
Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of
Gothenburg, Sweden
- Department of Neurology, Sahlgrenska
University Hospital, Sweden
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders
Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Radboud
University Medical Center, The Netherlands
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Italy
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Estonia
| | | | | | - Christian Enzinger
- Division of Neuroradiology, Vascular
and Interventional Radiology, Medical University of Graz, Austria
| | - Dalius Jatuzis
- Department of Neurology and
Neurosurgery, Center for Neurology, Vilnius University, Lithuania
| | - Bob Siegerink
- Centre for Stroke Research Berlin,
Charité Universitätsmedizin Berlin, Germany
| | - Patricia Martínez-Sánchez
- Department of Neurology and Stroke
Centre, IdiPAZ Health Research Institute, La Paz University Hospital, Autonoma of
Madrid University, Spain
| | - Armin J Grau
- Department of Neurology, Klinikum
Ludwigshafen, Germany
| | | | - Per-Henrik Groop
- Folkhälsan Institute of Genetics,
Folkhälsan Research Center, Biomedicum Helsinki, University of Helsinki,
Finland
| | - Sylvain Lanthier
- Division of Neurology and Research
Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Canada
| | - Hugo Ten Cate
- Department of Internal Medicine,
Cardiovascular Research Institute Maastricht, The Netherlands
| | - Pirkko Pussinen
- Oral and Maxillofacial Diseases,
University of Helsinki and Helsinki University Hospital, Finland
| | - Susanna Paju
- Oral and Maxillofacial Diseases,
University of Helsinki and Helsinki University Hospital, Finland
| | - Juha Sinisalo
- Department of Cardiology, Heart and
Lung Center, Helsinki University Hospital, Finland
| | - Mika Lehto
- Department of Cardiology, Heart and
Lung Center, Helsinki University Hospital, Finland
| | - Arne Lindgren
- Department of Clinical Sciences Lund,
Neurology, Lund University, Sweden
- Department of Neurology and
Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - José Ferro
- Department of Neurosciences
(Neurology), Hospital de Santa Maria, University of Lisbon, Portugal
| | - Steven Kittner
- Department of Neurology, Baltimore
Veterans Administration Hospital, USA
- University of Maryland, USA
| | - Franz Fazekas
- Department of Neurology, Medical
University of Graz, Austria
| | - Eva Gerdts
- Department of Clinical Science,
University of Bergen, Norway
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki
University Hospital, Finland
- Department of Clinical Neuroscience,
Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of
Gothenburg, Sweden
- Department of Neurology, Sahlgrenska
University Hospital, Sweden
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10
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Romac R, Barak O, Glavas D, Susilovic Grabovac Z, Lozo P, Roje I, Caljkusic K, Drmic-Hofman I, Davis JT, Dujic Z, Lovering AT. Characterization of blood flow through intrapulmonary arteriovenous anastomoses and patent foramen ovale at rest and during exercise in stroke and transient ischemic attack patients. Echocardiography 2017; 34:676-682. [DOI: 10.1111/echo.13519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Rinaldo Romac
- Department of Neurology; University Hospital Center Split; Split Croatia
| | - Otto Barak
- Department of Integrative Physiology; University of Split School of Medicine; Split Croatia
- Faculty of Medicine; University of Novi Sad; Novi Sad Serbia
| | - Duska Glavas
- Division of Cardiology; Department of Internal Medicine; University Hospital Center Split; Split Croatia
| | - Zora Susilovic Grabovac
- Division of Cardiology; Department of Internal Medicine; University Hospital Center Split; Split Croatia
| | - Petar Lozo
- Division of Cardiology; Department of Internal Medicine; University Hospital Center Split; Split Croatia
| | - Igor Roje
- Department of Neurology; University Hospital Center Split; Split Croatia
| | - Kresimir Caljkusic
- Department of Anesthesiology; University Hospital Center Split; Split Croatia
| | - Irena Drmic-Hofman
- Department of Pathology, Forensic Medicine and Cytology; University Hospital Center Split; Split Croatia
- Department of Medical Chemistry and Biochemistry; University of Split School of Medicine; Split Croatia
