Diagnostic Yield of Pelvic Magnetic Resonance Venography in Patients With Cryptogenic Stroke and Patent Foramen Ovale

Liberman, Ava L; Daruwalla, Vistasp; Collins, Jeremy D.; Maas, Matthew B.; Botelho, Marcos P Ferreira; Ayache, Jad Bou; Carr, James E.; Ruff, Ilana; Bernstein, Richard A.; Alberts, M. J.

doi:10.1161/strokeaha.114.005539

Cited by 34 publications

(36 citation statements)

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“…56,57 In 1 study, when compared with patients with known etiology for stroke, the rates of pelvic DVT in cryptogenic stroke were higher (20% vs. 4%), 58 though another more recent study showed no differences in the rates of DVT. 59 In addition, studies have shown that the prevalence of the otherwise rare May-Thurner syndrome (an anatomic vascular variant that predisposes towards development of DVT) in patients with cryptogenic stroke and PFO is approximately 6-8%. 60,61 Despite these conflicting results, pelvic vein thrombosis may still be an important source of thrombi in patients with cryptogenic stroke and DVT.…”

Section: Medical Therapymentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp coalesce into a single orifice that becomes the foramen secundum. The septum secundum then forms via involution of the ventrocranial wall and overlaps with the foramen secundum. The septum secundum does not close fully and an oval-shaped opening remains, which becomes the foramen ovale. 17 Prior to birth, the fetus is dependent on the maternal circulation for oxygenation, as the immature fetal lungs do not yet participate in oxygen exchange. As such, the foramen ovale (as well as the ductus arteriosus), enables shunting of blood away from the pulmonary circulation. At birth, when the neonate's lungs begin to participate in oxygen exchange, there is a precipitous drop in the pulmonary vascular resistance and there is reversal of flow through both the foramen ovale and ductus arteriosus. 18 In approximately 75% of individuals, the foramen ovale closes within a few years while in the remaining others, it stays open permanently as a PFO. EpidemiologyThe prevalence of PFO in the healthy adult population ranges from 15% to 25% on echocardiography and 15-35% on autopsy studies. 1,2,19,20 Observational and autopsy studies have showed that the prevalence of detected PFOs is lower in older patients and that detected PFOs in older individuals tend to be larger. 1,19,20 Those studies, however, may be confounded by selection and detection bias because none of the longitudinal studies have demonstrated that individual PFOs change in size. The prevalence of PFOs is equal among men and women, though there may be race-ethnic differences. 1,19,21 he foramen ovale is an important fetal structure that closes after birth in most individuals and remains open as a patent foramen ovale (PFO) in approximately 25% of the healthy population. 1-3 In these individuals, bypass of the pulmonary circulation via shunting from the right-sided venous circulation to the left-sided arterial circulation is possible. Although most patients with PFOs are completely asymptomatic, reports from the late 1800 s by Cohnheim and Litten described cases of patients who were found to have the triad of deep venous thrombosis (DVT), PFO and systemic embolization. They hypothesized that the PFO enabled bypass of a venous thrombosis to the systemic arterial circulation, a process now termed paradoxical embolization. 4,5 Since those initial observations, additional studies have demonstrated a strong association between the presence of PFO and cryptogenic stroke in young patients. 6-11 In addition to its association with stroke, PFO has also been implicated in platypneaorthodeoxia, 12 decompression illness, 13 myocardial infarction, 14 obstructive sleep apnea, 15 and migraine headaches. 16 This review will focus on the relationship between PFO and stroke, discussing the embryology, epidemiology, association, mechanisms, diagnostic methods, associated anatomic factors and management strategies. EmbryologyThe right and left atria begin as a single chamber and separation b...

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Section: Medical Therapymentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

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“…There are no published guidelines for the assessment of pelvic veins as part of the stroke workup and few studies have systematically investigated pelvic veins as a potential source for paradoxical emboli in CS patients [6,10,12]. Moreover, data from the two larger studies have been conflicting with almost tenfold different prevalence rates (ranging from 2% [12] to 20% [6]).…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, data from the two larger studies have been conflicting with almost tenfold different prevalence rates (ranging from 2% [12] to 20% [6]). However, differences in the extent of diagnostic workup, classification of cryptogenic stroke, differences in imaging modalities and interpretation as well as different inclusion and exclusion criteria may partially account for this variability [6,12]. …”

Section: Discussionmentioning

confidence: 99%

“…However, the diagnostic yield varies widely with a reported prevalence of lower extremity DVT ranging from 0 to 57% [5,6,7,8,9]. It has been suggested that paradoxical emboli originating from the pelvis may be an important alternate source of stroke in this population [6,10,11,12]. Yet, few studies have investigated the association between DVT and CS [5,6,7,8,9] and even less is known regarding the potential contribution of pelvic vein pathology as a source for paradoxical emboli in CS patients [10,11,12].…”

Section: Introductionmentioning

confidence: 99%

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Prevalence of Pelvic Vein Pathology in Patients with Cryptogenic Stroke and Patent Foramen Ovale Undergoing MRV Pelvis

