卵圆孔未闭与隐源性卒中的研究进展

经过全面筛查,仍有约40%找不到明确病因的缺血性卒中为隐源性卒中。卵圆孔未闭可引 起反常栓塞,进而发生缺血性卒中。近年来发现,部分隐源性卒中可能由卵圆孔未闭导致。本文将从 检查方法、作用、机制及治疗等方面对卵圆孔未闭与隐源性卒中的研究现状进行介绍。     

卵圆孔未闭与隐源性卒中的研究进展

隐源性卒中约占所有缺血性卒中的40%,其病因、诊断和治疗一直是临床工作者的研究热 点。近年来发现,卵圆孔未闭与隐源性卒中的发病密切相关,是隐源性卒中的重要危险因素。在临床 中常用经食管超声心动图、经胸壁超声心动图、经颅多普勒发泡试验和心脏MRI等方法来检测卵圆孔 未闭。反常栓塞是卵圆孔未闭导致隐源性卒中的主要发病机制。在头部影像学检查中,绝大多数卵圆 孔未闭相关隐源性卒中患者为多血管分布区的多发散在小梗死。在药物治疗方面,抗血小板药物相 对于抗凝药物,可能更适合大多数卵圆孔未闭合并隐源性卒中的患者。此外,近期多项临床随机对照 研究均表明,卵圆孔未闭封堵术对于预防卵圆孔未闭合并隐源性卒中患者卒中再发的疗效明显优于 药物治疗。     

经颅多普勒发泡实验在筛查隐源性卒中合并卵圆孔未闭的应用价值

目的探讨经颅多普勒发泡实验(C-TCD)在筛查隐源性卒中合并卵圆孔未闭中的应用价值。方法回顾分析60例隐源性卒中患者,包括发病特点,既往史,检验检查,分析相关数据。结果 60例患者均明确诊断为急性脑梗死、短暂性脑缺血发作,行经颅多普勒超声发泡试验(c-TCD)发现,阳性33例,阴性27例,经食道超声心动(TEE)检查证实有26例合并心脏卵圆孔未闭,16例合并下肢静脉血栓形成。结论 PFO在隐源性卒中中为常见病因,但常规检查很难发现,本研究通过c-TCD初步筛查PFO,阳性率及敏感性高于TEE,特异性亦较高,对于隐源性卒中合并PFO,可作为病因筛查的首选。     

青年隐源性卒中的病因学研究进展

青年脑卒中多不具备脑血管病常见的危险因素,病因以非常见类型或病因不明确为主.由于青年脑卒中的总体发病率逐年增加,且脑卒中复发率亦与病因防控相关,故而对青年隐源性缺血性卒中的病因学进行深入研究,并针对病因进行防治显得尤为重要.现对近年来报道的青年隐源性缺血性卒中的病因学研究进展进行综述.     

卵圆孔未闭与缺血性卒中的关系

正随着缺血性卒中分型理论在国内的普及[1-2],人们越来越重视针对卒中病因的筛查和研究。病因不同,缺血性卒中二级预防的策略就可能不同,如心源性卒中侧重于抗凝治疗,而大动脉粥样硬化性卒中则强调抗血小板聚集。近年,所谓隐源性卒中的病因研究,在国内逐渐受到重视。本文将简要介绍隐源性卒中研究中所涉及的相关问题,重点阐述卵圆孔未闭(patent foramen ovale,PFO)在缺血性卒中发病中的     

专题综述:卵圆孔未闭与卒中

正编者按缺血性卒中是一种综合征,按病因一般可归为5类,病因不同,防治策略亦有区别。隐源性卒中占整个缺血性卒中病患群体的比率达20%~30%,其中50%以上与心源性栓子相关,研究发现,卵圆孔未闭(patent foramen ovale,PFO)与隐源性卒中的发病有一定的关系。近年,国内逐渐开始了相关的临床工作,我们在借鉴国外经验的同时,也需要注意它们所存在的一些问题。     

Neurology：房性心脏病，卒中的新病因？

<正>隐源性卒中占所有缺血性卒中的20%～25%,远端栓塞是被广泛接受的解释。因此,有人提出这是一种新的卒中形式:原因不明的栓塞性卒中(embolicstrokeof undetermined source,ESUS)。未被检测到的阵发性心房颤动被认为是ESUS的首要病因,因此临床实践中对越来越多的患者进行长程心脏监测。但是,研究发现即     

肺动静脉瘘与缺血性卒中

肺动静脉瘘为隐源性卒中的危险因素，特别是在中青年人群中。但由肺动静脉瘘引起缺 血性卒中的比例极少，因此关于肺动静脉瘘和缺血性卒中的现有文献有限，且多为病例报道。多发性 肺动静脉瘘患者缺血性卒中的患病率高达到60%。因此，临床应警惕肺动静脉瘘这一缺血性卒中的 特殊病因，尤其是在病因不明的青年缺血性卒中患者中。     