| | - James T. Davis
- Department of Kinesiology, Recreation and Sport; Indiana State University; Terre Haute IN USA
| | - Zeljko Dujic
- Department of Integrative Physiology; University of Split School of Medicine; Split Croatia
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Abstract
A patent foramen ovale (PFO) is common and found in nearly 25% of healthy individuals. The majority of patients with PFO remain asymptomatic and they are not at increased risk for developing a stroke. The presence of PFO, however, has been found to be higher in patients with cryptogenic stroke, suggesting there may be a subset of patients with PFO who are indeed at risk for stroke. Paradoxical embolization of venous thrombi through the PFO, which then enter the arterial circulation, is hypothesized to account for this relationship. Although aerated-saline transesophageal echocardiography is the gold standard for diagnosis, aerated-saline transthoracic echocardiography and transcranial Doppler are often used as the initial diagnostic tests for detecting PFO. Patients with cryptogenic stroke and PFO are generally treated with antiplatelet therapy in the absence of another condition for which anticoagulation is necessary. Based on the findings of 3 large randomized clinical trials, current consensus guidelines do not recommend percutaneous closure, though this is an area of controversy. The following review discusses the relationship of PFO and cryptogenic stroke, focusing on the epidemiology, pathophysiological mechanisms, diagnostic tools, associated clinical/anatomic factors and treatment. (Circ J 2016; 80: 1665-1673).
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12
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Homma S, Messé SR, Rundek T, Sun YP, Franke J, Davidson K, Sievert H, Sacco RL, Di Tullio MR. Patent foramen ovale. Nat Rev Dis Primers 2016; 2:15086. [PMID: 27188965 DOI: 10.1038/nrdp.2015.86] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.
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Affiliation(s)
- Shunichi Homma
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Yee-Ping Sun
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Karina Davidson
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
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13
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Alushi B, Biasco L, Orzan F, Omedé P, Sciuto F, Moretti C, Belli R, Defilippi G, Barisone G, Cerrato P, Gaita F. Patent foramen ovale treatment strategy: an Italian large prospective study. J Cardiovasc Med (Hagerstown) 2015; 15:761-8. [PMID: 24978876 DOI: 10.2459/jcm.0000000000000138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM There is still controversy regarding the benefit of percutaneous closure of patent foramen ovale (PFO) among patients with cryptogenic stroke. Here we aimed to evaluate the factors associated with treatment choice and predictors of adverse events in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO. METHODS Of 418 consecutive patients with PFO and cryptogenic stroke or TIA, 262 underwent percutaneous PFO closure, whereas 156 were medically treated. Multivariable logistic regression models were developed to evaluate factors influencing the treatment strategy and predictors of outcome, a composite of stroke, TIA or all-cause mortality. RESULTS Patients with large interatrial right-to-left shunt were more likely treated with percutaneous closure [odds ratio (OR) = 4.79, 95% confidence interval (2.73-8.42); P < 0.0001], whereas those with multiple cerebrovascular accident (CVA) risk factors were more likely treated medically [OR = 0.15 (0.03-0.60); P = 0.023]. Age greater than 55 years [OR = 2.70 (1.05-6.88); P = 0.04], previous CVAs [OR = 2.49 (1.03-6.02); P = 0.02] and atrial septal aneurism [ASA, OR = 2.64 (1.09-6.39); P = 0.02], but not percutaneous closure of PFO [OR = 1.10 (0.44-2.74); P = 0.81], were independent predictors of outcome. CONCLUSION Among patients with cryptogenic stroke and PFO, the presence of large interatrial right-to-left shunt and multiple CVA risk factors influenced the treatment choice. Older age, multiple previous CVAs and ASA, but not PFO closure, independently predicted the composite outcome of cryptogenic stroke, TIA or all-cause mortality.