Osgood

Budman

Carandang³

et al. 2015

Cerebrovasc Dis

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Background: A substantial proportion of ischemic strokes has no any identified underlying cause. Notably, the prevalence of a patent foramen ovale (PFO) is increased in cryptogenic stroke (CS) populations, which may serve as a conduit for paradoxical emboli originating from deep vein thrombosis (DVT) including the pelvic veins. Yet, there are no published guidelines for the assessment of pelvic veins as part of the stroke workup and few studies have systematically investigated pelvic veins as a potential source for paradoxical emboli in CS patients. Further, there is a relative paucity of data regarding pelvic DVT in CS and results have been conflicting. Hence, we sought to determine the prevalence of pelvic DVT in select CS patients with PFO who underwent magnetic resonance venography (MRV). Methods: We retrospectively identified patients (n = 50) who underwent contrast-enhanced pelvic MRV at the discretion of the treating physician for the evaluation of CS in the presence of a PFO during hospitalization at a single academic stroke center between January 2011 through December 2013. Multivariable logistic regression analyses were used to assess for factors independently associated with the presence of an abnormal MRV pelvis. Results: Patients (47 ± 13 years of age) had MRV performed 4 ± 3 days after their incident stroke. Nine patients had an abnormal MRV (18%). Of these, four (8%) had pelvic vein thrombosis and 5 (10%) a May-Thurner anatomic variant. All patients with pelvic DVT were subsequently anticoagulated with warfarin (none had abnormal hypercoagulability testing). Clinical clues suggesting paradoxical embolism were present in as many as 40% of patients. On multivariable logistic regression, a history of any risk factors predisposing to DVT (OR 6.7; coefficient 1.9; BCa 95% CI 0.08-20.2; p = 0.014) as well as the number of predisposing risk factors (OR 3.9; coefficient 1.4; BCa 95% CI 0.25-4.2; p = 0.005) predicted the presence of pelvic vein pathology on MRV. Conclusion: We demonstrate a relatively high prevalence of pelvic DVT among select CS patients emphasizing the importance of considering the pelvic veins as a potential source for emboli particularly in the presence of risk factors known to predispose DVT. Because patients were included at the treating physician's discretion, our results reflect ‘real-life' practice. Our results may be of clinical importance as inclusion of pelvic vein imaging in CS patients with PFO had impactful therapeutic and nosologic implications. Further study is needed to define patients most likely to benefit from pelvic vein imaging.

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“…17,18 Indeed, a venous source of embolism is only rarely documented in patients with CS and a PFO; in the recent RE-SPECT (randomized evaluation of recurrent stroke comparing pfo closure to established current standard of care treatment) trial the prevalence of deep vein thrombosis (DVT) was 3.6% in the whole study population. 19 Notably, recent reports suggest that a MRI venogram performed early after a CS can diagnose a peripheral or pelvic venous thrombosis in up to 8% of the patients with a PFO 20,21 also showing congenital anomalies of the pelvic veins possibly predisposing to DVT in an additional 10% of them. 22 Combined computed tomography (CT) venography and pulmonary angiography recently yielded similar results with respect to prevalence of DVT, diagnosing a silent pulmonary embolism in 4.4% of the patients as well.…”

Section: Patent Foramen Ovale and Cryptogenic Cerebrovascular Or Systmentioning

confidence: 99%

Patent foramen ovale and ischemic stroke: more shadows than lights? What the internist should know

Donti

2016

Ital J Med

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What is a foramen ovale?A foramen ovale (FO) is an anatomical structure allowing communication between the right and the left atrium. Differently from an atrial septal defect which is a hole in the atrial septum, the FO is a tunnel running from right to left between the septum secundum, on the right side, and the septum primum on the left side ( Figure 1).The width and length of the tunnel can be widely different from case to case, depending on the degree of separation and overlapping of the two septa. The septum primum, which is the thinner of the two septa, can be redundant and mobile forming an atrial septal aneurysm and it can harbor one or more fenestrations creating additional communications between the atria. The septum secundum, which is not a real septum but an infolding of the atrial wall filled with fat tissue, can vary in thickness, depending on the amount of fat, up to more than 10 mm (lipomatous hypertrophy). Therefore, the anatomical features of the FO are consistently variable and additional anatomical structures such as a redundant Eustachian valve or a Chiari network, can further add to the complexity of its anatomy. The FO is essential for fetal life allowing the oxygenated blood coming from the placenta via the inferior vena cava to cross the atrial septum reaching the left ventricle and ascending aorta to mainly supply the brain; the well-developed Eustachian valve of the fetus plays a crucial role by directing the blood from the inferior vena cava to the entrance of the FO on the right side of the septum.After birth, respiration lowers the pulmonary vascular resistances increasing the pulmonary blood flow and the blood inflow into the left atrium which, in turn, increases left atrial pressure forcing the septum primum against the septum secundum and functionally closing the FO. With time, the two septa become fused to each other, anatomically sealing the FO. This sealing process does not occur in many people leaving a patent foramen ovale (PFO) in around 25%-30% of the general population as shown by autopsy findings and echocardiographic reports. ABSTRACTThe foramen ovale (FO) is an anatomical structure normally present in the fetus, which can persist in up to 25%-30% of the general population after birth. Normally it does not cause any harm but it has been associated with different pathological conditions; the more frequently encountered in clinical practice is an ischemic stroke or transient ischemic attack without any recognizable cause. However, a causal link between the cerebrovascular event and a right to left shunt through the FO is hard to demonstrate in most cases and which is the best treatment for secondary prevention is still a matter of debate with antithrombotic therapy or transcatheter closure of the FO as possible options. No definitive evidence of which is the most effective treatment is actually available so that a careful evaluation of each single patient is mandatory in order to select who will probably benefit the most from the interventional treatment as opposed to wh...

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Diagnostic Yield of Pelvic Magnetic Resonance Venography in Patients With Cryptogenic Stroke and Patent Foramen Ovale

Cited by 34 publications

References 30 publications

Patent Foramen Ovale and Stroke

Patent Foramen Ovale and Stroke

Prevalence of Pelvic Vein Pathology in Patients with Cryptogenic Stroke and Patent Foramen Ovale Undergoing MRV Pelvis

Patent foramen ovale and ischemic stroke: more shadows than lights? What the internist should know

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