Paradoxical embolism via a patent foramen ovale

Kumar, Tarun; Budnur, Srinivas Chikkaswamy; Mahadevappa, Nagesh Chamrajnagar; Singla, Vivek

doi:10.1136/bcr-2013-009818

Cited by 6 publications

(5 citation statements)

References 3 publications

(4 reference statements)

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“…The other is embolization. The emboli could come from a large cerebral artery with atherosclerosis, via a patent foramen ovale or other right‐to‐left shunt, of air embolism, fat embolism or amniotic fluid embolism . Antiplatelet agents prevent emboli of white thrombus (platelet aggregates that usually form on large arteries, such as at the site of a carotid stenosis or aortic arch atheroma).…”

Section: Discussionmentioning

confidence: 99%

Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE

Liu

Meng

et al. 2020

Euro J of Neurology

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Background and purpose: The aim was to explore the risk of early stroke recurrence within 3 months after watershed infarction and to investigate whether early dual antiplatelet therapy is more effective in decreasing such risk. Methods: Patients enrolled in the Clopidogrel in High-risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial and who had acute infarction on diffusion-weighted imaging were included in this subgroup analysis. All magnetic resonance images were read centrally by two neurologists who were blinded to the patients' baseline and outcome information. The primary outcome was any stroke recurrence within 3 months. The hazard ratios were adjusted by known predictors of stroke recurrence. Results: Of the 1089 patients with magnetic resonance imaging data enrolled in CHANCE, 834 (76.58%) patients had acute infarcts on diffusion-weighted imaging. The median and range of duration from randomization to stroke recurrence was 1.5 (1-6) days. Patients with watershed infarction had higher risk of stroke recurrence than those without (17.20% vs. 6.34%) within the first week after initial stroke; the hazard ratio (95% confidence interval) was 2.799 (1.536-5.101) adjusted by age, sex, smoking, body mass index, medical history, time to randomization, open-label aspirin dose at first day, single or dual antiplatelet therapy, National Institutes of Health Stroke Scale score at randomization, in-hospital treatment and white matter lesions, P < 0.001. There was no interaction between antiplatelet therapy and the presence of watershed infarction (P = 0.544). Conclusions: Minor stroke with watershed infarction has high recurrent risk in the first week. Dual antiplatelet therapy may be safely implemented, yet watershed infarction mechanisms of hypoperfusion and emboli may not be addressed.

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Section: Discussionmentioning

confidence: 99%

Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE

Liu

Meng

et al. 2020

Euro J of Neurology

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“…An analysis of 12 anecdotal reports of PE-related PDE [92][93][94][95][96][97][98][99][100][101][102][103][104][105] reveals three patterns of clinical presentation (Table 4), namely, simultaneous occurrence of typical PE symptoms(or hypoxaemia) and symptoms of PDE, occurrence of PE symptoms followed by occurrence of stroke a day or so later, and occurrence of stroke without any documentation of breathlessness. In the latter category were four patients [102][103][104][105] in whom PDE-related stroke occurred in a PE patient who had reported neither breathlessness, chest pain or cough. Nevertheless, subsequent transthoracic echocardiography(TTE) revealed either right heart dilatation and elevation in pulmonary artery systolic pressure [103], or intracardiac thrombus [102,104,105], thereby raising the index of suspicion for PE.…”

Section: Pulmonary Embolism-related Pde (Table 4)mentioning

confidence: 99%

“…In the latter category were four patients [102][103][104][105] in whom PDE-related stroke occurred in a PE patient who had reported neither breathlessness, chest pain or cough. Nevertheless, subsequent transthoracic echocardiography(TTE) revealed either right heart dilatation and elevation in pulmonary artery systolic pressure [103], or intracardiac thrombus [102,104,105], thereby raising the index of suspicion for PE. The utility of TTE in identifying PE in patients with PDE [102][103][104][105] has its counterpart in the utility of TTE for differentiating PE from suspected AMI [106].…”