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Affiliation(s)
- Brunilda Alushi
- aDivision of Cardiology, University of Turin, San Giovanni Battista Hospital, Turin, Italy bDivision of Cardiology, Maria Vittoria Hospital, Turin, Italy cDivision of Cardiology, Cardinal Massaia Hospital, Asti, Italy dDepartment of Neuroscience, San Giovanni Battista Hospital, Turin, Italy
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14
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Kalaria C, Kittner S. The Therapeutic Value of Laboratory Testing for Hypercoagulable States in Secondary Stroke Prevention. Neurol Clin 2015; 33:501-13. [DOI: 10.1016/j.ncl.2015.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Calabrò RS, Pezzini A, Casella C, Bramanti P, Triolo O. Ischaemic stroke provoked by sexual intercourse. J Clin Neurosci 2013; 20:1316-7. [DOI: 10.1016/j.jocn.2012.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/24/2012] [Accepted: 10/04/2012] [Indexed: 10/26/2022]
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16
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Lantz M, Sjöstrand C, Kostulas K. Ischemic Stroke and Patent Foramen Ovale: Risk Factors and Genetic Profile. J Stroke Cerebrovasc Dis 2013; 22:841-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/28/2012] [Accepted: 06/04/2012] [Indexed: 10/28/2022] Open
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17
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Pristipino C, Anzola GP, Ballerini L, Bartorelli A, Cecconi M, Chessa M, Donti A, Gaspardone A, Neri G, Onorato E, Palareti G, Rakar S, Rigatelli G, Santoro G, Toni D, Ussia GP, Violini R. Management of patients with patent foramen ovale and cryptogenic stroke: A collaborative, multidisciplinary, position paper. Catheter Cardiovasc Interv 2013; 82:E38-51. [DOI: 10.1002/ccd.24637] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 08/28/2012] [Indexed: 11/09/2022]
Affiliation(s)
- Christian Pristipino
- Clinical Research Centre and Cardiovascular Department; San Filippo Neri Hospital; Roma; Italy
| | | | - Luigi Ballerini
- Women and Children Department; S. Carlo Hospital; Potenza; Italy
| | - Antonio Bartorelli
- Interventional Cardiology Area; Monzino Cardiology Centre; Milano; Italy
| | - Moreno Cecconi
- Cardiological; Medical and Surgical Sciences Department; University United Hospitals; Ancona; Italy
| | - Massimo Chessa
- Pediatric Cardiology and Adult with Congenital Heart Disease Department; IRCCS Policlinico San Donato; San Donato Milanese; Italy
| | - Andrea Donti
- Pediatric and Developmental Age Cardiology-Bologna University-S. Orsola Malpighi Hospital; Bologna; Italy
| | | | | | | | - Gualtiero Palareti
- Angiology and Coagulation Disorders Unit-S.Orsola Malpighi Hospital; Bologna; Italy
| | - Serena Rakar
- Cardiology Department; Cattinara Hospital; Trieste; Italy
| | - Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Department; Rovigo General Hospital; Rovigo; Italy
| | - Gennaro Santoro
- Cardiology and Vessel Department; Careggi Hospital; Firenze; Italy
| | - Danilo Toni
- Neurology and Psychiatry Department; Sapienza University; Roma; Italy
| | - Gian Paolo Ussia
- Invasive Cardiology Unit, Ferrarotto Hospital; Catania University; Catania; Italy
| | - Roberto Violini
- Interventional Cardiology Unit; San Camillo Hospital; Roma; Italy
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18
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Favaretto E, Sartori M, Conti E, Legnani C, Palareti G. G1691A factor V and G20210A FII mutations, acute ischemic stroke of unknown cause, and patent foramen ovale. Thromb Res 2012; 130:720-4. [DOI: 10.1016/j.thromres.2012.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 06/17/2012] [Accepted: 07/17/2012] [Indexed: 12/22/2022]
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19
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Udar kryptogenny – drożny otwór owalny – migrena z aurą: przypadkowa triada czy związek przyczynowo-skutkowy? Część I. Neurol Neurochir Pol 2012; 46:161-8. [DOI: 10.5114/ninp.2012.28259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Pezzini A. Genetic determinants of juvenile stroke. Thromb Res 2011; 129:330-5. [PMID: 22113147 DOI: 10.1016/j.thromres.2011.10.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 10/28/2011] [Accepted: 10/30/2011] [Indexed: 10/15/2022]
