Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack

Lethen, Harald; Flachskampf, Frank A.; Schneider, R; Sliwka, Ulrich; Köhn, Gerlinde; Noth, Johannes; Hanrath, Peter

doi:10.1016/s0002-9149(97)00604-8

Cited by 161 publications

(106 citation statements)

References 29 publications

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“…Despite this difference in the prevalence of pelvic DVT, the prevalence of LE DVT in our study is comparable to that seen in other studies of CS patients. 6,8 A possible reason for our lower prevalence of pelvic DVT compared with the PELVIS study may be differences in imaging modalities. The PELVIS study exclusively used time of flight MRV, a noncontrast imaging technique that depends on flow directionality and rate to generate vascular signal.…”

Section: Discussionmentioning

confidence: 86%

“…5 Several studies have suggested that the deep veins of the lower extremity (LE) could be a source of paradoxical thromboembolism in CS patients with patent foramen ovale (PFO). [6][7][8] Deep pelvic veins have also been shown to harbor thrombi in patients diagnosed with pulmonary emboli 9,10 and CS. 11 The published prevalence of LE and pelvic deep venous thrombosis (DVT) in patients with CS is highly variable, ranging from 3.2% to 65.5%, depending on imaging modality.…”

mentioning

confidence: 99%

“…11 The published prevalence of LE and pelvic deep venous thrombosis (DVT) in patients with CS is highly variable, ranging from 3.2% to 65.5%, depending on imaging modality. [6][7][8]12 One large multicenter prospective study, the Paradoxical Emboli From Large Veins in Ischemic Stroke (PELVIS) study, found an 11.6% prevalence of pelvic DVT in IS patients with a disproportionate amount in CS patients. 11 The role of systematic deep venous imaging in the evaluation of patients with IS remains uncertain, especially in the evaluation of patients with CS.…”

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confidence: 99%

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

Liberman

Daruwalla

Collins

et al. 2014

Stroke

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Background and Purpose— Paradoxical embolization is frequently posited as a mechanism of ischemic stroke in patients with patent foramen ovale. Several studies have suggested that the deep lower extremity and pelvic veins might be an embolic source in cryptogenic stroke (CS) patients with patent foramen ovale. Methods— Consecutive adult patients with ischemic stroke or transient ischemic attack and a patent foramen ovale who underwent pelvic magnetic resonance venography as part of an inpatient diagnostic evaluation were included in this single-center retrospective observational study to determine pelvic and lower extremity (LE) deep venous thrombosis (DVT) prevalence in CS versus non-CS stroke subtypes. Results— Of 131 patients who met inclusion criteria, 126 (96.2%) also had LE duplex ultrasound data. DVT prevalence overall was 7.6% (95% confidence interval, 4.1–13.6), pelvic DVT 1.5% (95% confidence interval, 0.1–5.8), and LE DVT 7.1% (95% confidence interval, 3.6–13.2). One patient with a pelvic DVT also had a LE DVT. Comparing patients with CS (n=98) with non-CS subtypes (n=33), there was no significant difference in the prevalence of pelvic DVT (2.1% versus 0%, P =1), LE DVT (6.2% versus 10.3%, P =0.43), or any DVT (7.2% versus 9.1%, P =0.71). Conclusions— Among patients with ischemic stroke/transient ischemic attack and patent foramen ovale, the majority of detected DVTs were in LE veins rather than the pelvic veins and did not differ by stroke subtype. The routine inclusion of pelvic magnetic resonance venography in the diagnostic evaluation of CS warrants further prospective investigation.

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Section: Discussionmentioning

confidence: 86%

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confidence: 99%

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confidence: 99%

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

Liberman

Daruwalla

Collins

et al. 2014

Stroke

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“…The source of the clots cannot be established in most patients; fewer than 10% will have deep-vein thrombosis apparent on phlebography. 4 Although most emboli presumably arise from systemic veins, the PFO itself has been suspected to be a source of thrombus because of stagnated blood in the tunnel. However, the fact that, to our knowledge, dislodging of such thrombi has not been reported during transcatheter PFO closures argues against this hypothesis.…”

Section: Paradoxical Embolismmentioning

confidence: 99%

Contemporary Management of Patent Foramen Ovale

2003

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“…The severity of shunt was assessed by transesophageal echocardiography using modified Lethen criteria, Ͻ10 (small), and Ͼ10 (large) microbubbles/3 seconds, respectively, with contrast echo. 3 Three of 5 (60%) patients with large PFO had dramatic recovery, and 7 of 8 (88%) patients with small PFO had one. Therefore, there was no difference in rate of dramatic recovery between large and small PFO.…”

Section: Response To Letter By Sharma Et Al and Leibeskindmentioning

confidence: 95%

Response to Letter by Sharma et al and Leibeskind

Kimura

Iguchi

Shibazaki

et al. 2009

Stroke

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Response to Letter by Sharma et al and LeibeskindResponse:We would like to thank Dr Sharman et al and Dr Liebeskind for their interest in our recent publication in which presence of a right-to-left shunt was associated with dramatic improvement after thrombolytic therapy in acute ischemic stroke patients. We demonstrated that tissue plasminogen activator (t-PA) thrombolysis was more effective in stroke patients with a right-to-left shunt than in patients without a right-to-left shunt. We believed that the action of t-PA is considered to be fibrin-dependent because of its favorable binding constant for fibrin-bound plasminogen and its activation of plasminogen in association with fibrin. 1,2 Sharma et al proposed the possibility that high dose of t-PA through patent foramen ovale (PFO) could result in high rate of recanalization of occluded artery after t-PA infusion. They took interest in the relationship between size or function grading of PFO and dramatic clinical recovery. We were very interested in their suggestion and investigated size of PFO in our patients. Contrast transcranial Doppler demonstrated an right to left shunt in 17 (35.4%) patients. Of them, 13 patients were examined by transesophageal echocardiography to evaluate the PFO. The severity of shunt was assessed by transesophageal echocardiography using modified Lethen criteria, Ͻ10 (small), and Ͼ10 (large) microbubbles/3 seconds, respectively, with contrast echo. 3 Three of 5 (60%) patients with large PFO had dramatic recovery, and 7 of 8 (88%) patients with small PFO had one. Therefore, there was no difference in rate of dramatic recovery between large and small PFO. However, the sample size is small. We should need more samples to elucidate Sharman's hypothesis.Liebeskind suggested that venous hemodaynamics enhanced collateral perfusion in patients with PFO, which induced the dramatic recovery after t-PA therapy. We read the comments with great interest. As Liebeskind mentioned, venous hemodaynamics might be affected by parallel cardiac preload. Therefore, we believe that patients with atrial fibrillation (AF) may have potential heart failure, and venous pressure is increased. In the present study, 24 patients with AF were enrolled. In fact, of them, 11 patients had brain natriuretic peptide Ͼ200 pg/mL, which indicates potential cardiac failure. However, patients with AF did not have more frequently dramatic recovery than those without AF (29.2% versus 58.3%; Pϭ0.0417). Thus, we did not reach agreement that venous hemodaynamics enhanced collateral perfusion, which might induce the dramatic recovery after t-PA therapy. Off course, there is difference in venous hemodaynamics between patients with PFO and AF. Therefore, we should need a study to elucidate Liebeskind's hypothesis. DisclosuresNone.

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Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack

Cited by 161 publications

References 29 publications

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

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

Contemporary Management of Patent Foramen Ovale

Response to Letter by Sharma et al and Leibeskind

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