Section: Pulmonary Embolism-related Pde (Table 4)mentioning

confidence: 99%

“…Nevertheless, subsequent transthoracic echocardiography(TTE) revealed either right heart dilatation and elevation in pulmonary artery systolic pressure [103], or intracardiac thrombus [102,104,105], thereby raising the index of suspicion for PE. The utility of TTE in identifying PE in patients with PDE [102][103][104][105] has its counterpart in the utility of TTE for differentiating PE from suspected AMI [106]. In the latter case report a 32 year old man presented with anterior chest pain and dyspnoea, and he had ST segment elevation in V3-V6.…”

Section: Pulmonary Embolism-related Pde (Table 4)mentioning

confidence: 99%

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Atypical manifestations of pulmonary embolism

Jolobe¹

2020

Arch Vas Med

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Pulmonary embolism (PE) is an age-related disorder which is potentially fatal, but frequently misdiagnosed. However, the true prevalence of pulmonary embolism is unknown. Inaccurate estimates of PE prevalence might, in part, be attributable to underrecognition of atypical presentations of this disorder. If true prevalence is unknown, the positive predictive values of both typical and atypical symptoms and signs of PE will be unreliable. The negative predictive value of those parameters will, likewise, be unreliable. The aim of this review is to make clinicians more aware of atypical manifestations of PE, thereby increasing the likelihood of correct diagnosis and, hence, ascertainment of the true prevalence of PE. The range of atypical manifestations was explored by a literature search, using MEDLINE from using the search terms atypical, uncommon, unusual, pulmonary embolism, lung embolism, pulmonary thromboembolism.This search revealed atypical presenting features such as non pleuritic retrosternal pain, abdominal pain, atypical breathing patterns, pulmonary oedema, Dressler's syndrome, atypical radiographic manifestations, atypical electrocardiographic features, manifestations associated with oxygen saturation of 95% or more, coexistence of acute myocardial infarction and pulmonary embolism, coexistence of thoracic aortic dissection and pulmonary embolism, neurological manifestations other than stroke, paradoxical embolism, acute venous thrombosis of atypical location, and pulmonary embolism with normal D-dimer levels.Atypical manifestations of pulmonary embolism https://www.heighpubs.org/hjvsm 009 https://dx.

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“…The prevailing hypothesis currently is that of a paradoxical embolism, i.e., a PFO allows blood-borne material (usually venous thrombus) to bypass the pulmonary circuit to enter systemic arterial circulation, and subsequently pass into the cerebral vasculature (29). This is supported by case-reports documenting visualised thrombus in the interatrial septum in the setting of embolic stroke (30,31). However, alternative hypotheses also speculate formation of thrombotic material in situ within the PFO (at the level of the foramen channel or ASA), with the potential for embolization (23,27).…”

Section: Cryptogenic Strokementioning

confidence: 99%

Current management aspects in adult congenital heart disease: non-surgical closure of patent foramen ovale

Vaidya

Khandkar

Celermajer

2018

Cardiovasc. Diagn. Ther

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A patent foramen ovale (PFO) is a remnant interatrial communication, best diagnosed with transoesophageal echocardiography (TOE) and bubble study. Although quite common and often asymptomatic, PFO is associated with cryptogenic stroke and migraine. Approximately one-half of patients with a cryptogenic stroke have a PFO, and the dilemma regarding whether or not to proceed with percutaneous device closure, to reduce the risk of future recurrent events due to paradoxical embolism, has been subject to debate for nearly two decades. Despite promising observational data, initial randomised clinical trials failed to demonstrate superiority of closure over medical therapy. However, long-term follow-up data from one of these early trials, combined with two new randomised trials, have provided more evidence for the benefits of closure in selected patients. This new evidence suggests that younger patients with high-risk features such as an atrial septal aneurysm (ASA) or large interatrial shunt are more likely to benefit from PFO closure, after fastidious exclusion of an alternative cause for the index stroke. However, issues which require further clarification include whether anticoagulant therapy is preferable to antiplatelet therapy for medical management, and which particular type of closure device is optimal. Finally, despite promising retrospective observational data suggesting improvement in migraine attacks after PFO closure, high quality evidence is lacking in this regard.

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Paradoxical embolism via a patent foramen ovale

Cited by 6 publications

References 3 publications

Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE

Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE

Atypical manifestations of pulmonary embolism

Current management aspects in adult congenital heart disease: non-surgical closure of patent foramen ovale

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