卵圆孔未闭并隐源性卒中的临床及影像学分析

目的探讨卵圆孔未闭(patent foramen ovale,PFO)并隐源性卒中(cryptogenic stroke,CS)的临床及影像学特征。方法连续性纳入2015年3月~2015年12月入住郑州大学附属洛阳中心医院神经内科的年龄≤65岁的急性缺血性脑卒中患者,对其进行脑血管病危险因素筛查,并行TOAST分型。对所有入组患者通过经胸超声心动图声学造影(c TTE)联合经颅多普勒声学造影(c TCD)(即发泡试验)行PFO筛查,两者均为阳性视为存在PFO。分析PFO在急性缺血性卒中中检出率,及PFO并CS的分流量、影像学分布特征及部分封堵术后疗效观察。结果共纳入141例符合标准的急性缺血性卒中患者。隐源性卒中48例(34.0%),非隐源性卒中93例(66.0%)。PFO阳性率在缺血性卒中组、CS组、非CS组中分别为31.2%(44/141)、47.9%(23/48)、22.6%(21/93)。PFO阳性组中,隐源性卒中较非隐源性卒中存在较大的分流量,且差异有统计学意义(P=0.007)。而PFO相关性隐源性卒中与非PFO相关性隐源性卒中患者在其病灶分布的部位、数量之间的差异无统计学意义。PFO封堵术后6月随访未见复发,但尚缺乏对照性研究。结论 PFO及其分流量与CS密切相关,但PFO并CS患者无特异性影像学表现,应加强对此类患者的筛查与管理。     

心源性卒中的病因和风险

<正>约90%的卒中为缺血性卒中,尽管诊断技术在进步,但不明原因的缺血性卒中仍然常见,被称为隐源性卒中。隐源性卒中大多数具有栓塞特征,其栓子可能起源于心脏。心输出血量的15%供应大脑,各种心脏栓子随着血流进入头颈动脉,阻塞脑动脉及其分支,由于脑血流突然中断导致缺血性卒中,该类型卒中大多数起病突然、神经功能受损严重。栓子在最初的     

Sleep apnea syndrome and patent foramen ovale: a dangerous association in ischemic stroke?

BackgroundThe coexistence of patent foramen ovale (PFO) and sleep apnea syndrome (SAS) might be related to the pathogenesis of cryptogenic stroke (CS). We aimed to determine the prevalence of SAS in patients with cryptogenic stroke and PFO.MethodsThis is a prospective case-control study in which we included ischemic stroke patients consecutively admitted to our hospital's Acute Stroke Unit. Contrast transcranial Doppler (c-TCD) and sleep polygraphy within the first 72 h after stroke onset were performed to detect PFO and SAS. Demographic and clinical characteristics, time of stroke onset, score in the National Institute of Health Stroke Scale (NIHSS), and stroke subtype were registered.ResultsA total of 97 patients were studied. Overall, 76% were men, with a mean ± SD age of 61 ± 13 years, and an NIHSS of 5 ± 5. Subtype of stroke was cryptogenic (CS) in 28 (29%) and non-CS in 69 (71%) of patients. PFO was more frequent among patients with CS (64% vs 29%, p = 0.002) and without SAS (60% vs 32%, p = 0.013). SAS was diagnosed in 74% of the whole group, with a higher prevalence in patients with known stroke etiology (83% vs 53%, p = 0.003). Finally, the prevalence of SAS and PFO coexistence was similar in patients with or without cryptogenic stroke (25% vs 22%, p = 1), and when comparing the group of patients with cryptogenic wake-up stroke to the other stroke patients (43% vs 21%, p = 0.35).ConclusionsAccording to our results, there is no evidence of an association of PFO and SAS in the pathogenesis of cryptogenic stroke.     

Cryptogenic stroke in a boy with atrial septal defect and hyperhomocysteinemia

In children, clinical recognition of stroke and determination of its exact etiology are extremely difficult. The authors described a case of cryptogenic stroke in a 14-year-old-boy with asymptomatic atrial septal defect and hypercoagulable state. Paradoxical embolism was hypothesized as the responsible etiopathological mechanism. It is crucial to increase clinician awareness of stroke in children.     

Cryptogenic stroke, aortic arch atheroma and patent foramen ovale

Cryptogenic stroke represents a diagnostic challenge. Several conditions have been found to be more frequent in patients with cryptogenic stroke. Aortic arch atheroma (AAA) and patent foramen ovale (PFO) have been shown to be highly prevalent in the adult population, especially in patients with ischemic cerebrovascular events, particularly cryptogenic strokes. In both conditions, clinical relevance and stroke risk are related to age, with AAA being more frequent and severer in patients >55 years, and the relationship between stroke and PFO being stronger in those <55 years of age. This review is focused on the prevalence, risk of stroke and therapeutic strategies in patients with cryptogenic stroke related to AAA or PFO.     