Abstract
Stroke is a heterogeneous multifactorial disorder. Although epidemiological data from twin and family studies provide substantial evidence for a genetic basis for stroke, the contribution of genetic factors identified so far is small. Large progress has been made in single-gene disorders associated with ischemic stroke, particularly at young age. The identification of NOTCH3 mutations in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) and of TREX1 mutations in retinal vasculopathy with cerebral leukodystrophy (RVCL) have led to new insights on lacunar stroke and small-vessel disease. Studies of sickle-cell disease have drawn attention to the importance of modifier genes and of gene-gene interactions in determining stroke risk, while there is now evidence that Fabry disease is an underdiagnosed cause of stroke. Furthermore, stroke is a well-known complication of several heritable connective tissue disorders, including Marfan's syndrome (FBN1 mutations) and Ehlers-Danlos syndrome type IV (COL3A1 mutations), which predispose to cervical artery dissection, the most frequent cause of cerebral ischemia at young age. By contrast, little is known about the genes associated with multifactorial stroke. The reported genome-wide association studies of ischemic stroke have shown that no single common genetic variant imparts major risk. Pharmacogenomic studies have uncovered genetic determinants of response to warfarin, statins and clopidogrel. Larger studies with samples numbering in the thousands are ongoing to identify common variants with smaller effects on risk. This approach will contribute to the identification of additional genes, novel pathways, and eventually novel therapeutic approaches to cerebrovascular disorders.
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Affiliation(s)
- Alessandro Pezzini
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia.
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21
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Hamedani AG, Cole JW, Cheng Y, Sparks MJ, O'Connell JR, Stine OC, Wozniak MA, Stern BJ, Mitchell BD, Kittner SJ. Factor V leiden and ischemic stroke risk: the Genetics of Early Onset Stroke (GEOS) study. J Stroke Cerebrovasc Dis 2011; 22:419-23. [PMID: 22100829 DOI: 10.1016/j.jstrokecerebrovasdis.2011.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/14/2011] [Accepted: 10/15/2011] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Factor V Leiden (FVL) has been associated with ischemic stroke in children but not in adults. Although the FVL mutation is associated with increased risk for venous thrombosis, its association with ischemic stroke in young adults remains uncertain. Therefore, we examined the association between FVL and ischemic stroke in participants of the Genetics of Early Onset Stroke (GEOS) study. METHODS A population-based case control study identified 354 women and 476 men 15 to 49 years of age with first-ever ischemic stroke and 907 controls. Participant-specific data included vascular risk factors, FVL genotype and, for cases, the ischemic stroke subtype by modified Trial of ORG 10172 in Acute Stroke criteria. Logistic regression was used to calculate odds ratios for the entire population and for subgroups stratified by risk factors and ischemic stroke subtype. RESULTS The frequency of the FVL mutation was similar between ischemic stroke patients (3.6%; 95% confidence interval [CI] 2.5%-5.1%) and nonstroke controls (3.8%; 95% CI 2.7%-5.2%). This frequency did not change significantly when cases were restricted to patients with stroke of undetermined etiology (4.1%; 95% CI 2.6%-6.4%). CONCLUSIONS Among young adults, we found no evidence for an association between FVL and either all ischemic stroke or the subgroup with stroke of undetermined etiology.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland 21201-1509, USA
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22
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Abstract
