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Badea RŞ, Ribigan AC, Grecu N, Terecoasǎ E, Antochi FA, Bâldea Mihǎilǎ S, Tiu C, Popescu BO. Differences in clinical and biological factors between patients with PFO-related stroke and patients with PFO and no cerebral vascular events. Front Neurol 2023; 14:1104674. [PMID: 36998773 PMCID: PMC10043389 DOI: 10.3389/fneur.2023.1104674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
BackgroundWhile stroke is one of the most dissected topics in neurology, the primary prevention of PFO-related stroke in young patients is still an unaddressed subject. We present a study concerning clinical, demographic, and laboratory factors associated with stroke and transient ischemic attack in patients with patent foramen ovale (PFO), as well as comparing PFO-patients with and without cerebrovascular ischemic events (CVEs).Patients and methodsConsecutive patients with PFO-associated CVEs were included in the study; control group was selected from patients with a PFO and no history of stroke. All participants underwent peripheral routine blood analyses, as well as, on treating physician's recommendations, screening for thrombophilia.ResultsNinety-five patients with CVEs and 41 controls were included. Females had a significantly lower risk of CVEs than males (p = 0.04). PFO size was similar between patients and controls. Patients with CVEs had more often hypertension (n = 33, 34.7%), p = 0.007. No significant differences were found between the two groups with regard to routine laboratory tests and thrombophilia status. Hypertension and gender were identified in a binomial logistic regression model as independent predictors for CVEs, but with an area under the ROC curve of 0.531, suggesting a very poor level of discrimination between the two groups.Discussion and conclusionsThere is little difference between patients with PFO with and without CVEs in terms of PFO size and routine laboratory analyses. While still a controversial topic in the specialty literature, classic first-level thrombophilic mutations are not a risk factor for stroke in patients with PFO. Hypertension and male gender were identified as factors associated with a higher risk of stroke in the setting of PFO.
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Affiliation(s)
- Raluca Ştefania Badea
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
- *Correspondence: Raluca Ştefania Badea
| | - Athena Cristina Ribigan
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Nicolae Grecu
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Elena Terecoasǎ
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Florina Anca Antochi
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Sorina Bâldea Mihǎilǎ
- Cardiology and Cardiovascular Surgery Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, Bucharest, Romania
| | - Cristina Tiu
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- Neurology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, Colentina Clinical Hospital, Bucharest, Romania
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Pristipino C, Germonpré P, Toni D, Sievert H, Meier B, D'Ascenzo F, Berti S, Onorato E, Bedogni F, Mas JL, Scacciatella P, Hildick-Smith D, Gaita F, Kyrle P, Thomson J, Derumeaux G, Sibbing D, Chessa M, Hornung M, Zamorano J, Dudek D. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. EUROINTERVENTION 2021; 17:e367-e375. [PMID: 33506796 PMCID: PMC9724983 DOI: 10.4244/eij-d-20-00785] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
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Affiliation(s)
- Christian Pristipino
- San Filippo Neri - ASL Roma 1 Hospital, Via Alessandro Poerio 140, 00152 Rome, Italy
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Horst Sievert
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom,University California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Fabrizio D'Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Jean-Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Massimo Chessa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marius Hornung
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany
| | | | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland,Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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3
