Patent foramen ovale (PFO): is there life before death in the presence of PFO?

Patent foramen ovale (PFO) is an embryologic remnant with incomplete postnatal adhesion of the cardiac atrial septum primum and secundum. After birth, the prevalence of PFO decreases from about 35% at young to approximately 20% at old age. PFO has been associated with numerous conditions such as decompression illness in divers, migraine, high‐altitude pulmonary oedema, cerebrovascular and coronary ischaemia, and obstructive sleep apnoea syndrome. PFO is the cause of intermittent atrial right‐to‐left shunt, and it can be the source of cardiac paradoxical embolism. So far, randomized controlled trials have not documented a reduced rate of cerebrovascular recurrent events in patients receiving PFO device closure as compared to those on medical treatment. The purpose of this article was to critically evaluate evidence on the pathophysiologic, clinical as well as prognostic relevance of PFO.     

Patent foramen ovale in patients with tension headache: is it as common as in migraineurs? An age- and sex-matched comparative study

The association of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with migraine headache attack (MHA) has been clearly shown. The same findings have been recently demonstrated also in cluster headache. Although tension-type headaches (TTH) are the most common kind of headache, their association with these atrial septal abnormalities has never been studied before. The study was conducted to clarify whether there was a significant association between the presence of such atrial septal abnormalities and tension headache, when compared with migraineurs. One hundred consecutive patients with migraine and 100 age- and sex-matched subjects with TTH and 50 healthy volunteers with no headache were enrolled in the study and underwent a complete transesophageal echocardiographic study with contrast injections at rest and with the Valsalva maneuver. There was no significant difference between the age and the sex of the participants of the three groups. The overall prevalence of PFO was 23% in patients with TTH and that of large PFOs was only 11%. The 23% prevalence of PFO in patients with TTH was not statistically different from 16% found in our normal control group. Furthermore, we found a significantly higher prevalence of PFO in migraineurs (50%) when compared with patients with tension headache (p < 0.001). This was also true for the collective presence of large PFOs and ASAs (35%) (p < 0.001). Although atrial septal anomalies have an association with MHA, they do not have a significant association with TTH.     

Intensity versus task-specificity after stroke: how important is intensity?

Recent evidence suggests that intense training regimens can increase the use and function of the more affected limbs of stroke patients. The efficacy of these intense regimens has led some to conclude that intense training regimens should be more widely applied clinically and has caused some physicians to attempt implementation of more intense training regimens with stroke patients. However, intense protocols may not be needed to produce positive motor changes in some patients and may not be plausible in some environments or with some patients. In this commentary, we review the evidence supporting the efficacy of less intense, task-specific training regimens emphasizing the use of the more affected limb. We submit that intensity does not need to be altered to induce substantial clinical improvements, as some have suggested. Rather, the results of the studies suggest that the nature of stroke motor therapy itself can be altered to be more task-specific while remaining within the typical contact time parameters (i.e., 30-45 min/session), yet can be more efficacious than more traditional motor rehabilitative approaches.     

Thrombus in transit within a patent foramen ovale: An argument for consideration of prophylactic closure?

Recurrent pulmonary embolism (PE) in prothrombotic patients with patent foramen ovale (PFO) is not considered a setting for elective PFO closure. We describe a 35-year-old woman with known PFO, recurrent PE on warfarin, and Klippel-Trenaunay syndrome-a condition with predisposition for thromboembolism-who suffered concurrent saddle PE and devastating stroke with further impending paradoxical embolus across the PFO. Optimal management in patients with biatrial thromboembolus caught in transit across PFO is challenging. Patients with recurrent PE, prothrombotic states, and PFO should be considered for PFO closure. Prompt diagnosis of impending paradoxical embolus with echocardiography and consideration of surgical removal and PFO closure are critical.     

Livedo reticularis and migraine: a marker for stroke risk?