Factor V Leiden is a genetic disorder characterized by a poor anticoagulant response to activated Protein C and an increased risk for venous thromboembolism. Deep venous thrombosis and pulmonary embolism are the most common manifestations, but thrombosis in unusual locations also occurs. The current evidence suggests that the mutation has at most a modest effect on recurrence risk after initial treatment of a first venous thromboembolism. Factor V Leiden is also associated with a 2- to 3-fold increased relative risk for pregnancy loss and possibly other obstetric complications, although the probability of a successful pregnancy outcome is high. The clinical expression of Factor V Leiden is influenced by the number of Factor V Leiden alleles, coexisting genetic and acquired thrombophilic disorders, and circumstantial risk factors. Diagnosis requires the activated Protein C resistance assay (a coagulation screening test) or DNA analysis of the F5 gene, which encodes the Factor V protein. The first acute thrombosis is treated according to standard guidelines. Decisions regarding the optimal duration of anticoagulation are based on an individualized assessment of the risks for venous thromboembolism recurrence and anticoagulant-related bleeding. In the absence of a history of thrombosis, long-term anticoagulation is not routinely recommended for asymptomatic Factor V Leiden heterozygotes, although prophylactic anticoagulation may be considered in high-risk clinical settings. In the absence of evidence that early diagnosis reduces morbidity or mortality, decisions regarding testing at-risk family members should be made on an individual basis.
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23
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Calabrò RS, Gervasi G, Bramanti P. Can interaction between atrial septal abnormalities and genetic prothrombotic polymorphisms play a role in cryptogenic ischemic stroke? Description of a family. Neurol Sci 2011; 33:117-9. [PMID: 21614578 DOI: 10.1007/s10072-011-0635-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 05/13/2011] [Indexed: 10/18/2022]
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24
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Pezzini A, Grassi M, Lodigiani C, Patella R, Gandolfo C, Casoni F, Musolino R, Calabrò RS, Bovi P, Adami A, DeLodovici ML, Del Zotto E, Rota LL, Rasura M, Del Sette M, Giossi A, Volonghi I, Zini A, Cerrato P, Costa P, Magoni M, Iacoviello L, Padovani A. Predictors of Migraine Subtypes in Young Adults With Ischemic Stroke. Stroke 2011; 42:17-21. [DOI: 10.1161/strokeaha.110.592246] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The mechanisms underlying the relationship between migraine and ischemic stroke remain uncertain. The aim of the present study was to investigate the predictive value of major cardiovascular risk factors, cardiac interatrial abnormalities, and additional biological markers on migraine subtypes in young adults with ischemic stroke.
Methods—
Ischemic stroke patients aged 45 years or younger were consecutively enrolled as part of the Italian Project on Stroke in Young Adults. A comprehensive evaluation was performed including assessment of self-reported migraine and cardiovascular risk factors, interatrial right-to-left shunt, and genotyping to detect factor V Leiden and the G20210A mutation in the prothrombin gene.
Results—
Nine hundred eighty-one patients (mean age, 36.0±7.6 years; 50.7% women) were included. The risk of migraine with aura increased with decreasing number of cardiovascular risk factors (OR, 0.50; 95% CI, 0.24–0.99 for 2 factors or more), increasing number of thrombophilic variants (OR, 2.21; 95% CI, 1.05–4.68 for carriers of at least 1 of the 2), and the presence of right-to-left shunt (OR, 2.41; 95% CI, 1.37–3.45), as compared to patients without migraine. None of these factors had influence on the risk of migraine without aura.
Conclusions—
In young adults with ischemic stroke, low cardiovascular risk profile, right-to-left shunt, and an underlying procoagulant state are predictors of migraine with aura. The biological effects of these factors should be considered in future studies aimed at investigating the mechanisms linking migraine to brain ischemia.