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Deng Y, Huang X, Wang G, Cao J, Wang S, Li Y, Wang Y, Ye J, Zhang P, Chen X, Luo Y, He K. Applicability of Transthoracic Contrast Echocardiography for the Diagnosis and Treatment of Idiopathic Pulmonary Arteriovenous Malformations. Front Cardiovasc Med 2021; 8:656702. [PMID: 34322523 PMCID: PMC8311437 DOI: 10.3389/fcvm.2021.656702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/21/2021] [Indexed: 12/27/2022] Open
Abstract
Objective: To explore the preferred test to screen for pulmonary arteriovenous malformations (PAVMs) and to predict the probability of interventional embolization. Methods: We performed a retrospective observational study evaluating patients with idiopathic PAVMs from 2009 to 2019. After clinical evaluation, a total of 105 patients were studied, including 71 patients with positive digital subtraction pulmonary angiography (DSPA) findings and 34 with negative DSPA findings. The following patient data were assessed: blood test, chest radiograph, transthoracic contrast echocardiography (TTCE), and DSPA findings. Results: The majority of patients with idiopathic PAVMs were female (66.2% with positive DSPA findings). We found a good κ-coefficient of 0.77 with strong consistency for inter observer agreement concerning the pulmonary right-to-left shunt (RLS) grade on TTCE, which was superior to conventional chest radiographs. The positive predictive value (PPV) of the radiographic features for PAVMs on DSPA was 0.83 (95% CI 0.64-1.0) and 0.44 for the possibility of embolization (95% CI 0.19-0.70). The PPV of the shunt grade of PAVMs on DSPA was 0.14 (95% CI 0.01-0.29) for grade 1, 0.74 (95% CI 0.60-0.88) for grade 2, and 0.97 (95% CI 0.92-1.0) for grade 3. The PPVs of pulmonary shunt grades 2 and 3 on TTCE for the possibility of embolization for PAVMs were 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively. Conclusion: TTCE is the preferred screening test for PAVMs. The pulmonary RLS grade on TTCE not only identifies the likelihood of PAVMs but also predicts the probability for embolization.
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Affiliation(s)
- Yujiao Deng
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xin Huang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Guangyi Wang
- Department of Cardiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jian Cao
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Shengshu Wang
- Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second Medical Center of Chinese PLA General Hospital, Institute of Geriatrics, Beijing, China
| | - Yue Li
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yiru Wang
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | | | | | - Yukun Luo
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Kunlun He
- Translational Medicine Research Center, Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing, China
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Ioannidis SG, Mitsias PD. Patent Foramen Ovale in Cryptogenic Ischemic Stroke: Direct Cause, Risk Factor, or Incidental Finding? Front Neurol 2020; 11:567. [PMID: 32670184 PMCID: PMC7330017 DOI: 10.3389/fneur.2020.00567] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/19/2020] [Indexed: 01/27/2023] Open
Abstract
Patent foramen ovale (PFO) has been associated with cryptogenic stroke. There is conflicting data and it remains uncertain whether PFO is the direct cause, a risk factor or an incidental finding. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signaling disruption. Main risk factors linked with PFO-attributable strokes are young age, PFO size, right-to-left shunt degree, PFO morphology, presence of atrial septal aneurysm, intrinsic coagulation-anticoagulation systems imbalance, and co-existence of other atrial abnormalities, such as right atrial septal pouch, Eustachian valve and Chiari's network. These may act independently or synergistically, multiplying the risk of embolic events. The RoPE score, a scale that includes factors such as young age, cortical infarct location and absence of traditional stroke risk factors, is associated with the probability of a PFO being pathogenic and stroke recurrence risk after the index stroke. Multiple investigators have attempted to correlate other PFO features with the risk of PFO-related stroke, but further investigation is needed before any robust conclusions are reached. PFO presence in young patients with cryptogenic stroke should be considered as etiologically suspect. Caution should be exercised in interpreting the relevance of other PFO features.