Non-cardioembolic Mechanisms in Cryptogenic Stroke: Clinical and Diffusion-weighted Imaging Features

Background

The role of several cardiogenic risk factors, including patent foramen ovale, in patients with cryptogenic stroke has been extensively studied. However, little attention has been paid to the role of non-cardioembolic causes of cryptogenic stroke. We therefore sought to identify the characteristics of cryptogenic stroke.

Methods

We studied 832 patients with acute infarction in the middle cerebral arterial territory. We divided the patients into four subtypes: 402 with large artery atherosclerosis (LAA), 133 with cardioembolism, 182 with small arterial occlusion (SAO), and 115 with cryptogenic stroke. We compared risk factors and lesion patterns observed by diffusion-weighted imaging (DWI) between patients with cryptogenic stroke and those with stroke of other subtypes.

Results

Both risk factors and DWI lesion patterns differed between the cryptogenic and cardioembolic groups (P<0.05). Risk factors for cryptogenic stroke were similar to those for the LAA and SAO groups. Similarly, DWI lesion patterns for cryptogenic stroke were similar to LAA patients. Large cortical infarcts on DWI were more common in the cardioembolic group than in the LAA or cryptogenic groups (P<0.001). In contrast, deep, non-lacunar (OR 5.02; 95% CI 2.68~9.40; P<0.001) and superficial perforator infarcts (OR 2.23; 95% CI 1.08~4.59; P=0.029) were independently associated with the cryptogenic group.

Conclusions

Our results indicate that non-cardioembolic causes, such as macro- and microangiopathy, are important mechanisms in the pathogenesis of cryptogenic stroke.     

Prevalence of atrial septal abnormalities in older patients with cryptogenic ischemic stroke or transient ischemic attack

OBJECTIVE: To evaluate the association of atrial septal abnormalities - patent foramen ovale (PFO), atrial septal aneurysm (ASA), or the combination of both (PFO+ASA) - with cryptogenic stroke or transient ischemic attack (TIA) in older patients. METHODS: We examined the prevalences of PFO, ASA, and PFO+ASA in 132 consecutive patients aged 55 years or more who underwent transesophageal echocardiography (TEE) for evaluation of ischemic stroke or TIA. We compared patients with cryptogenic stroke/TIA and those with stroke/TIA of known cause. RESULTS: PFO+ASA was more common in patients with cryptogenic stroke/TIA than in patients with stroke/TIA of known cause (12/62 or 19% vs. 2/70 or 3%; adjusted odds ratio, 7.4; 95% CI, 1.4-38.2). Differences between groups for isolated PFO, and isolated ASA were not significant. The association of PFO+ASA with cryptogenic stroke/TIA was confirmed in the subgroup of patients aged 75 years or more (odds ratio, 15.0; 95% CI, 1.5-146.7). CONCLUSION: This study indicates a significant association of PFO+ASA with cryptogenic stroke or TIA in older patients.     

The diagnostic efficiency of transesophageal compared to transthoracic echocardiographic findings from 405 patients with ischemic stroke

This study compared the diagnostic efficacy of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) for patients with stroke. Examination with TTE was followed by TEE. Stroke causes were classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) and Causative Classification of Stroke (CCS) criteria before and after TEE to determined, cryptogenic or unclassified groups. We identified that 55.1% of patients had a determined etiology for stroke with TTE; adding TEE to the examinations increased the proportion of patients with determined stroke etiology to 69.4% (κ = 0.79). TTE alone showed fair agreement with the combined results of TTE and TEE in determining the cause of stroke in young adults (κ = 0.38). TEE improved the detection of cardio-aortic sources, but had no impact on patients who had a determined cause for stroke with other examinations. TEE examination was most useful in young adults with stroke and in patients with an undetermined cause for stroke despite TTE examination and other standard investigations.     

Histological features of intracranial thrombi in stroke patients with cancer

The histological features of thrombus in stroke patients with cancer are not well known. Using immunohistochemical staining of thrombi retrieved during mechanical thrombectomy in stroke patients, thrombus compositions were compared between 16 patients with active cancer, 16 patients with inactive cancer, and 16 patients without any history of cancer. The active cancer group showed higher platelet and lower erythrocyte fractions than the inactive cancer or the control group. Four patients with vegetation showed very high platelet and low erythrocyte fractions. Patients with cryptogenic etiology in the active cancer group showed a similar pattern to those with vegetation. These findings may aid the determination of treatment strategies in cancer‐associated stroke. ANN NEUROL 2019