BACKGROUND AND PURPOSE: Livedo reticularis is a dermatopathy characterized by an irregular, violaceous, netlike pattern which spares the face. Associated with a variety of conditions, it occurs consequent to pathological or physiological narrowing of small and medium arteries at the dermis-subcutis border. Sneddon syndrome refers to the idiopathic coupling of livedo reticularis and stroke in the absence of traditional vascular risk factors. Over 50% of persons with Sneddon syndrome describe a history of headache. We undertook this study to determine the frequency of livedo reticularis in our headache clinic. METHODS: We performed a retrospective chart review of consecutive patients attending a headache clinic over a period of 6 months. The patients had all been seen by one physician (G.E.T.) who noted the presence or absence of livedo reticularis. The charts were reviewed for age, sex, and vascular risk factors, including current use of oral contraceptives, and history of smoking, coronary artery disease, hypertension, diabetes mellitus, stroke, or arthritis. RESULTS: Charts from 133 patients with headache were reviewed (24 men [18%], 109 women [82%]; mean age, 42 +/- 13 years). Livedo reticularis was observed in 29 patients (22%) and in a similar proportion in men (25%) and women (21%). When we stratified the migraine population by presence or absence of livedo, we found no significant difference in age (44.5 versus 41.7 years, P =.16). There was a higher frequency of stroke diagnosis in the cohort with livedo reticularis (28%[8 of 29] versus 7%[7 of 104], P =.005), but we found no significant differences in frequency of hypertension, oral contraceptive use, diabetes mellitus, coronary artery disease, arthritis, or cigarette smoking. CONCLUSIONS: In our headache clinic, livedo reticularis is present in more than one fifth of patients. A history of stroke is more frequent in this subset of migraineurs, raising the possibility that livedo reticularis can be used as a clinical marker to identify those migraineurs with an increased risk of stroke.     

Sustained risk of recurrent thromboembolic events in patients with patent foramen ovale and paradoxical embolism: long-term follow-up over more than 15 years

Background  

Patients with patent foramen ovale (PFO) and cryptogenic stroke are at risk of recurrence. Therapeutic regimens range from no treatment to anticoagulation treatment to surgical or interventional closure. However, long-term follow-up is only available for up to 4 years.     

The assessment of stroke and bleeding risk in atrial fibrillation: where are we now?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Patients with AF are at increased risk of thromboembolism and ischemic stroke. Many stroke risk factors, including increasing age, diabetes mellitus, hypertension and congestive heart failure, are themselves associated with the development of AF. The risk of stroke in AF is not homogeneous, and many different risk stratification schemas are available for the evaluation of thromboembolic stroke risk in AF patients. In addition, the risk of bleeding associated with anti-thrombotic therapy also needs to be considered during the anti-thrombotic therapy decision-making process. However, there are few published and validated bleeding risk schema available for AF patients. The availability of user-friendly risk stratification schemas could accurately discriminate patients' risk for stroke and anticoagulant therapy-related bleeding, and improve adherence to guidelines for thromboprophylaxis in AF.     

The assessment of stroke and bleeding risk in atrial fibrillation: where are we now?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Patients with AF are at increased risk of thromboembolism and ischemic stroke. Many stroke risk factors, including increasing age, diabetes mellitus, hypertension and congestive heart failure, are themselves associated with the development of AF. The risk of stroke in AF is not homogeneous, and many different risk stratification schemas are available for the evaluation of thromboembolic stroke risk in AF patients. In addition, the risk of bleeding associated with anti-thrombotic therapy also needs to be considered during the anti-thrombotic therapy decision-making process. However, there are few published and validated bleeding risk schema available for AF patients. The availability of user-friendly risk stratification schemas could accurately discriminate patients’ risk for stroke and anticoagulant therapy-related bleeding, and improve adherence to guidelines for thromboprophylaxis in AF.     

COVID-19-associated stroke risk: Could nutrition and dietary patterns have a contributing role?

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has created a life-threatening world pandemic. Unfortunately, this disease can be worse in older patients or individuals with comorbidities, having dangerous consequences, including stroke. COVID-19–associated stroke widely increases the risk of death from COVID-19. In addition to the personal hygiene protocols and preventive policies, it has been proven that immune-compromised, oxidative, and pro-coagulant conditions make a person more susceptible to severe COVID-19 complications, such as stroke; one of the most effective and modifiable risk factors is poor nutritional status. Previous literature has shown that healthy dietary patterns, such as the Mediterranean diet, some food groups, and specific micronutrients, reduce the risk of ischemic and hemorrhagic stroke. In this work, for the first time, we hypothesized that a healthy diet could also be a protective/preventive factor against COVID-19–associated stroke risk. In order to prove this hypothesis, it is required to study nutritional intake and dietary patterns in patients suffering from COVID-19–associated stroke. If this hypothesis is proven, the chronic supportive role of a healthy diet in critical situations will be highlighted once again.     

Ventiloffenes Foramen ovale:¶Konservative oder operative Therapie?