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Affiliation(s)
| | - Panayiotis D Mitsias
- Department of Neurology, University Hospital of Heraklion, Heraklion, Greece.,School of Medicine, University of Crete, Heraklion, Greece.,Department of Neurology and Comprehensive Stroke Center, Henry Ford Hospital, Detroit, MI, United States.,School of Medicine, Wayne State University, Detroit, MI, United States
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Ling Y, Wang M, Pan X, Zhao H. Clinical features of right-to-left shunt in the different subgroups of migraine. Brain Behav 2020; 10:e01553. [PMID: 32011802 PMCID: PMC7066358 DOI: 10.1002/brb3.1553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Several investigations have documented an association between migraine and right-to-left shunt (RLS). However, whether there are specific clinical features that can distinguish between migraine patients with and without RLS is unclear. This study aims to explore whether there are specific clinical features that can distinguish between migraine patients with and without RLS, and to investigate the relationship between the degree of shunt and clinical parameters of headache. METHODS In this study, we enrolled consecutive migraineurs who underwent a structured, standardized questionnaire for family and personal history and for detailed migraine features. RLS was diagnosed based on a contrast enhancement transcranial Doppler (c-TCD) examination. RESULTS Overall, 113 migraine with aura (MA) and 192 migraine without aura (MO) patients were included. Patients with MA and RLS (MARLS+) had a higher frequency for sensory aura symptoms than those with MA without RLS (MARLS-) (27.4% vs. 10.0%, p = .03). Patients with MO and RLS (MORLS+) presented with significantly younger initial age of migraine onset and experienced more severe pain intensity than those with MO without RLS (MORLS-) (mean ± SD, 25.6 ± 8.9 vs. 29.8 ± 12.7 years, p = .008 and 5.9 ± 1.4 vs. 5.3 ± 1.3, p = .006, respectively). There was no relationship between the degree of shunt and the clinical parameters of headache. CONCLUSIONS Our results indicate that MO patients presented with a younger initial age of migraine onset and that sensory aura symptoms in MA patients may predict the presence of RLS. However, we did not find support for relationship between the degree of shunt and clinical parameters of headache.
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Affiliation(s)
- Yanyan Ling
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Min Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Xudong Pan
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hongqin Zhao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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Polivka J, Polivka J, Pesta M, Rohan V, Celedova L, Mahajani S, Topolcan O, Golubnitschaja O. Risks associated with the stroke predisposition at young age: facts and hypotheses in light of individualized predictive and preventive approach. EPMA J 2019; 10:81-99. [PMID: 30984317 DOI: 10.1007/s13167-019-00162-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 12/25/2022]
Abstract
Stroke is one of the most devastating pathologies of the early twenty-first century demonstrating 1-month case-fatality rates ranging from 13 to 35% worldwide. Though the majority of cases do occur in individuals at an advanced age, a persistently increasing portion of the patient cohorts is affected early in life. Current studies provide alarming statistics for the incidence of "young" strokes including adolescents. Young stroke is a multifactorial disease involving genetic predisposition but also a number of modifiable factors, the synergic combination of which potentiates the risks. The article analyzes the prevalence and impacts of "traditional" risk factors such as sedentary lifestyle, smoking, abnormal alcohol consumption, drug abuse, overweight, hypertension, abnormal sleep patterns, and usage of hormonal contraceptives, among others. Further, less explored risks such as primary vascular dysregulation and associated symptoms characteristic for Flammer syndrome (FS) are considered, and the relevance of the FS phenotype for the stroke predisposition at young age is hypothesized. Considering the high prevalence of known genetic and modifiable risk factors in the overall predisposition to the young stroke, the risk mitigating measures are recommended including innovative screening programs by application of specialized questionnaires and biomarker panels as well as educational programs adapted to the target audiences such as children, adolescents, and young adults.
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Affiliation(s)
- Jiri Polivka
- 1Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
- 2Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
- 3Department of Neurology, University Hospital Pilsen, and Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
| | - Jiri Polivka
- 3Department of Neurology, University Hospital Pilsen, and Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
| | - Martin Pesta
- 2Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
- 4Department of Biology, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
| | - Vladimir Rohan
- 3Department of Neurology, University Hospital Pilsen, and Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
| | - Libuse Celedova
- 5Department of Social and Assessment Medicine, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
| | | | - Ondrej Topolcan
- 7Department of Immunochemistry, University Hospital Pilsen, Pilsen, Czech Republic
| | - Olga Golubnitschaja
- 8Radiological Clinic, UKB, Rheinische Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
- 9Breast Cancer Research Centre, UKB, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
- 10Centre for Integrated Oncology, Cologne-Bonn, UKB, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
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