Interatrial septum rupture during balloon measurement of a patent foramen ovale in a young patient presenting cryptogenic stroke.

We report the case of a 36-year-old woman admitted for cryptogenic stroke, in whom the Patent Foramen Ovale (PFO) diameter measurement, with a purpose built sizing balloon, performed before the closure procedure, was complicated with the rupture of the inter-atrial septum generating an Atrial Septal Defect (ASD) with a significant left-to-right shunt. This kind of complication may not be easy to handle, changing the initial procedural strategy from PFO to ASD closure technique requiring specific material and operator's technical skill.     

缺血性卒中相关性卵圆孔未闭的介入治疗

卵圆孔未闭是缺血性卒中的一个新的危险因素,但其具体机制仍不明,许多相关问题尚需进一步探讨。通过对相关文献进行比较,进一步肯定了卵圆孔未闭与缺血性或不明原因的卒中之间有很强的联系。房间隔瘤伴发卵圆孔未闭是脑梗死的危险因素。经皮导管卵圆孔未闭封堵术的应用前景看好,但还需要进行进一步的前瞻性研究。     

Intracardiac thrombosis in multiple chambers and descending aorta manifested as systemic and pulmonary thromboembolism

We report a case with multiple thrombosis that underwent sudden circulatory collapse due to acute pulmonary embolism and ischemic stroke. Further confirmed by transesophageal echocardiography, the thrombus in both atria was detected by transthoracic echocardiography. In addition, patent foramen ovale and another thrombus in the descending aorta were readily identified by transesophageal echocardiography. Aspirin was prescribed and thrombi disappeared 1 month later. Our case report suggests that patients undergoing sudden collapse with unexplained hypoxemia and new neurological deficit secondary to coexistence of pulmonary and systemic embolism should be promptly evaluated by echocardiography, especially transesophageal one, with high suspicion for paradoxical embolism.     

Anatomy of the accessory mental foramen in a Saudi subpopulation: A multicenter CBCT study

AimThe aim of this is to evaluate the prevalence and location of the accessory mental foramen (AMF) in a Saudi population using cone-beam computed tomography (CBCT).MethodologyCBCT data were retrieved from two dental facilities at two universities located in two different cities and filtered over a period of four years. The scans were aligned when the AMF was noticed, and then the size of both the AMF and mental foramen (MF), its location, and the distance from the AMF to the MF were recorded. The AMF measurements were compared between males and females and between the two sides of the mandible.ResultsIn total, 603 CBCT scans were investigated. The percentage of scans with an AMF was 9.95% (n = 60), and AMFs were almost equally distributed on both sides. Only four cases (0.66%) of a second AMF were detected among the scans. The MFs on both sides were significantly larger in males than in females (P > 0.05), but they showed no differences in the sizes of the AMFs. The AMFs were most commonly located inferior and posterior to the MF. The distance between the MF and AMF ranged from 2.32 to 5 mm.ConclusionsThe prevalence of the AMF in this Saudi population was 9.95%, and it was significantly more prevalent in males than in females. Its proximity to the MF makes it clinically important to conduct proper detailed planning prior to performing any procedure that might risk the vital structures.     

卵圆孔未闭致缺血性卒中临床分析

目的：探讨青年缺血性卒中的可能原因和防治方法。方法分析收集2012年5月至2012年9月4个月间缺血性卒中的临床资料和防治措施。结果卵圆孔未闭（PFO）9例,其中＆lt;45岁的患者7例。结论对45岁以下原因不明的缺血性卒中患者,PFO 是1个独立的危险因素,除常规的同型半胱氨酸、血管炎系列（如抗心磷脂抗体）、血糖、血脂、心电图、TCD、颈部血管超声、心脏彩超、头颈部 CTA、MRA、颅脑 DSA 等,在有条件的医院应行经食道超声检查,提高 PFO 的检出率,行卵圆孔封堵术及早干预,降低卒中的再发风险。     

Primary Stroke in a Woman With Sickle Cell Anemia Responsive to Hydroxyurea Therapy

The most common cause of stroke in children with sickle cell anemia is infarction due to ischemia. In adults, however, stroke is most commonly hemorrhagic in nature. Other causes of stroke in patients with sickle cell disease are very rare. In this short communication, we describe a woman with sickle cell anemia responsive to hydroxyurea (HU) therapy who had primary stroke due to paradoxical embolization caused by a large atrial septal defect. Successful management of the stroke included surgical closure of the defect with trans-esophageal echocardiographic guidance. To the best of our knowledge, this is the first patient with sickle cell anemia and stroke due to congenital heart disease who did not require open heart surgery for successful management.     

Percutaneous Closure versus Medical Therapy Alone for Cryptogenic Stroke Patients with a Patent Foramen Ovale: Meta-Analysis of Randomized Controlled Trials

Of cryptogenic stroke patients younger than 55 years of age, up to 61% have had a patent foramen ovale (PFO). Observational studies have revealed reductions in recurrent neurologic events through PFO closure versus medical therapy, and randomized controlled trials have shown nonsignificant trends toward benefit. We systematically searched for randomized controlled trials of percutaneous PFO closure with medical therapy versus medical therapy alone in patients with cryptogenic stroke and performed a meta-analysis of treatment outcomes. The primary endpoint was combined death, stroke, and transient ischemic attack.We included 3 trials. Of 2,303 total patients, 1,150 underwent PFO closure and 1,153 received medical therapy (median follow-up period, 2.6 yr). The pooled incidence of the primary endpoint was 1.2 events per 100 patient-years in the closure group (95% confidence interval [CI], 0.2–2.3) and 1.8 in the therapy group (95% CI, 0.7–2.9) (P=0.32); the number needed to treat was 167 (range, 100–500). The corresponding pooled hazard ratio was 0.67 (95% CI, 0.44–1.01; P=0.054) in favor of closure. Closure was associated with an increased risk of atrial fibrillation: relative risk=3.51 (95% CI, 1.44–8.55; P=0.006). When stratified by device, use of the Amplatzer™ PFO Occluder resulted in significant stroke-prevention benefit over medical therapy alone: hazard ratio=0.44 (95% CI, 0.21–0.95; P=0.037).When compared with medical therapy alone, PFO closure with medical therapy showed a trend toward a decreased hazard of combined events, although the absolute event reduction was small and the number needed to treat was high.     

Body position and oxygenation: An intriguing relationship

Dyspnea and hypoxemia are among the most common symptoms and signs that need to be assessed in clinical practice.This case illustrates how simple steps in history taking and physical examination can be crucial for diagnosis.We present a patient with intermittent hypoxemia, initially attributed to a pulmonary infection. However, the hypoxemia persisted even after successful treatment of the infection. Computed tomography angiography of the chest and ventilation/perfusion lung scan excluded pulmonary embolism.We then observed that the hypoxemia and dyspnea were triggered by orthostatism. An echocardiogram with a bubble test showed a patent foramen ovale, with a right-to-left shunt, without pulmonary hypertension. After percutaneous closure of the foramen ovale, the symptoms completely resolved.This is a case of platypnea-orthodeoxia syndrome, which is usually associated with patent foramen ovale or atrial septal defect and is typically observed in the elderly. The features and causes of this curious syndrome are discussed.