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Affiliation(s)
- Alessandro Pezzini
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Mario Grassi
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Corrado Lodigiani
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Rosalba Patella
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Carlo Gandolfo
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Federica Casoni
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Rossella Musolino
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Rocco Salvatore Calabrò
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Paolo Bovi
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Alessandro Adami
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Maria Luisa DeLodovici
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Elisabetta Del Zotto
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Lidia Luciana Rota
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Maurizia Rasura
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Massimo Del Sette
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Alessia Giossi
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Irene Volonghi
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Andrea Zini
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Paolo Cerrato
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Paolo Costa
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Mauro Magoni
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Licia Iacoviello
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
| | - Alessandro Padovani
- From the Dipartimento di Scienze Mediche e Chirurgiche (A. Pezzini, E.D.Z., A.G., I.V., P.C., A. Padovani), Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia; Dipartimento di Scienze Sanitarie Applicate (M.G.), Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italia; Centro Trombosi (C.L., L.L.R.), IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italia; Stroke Unit (R.P., M.R.), Azienda Ospedaliera Sant'Andrea, Roma, Italia; Dipartimento di
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Patent foramen ovale and stroke: Should PFOs be closed in otherwise cryptogenic stroke? Curr Atheroscler Rep 2010; 12:251-8. [PMID: 20461560 DOI: 10.1007/s11883-010-0114-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Since initial reports of its association with ischemic stroke appeared in 1988, there has been continued controversy regarding the existence and strength of the association between patent foramen ovale (PFO) and ischemic stroke. Many case-control studies have reported an association between incident cryptogenic ischemic stroke and PFO, yet population-based studies have failed to confirm this association. Studies of the risk of recurrent stroke in patients with cryptogenic stroke with or without PFO have not shown an increased risk of recurrent stroke in patients with PFO. Meanwhile, use of devices to close PFOs and atrial septal defects percutaneously has increased dramatically since their introduction. Completion of the randomized clinical trials of PFO closure currently in progress is vital to determine if the benefits of PFO closure in cryptogenic stroke outweigh its risks.
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Hamedani AG, Cole JW, Mitchell BD, Kittner SJ. Meta-analysis of factor V Leiden and ischemic stroke in young adults: the importance of case ascertainment. Stroke 2010; 41:1599-603. [PMID: 20616326 DOI: 10.1161/strokeaha.110.581256] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The factor V Leiden mutation is associated with ischemic stroke in children but not in adults. Whether it is associated with ischemic stroke in young adults, however, is uncertain. METHODS To address this issue, we performed a meta-analysis of 18 case-control studies of ischemic stroke in adults 50 years of age and younger published before June 2009. RESULTS Across all studies, factor V Leiden was detected in 154 of 2045 cases (7.5%) and 217 of 5307 controls (4.1%), yielding a fixed-effect odds ratio of 2.00 (95% CI, 1.59-2.51). However, further analyses revealed substantial heterogeneity among these studies (P=0.005 for Q-test of heterogeneity). Hypothesizing that this heterogeneity could be related to differences among studies in case selection criteria, we stratified the meta-analysis into studies for which case samples were enriched or not enriched to include cases having an increased likelihood of prothrombotic genetic involvement ("selected" ischemic stroke studies, n=9) and those that recruited cases from consecutive neurology referrals or hospitalizations ("unselected" ischemic stroke studies, n=8). Among the 9 "selected" ischemic stroke studies, factor V Leiden was more strongly associated with stroke (OR, 2.73; 95% CI, 1.98-3.75), whereas among the 8 "unselected" ischemic stroke studies, the association between factor V Leiden and stroke was substantially weaker (OR, 1.40; 95% CI, 0.998-1.95). This difference was found to be statistically significant (P=0.003 for Woolf test for heterogeneity). CONCLUSIONS We conclude that factor V Leiden is associated with ischemic stroke in young adults, particularly in patient populations in which there is an increased clinical suspicion of prothrombotic state.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201-1509, USA
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