Foam sclerotherapy: a possible cause of ischaemic stroke?

Picard, Candice; Deltombe, Bertrand; Duru, Cécile; Godefroy, Olivier; Bugnicourt, Jean‐Marc

doi:10.1136/jnnp.2009.179952

Cited by 20 publications

(14 citation statements)

References 9 publications

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“…317 The incidence of major neurologic events after foam injection is rare; instances of stroke were reported by Bush et al 321 and others. 319,322,323 Immediate treatment with 100% oxygen and possibly hyperbaric oxygen therapy should be considered. Factors implicated in the risk of stroke after foam sclerotherapy include the use of air instead of carbon dioxide to prepare the foam, large bubble size, a patent foramen ovale, failure to elevate the limb after treatment, prolonged immobility after therapy, and an excessive amount of foam used during one session.…”

Section: Sclerotherapymentioning

confidence: 99%

“…Factors implicated in the risk of stroke after foam sclerotherapy include the use of air instead of carbon dioxide to prepare the foam, large bubble size, a patent foramen ovale, failure to elevate the limb after treatment, prolonged immobility after therapy, and an excessive amount of foam used during one session. 319,[322][323][324] Standardization of the bubble size using commercially prepared microfoam and the replacement of air with carbon dioxide in the solution may decrease the risk of neurologic complications. 325 A recent study Regan et al 326 proposed that the composition and properties of the foam, including bubble size and gaseous components, may indeed contribute to the potential for microcirculatory obstruction and cerebral ischemia.…”

Section: Sclerotherapymentioning

confidence: 99%

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The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum

Gloviczki

Comerota²,

Dalsing

et al. 2011

Journal of Vascular Surgery

1,268

952

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The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks, burden, and costs. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD, a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP classification is used for patients with CVD (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C(2); GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration ≥500 ms, vein diameter ≥3.5 mm) located underneath healed or active ulcers (CEAP class C(5)-C(6); GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B).

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Section: Sclerotherapymentioning

confidence: 99%

Section: Sclerotherapymentioning

confidence: 99%

The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum

Gloviczki

Comerota²,

Dalsing

et al. 2011

Journal of Vascular Surgery

1,268

952

View full text Add to dashboard Cite

show abstract

“…Dislodgement of a loose thrombus from the saphenofemoral junction (SFJ) was diagnosed in one case 9 and suspected in another case 8 of stroke after sclerotherapy.…”

Section: Failure To Diagnose Super¢cial Vein Thrombosismentioning

confidence: 99%

Paradoxical embolism, stroke and sclerotherapy

Parsi

2011

Phlebology

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Sclerotherapy has been associated with 13 published cases of stroke since 1994. Four earlier reports implicated liquid sclerosants while nine recent cases have followed foam sclerotherapy. This adverse event represents a very rare complication of a very popular procedure. Ten of the 13 reported patients recovered completely with no long-term sequelae. A right-to-left shunt and in particular a patent foramen ovale (PFO) was the most consistent risk factor. Paradoxical gas emboli were observed in the brain-supplying or the intra-cranial arteries of five patients with an immediate onset of stroke after foam sclerotherapy. Paradoxical clot embolism was suspected in three patients with a delayed onset of stroke and concurrent venous thrombosis. In the remaining five cases, which included two cases with an immediate onset after liquid sclerotherapy, no specific cause was identified. Patients with a past history of cryptogenic stroke or a long life history of recurrent classic migraine attacks (with aura) have a higher risk of neurological adverse events and may benefit from preoperative screening and percutaneous closure of PFO.

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“…The timing of the onset of symptoms was highly variable. In eight cases, symptoms occurred within minutes of treatment, 7,8,12,13,16,17 in three cases this occurred at 1 to 4 hours, 14,15,18 two cases reported symptoms the following day within 24 hours, 11,13 and the remaining cases were at 2 days, 3 days, and 5 days following treatments. 9,10,13 In two cases, residual weakness was observed at the time of discharge from hospital, and there was one reported fatality in the case of the patient who suffered a hemorrhagic stroke.…”

Section: Resultsmentioning

confidence: 95%

“…Confirmatory cerebral imaging of the presence of CVA was confirmed either by computed tomography imaging (CT) in four patients [7][8][9][10] or magnetic resonance imaging (MRI) in six patients. [11][12][13][14] One patient had normal MRI imaging but, due to persistent symptoms for 2 days, was classified as having had a CVA, 15 and one patient had thrombus in the right middle cerebral artery on autopsy. 16 The earliest case report found was in 1947, published in the British Medical Journal, of transient hemiplegia and speech disturbance in a 32-yearold female after the injection of sodium morrhuate, 16 and in 1951, a 62-year-old female patient who died shortly after injection of sodium morrhuate into varices 16 was found to have evidence of intracranial hemorrhage and thrombus in the middle cerebral artery at postmortem.…”

Section: Resultsmentioning

confidence: 98%