Zusammenfassung Ungeachtet der Schwierigkeiten bei der Best?tigung einer paradoxen Embolie konnte der Zusammenhang zwischen dem Vorliegen eines ventiloffenen Foramen ovale (PFO) und zerebraler Isch?mie-Ereignisse unklarer Ursache wiederholt nachgewiesen werden. Darüber hinaus wurde berichtet, da? das Risiko von Embolie-Rezidiven bei diesen Patienten 3–4% pro Jahr betr?gt. Eine zuverl?ssige Risikostratifikation der Patienten mit PFO auf der Basis klinischer oder echokardiographischer Befunde ist bisher – mit Ausnahme der h?modynamisch wirksamen Lungenembolie – in der Regel nicht m?glich. Das Vorliegen eines Vorhofseptumaneurysmas und eine weite ?ffnung des PFO w?hrend des Herzzyklus oder ein gro?er interatrialer Shunt bei der trans?sophagealen Kontrast-Echokardiographie werden jedoch von manchen Autoren als Risikofaktoren angesehen. Die sekund?re Pr?vention paradoxer Embolien mittels oraler Antikoagulanzen (Warfarin) beinhaltet das Risiko einer signifikanten Blutung (Inzidenzrate 2–5% pro Jahr) und mangelhaften Compliance der Patienten. Au?erdem scheint diese Therapieform wenig effektiv zu sein. Der chirurgische Verschlu? des PFO ist ein technisch ausgereifter, sicherer Eingriff. Erste Berichte best?tigen seine hohe Effektivit?t hinsichtlich der Rezidivprophylaxe, weitere prospektive Studien sind jedoch erforderlich, um die für eine chirurgische Behandlung geeigneten Patienten festzulegen. Kathetertechnische Verfahren zum PFO-Verschlu? stehen ebenfalls zur Verfügung und befinden sich derzeit in der Phase der klinischen Erprobung. Weitere technische Verbesserungen erscheinen jedoch erforderlich, um den Ablauf des interventionellen Eingriffes zu vereinfachen, die Stabilit?t dieser Systeme zu erh?hen und die Komplikationsgefahr zu minimieren. Eingegangen: 30. Juli 1999, Akzeptiert: 24. September 1999     

Physiotherapy after stroke: More is better?

Physiotherapy is an established component of stroke rehabilitation but uncertainties remain about the most appropriate intensity of therapy input. We conducted a systematic review of the randomised trials of physiotherapy after stroke where qualitatively similar therapy regimens were provided at different levels of intensity. A heterogeneous group of seven randomised trials (597 patients) was identified. Dichotomous outcomes (death or the combined poor outcome of death or deterioration) were analysed by use of the odds ratio and 95% confidence interval. Patients subjected to more intensive physiotherapy input showed a non-significant reduction in case fatality (odds ratio 0.60; 95% CI 033–1.09) and a significant reduction (OR 0.54; 95% CI 0.34–0.85; p<0.01) in the combined poor outcome of death or deterioration by the end of follow-up. Two statistical techniques were used to identify patterns within the continuous data. Firstly, impairment and disability scores were converted to a standardised measure of 0–100 and the weighted mean difference (WMD) between the scores in the intensive and conventional physiotherapy groups were then calculated. Modest improvements were observed in both the impairment (WMD+5; 95% CI–1–11) and disability scores (WMD+5; 95% CI 0–10) recorded at the initial review (median 3 months post-stroke), but not at the final review (median 1 year post-stroke). Secondly, Fisher's inverse chi-squared test was used to combine the p values from individual trials; this confirmed the above findings (p<0.05 at initial review; p>0.05 at final review). More intensive physiotherapy input was associated with a reduction in the combined poor outcome of death or deterioration and may enhance the rate of recovery. These observations warrant further investigation.     

Recovery plateau following stroke: fact or fiction?

PURPOSE: 'Plateau' is an expression frequently used in relation to decisions to discharge patients from physiotherapy following stroke. This paper critically considers the concept of recovery plateau in stroke, exploring (i) the evidence for plateau, (ii) potential contributing factors, and (iii) the consequences for patients, therapists and services. SEARCH STRATEGY: The concept of recovery plateau in stroke was reviewed drawing on standard critical appraisal methodology for the search strategy and critique. Electronic searches using Web of Knowledge, MEDLINE, CINAHL, Department of Health Website and the Cochrane Library from the earliest dates of coverage until February 2005 identified quantitative and qualitative literature related to stroke, plateau, recovery, outcome, rehabilitation and physiotherapy. DISCUSSION: The concept of plateau is ambiguous. Recovery has been considered to plateau within the first 6 months, yet recent studies indicate later recovery is possible. We suggest that 'plateau' relates not only to the patient's physical potential, but is influenced by how recovery is measured, the intensity and type of therapy, patients' actions and motivations, therapist values, and service limitations. CONCLUSION: 'Plateau' is conceptually more complex than previously considered. Current conceptualizations may limit potential recovery and hinder service development. Research into plateau which takes account of contextual issues of therapy provision is required.