Abstract:

The review is devoted to possibilities of ultrasound and functional diagnostic methods in the diagnosis of ischemic stroke of unknown etiology. Main causes of cryptogenic ischemic stroke are highlighted in the article. Advances in high resolution ultrasound of extracranial and intracranial vessels and of the heart, prolonged heart rhythm monitoring are instrumental techniques to identify arterial and cardiac hidden causes of stroke. We reviewed literature, on the basis of available data, designed a diagnostic algorithm for patients with patent foramen ovale (PFO) and risk of embolism from atherosclerotic plaque. 

References

I.       Petrikov S.S., Chamidova L.T. O conferencii «Neotlozhnaya pomosh bolnim s ostrimi narusheniaymi mozgovogo krovoobrasheniaya». [About conferention «Urgent treatment of patients with acute stroke»] Zhurnal im. N.V. Sklifisivskogo Neotbzhnayapomosh. 2015; 1:10-18 [In Russ].

2.      Grau A.J., Weimar C., Buggle F. et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke. 2001; 32(11): 2559-66.

3.      Li L., Yiin G.S., Geraghty O.C., et al. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology. 2015; 14(9): 903-13.

4.      Hart R.G., Diener H.C., Coutts S.B., Easton J.D. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13(4): 429-38.

5.      Tegeler C.H., Hart R.G. Atrial size, atrial fibrillation and stroke. Ann. Neurol. 1987; 21: 315- 316.

6.      Hohnloser S.H., Capucci A., Fain E. et. al. ASSERT Investigators and Committees ASymptomatic atrial fibrillation and Stroke Evaluation in pacemaker patients and the atrial fibrillation Reduction atrial pacing Trial (ASSERT). Am Heart J. 2006; 152(3): 442-447.

7.      Yaghi S., Elkind M.S. Cryptogenic stroke: a diagnostic challenge. Neurol Clin Pract. 2014(4): 386-393.

8.      Favilla C.G., Ingala E., Jara J. et al. Predictors of finding occult atrial fibrillation after cryptogenic stroke. Stroke. 2015(46): 1210-1215.

9.      Miller D.J., Khan M.A., Schultz L.R. et al. Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke. J Neurol Sci. 2013(324): 57-61.

10.    Gladstone D.J., Dorian P, Spring M. et al. Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the embrace trial. Stroke. 2015; 46: 936-941.

11.    Keach J.W., Bradley S.M., Turakhia M.P, Maddox TM. Early detection of occult atrial fibrillation and stroke prevention. Heart.2015; 101: 1097-102.

12.    Gladstone D.J., Dorian P, Spring M. et al. Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the embrace trial. Stroke.2015; 46:936-941.

13.    Brambatti M., Connolly S.J., Gold M.R. et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation.2014; 129: 2094-2099.

14.    Kamel H., O’Neal W.T., Okin PM., et al. Electrocardiographic left atrial abnormality and stroke subtype in atherosclerosis risk in communities study. Ann Neurol.2015; 78(5): 670-678.

15.    Kamel H., Soliman E.Z., Heckbert S.R. et al. P- wave morphology and the risk of incident ischemic stroke in the multi-ethnic study of atherosclerosis. Stroke. 2014; 45:2786-2788.

16.    Sinner M.F, Stepas K.A., Moser C.B. et al. B-type natriuretic peptide and c-reactive protein in the prediction of atrial fibrillation risk: the CHARGE-AF consortium of community-based cohort studies. Europace. 2014; 16: 1426-1433.

17.    Kernan W.N., Ovbiagele B., Black H. R., Bravata D. M. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2014; 45: 2160-2236.

18.    Melkumova E., Thaler D.E. Cryptogenic Stroke and Patent Foramen Ovale Risk Assessment. Interv Cardiol Clin. 2017; 6(4): 487-493.

19.    Alsheikh-Ali A.A., Thaler D.E., Kent D.M. Patent foramen ovale in cryptogenic stroke: incidental or pathogenic? Stroke. 2009; 40: 2349-2355.

20.    Overell J.R., BoneI., Lees K.R. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology. 2000; 55(8): 1172-1179.

21.    Ahmed N., Steiner T., Caso V., Wahlgren N. Recommendations from the ESO-Karolinska Stroke Update Conference. European Stroke Journal. 2016; 0(0): 1-8.

22.    Spencer M.P, Moehring M.A., Jesurum J. et al. Power m-mode transcranial Doppler for diagnosis of patent foramen ovale and assessing transcatheter closure. J Neuroimaging. 2004; 14(4): 342-349.

23.    Katsanos A.H., Patsouras D., Tsivgoulis G. et al. The value of transesophageal echocardiography in the investigation and management of cryptogenic cerebral ischemia: a single-center experience. Neurol Sci. 2016; 37(4): 629-32.

24.    Wei-jan C., Peiliang K.,Wen-Pin L., Fang-¥ue U. Detection Of Patent Foramen Ovale By Contrast Transesophageal Echocardiography. Chat. 1992; 101: 1515-20.

25.    Schnabel R.B., Yin X., Gona P, Larson MG. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet. 2015; 386(9989):154-62.

26.    Arboix A., Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev. 2012;8(1):54-67.

27.    Christian T. R.Stroke Prevention in Atrial Fibrillation. Circulation. 2012; 125(16): e588-90.

28.    Zabalgoitia M., Halperin J.l., Pearce L. A. et al. Transesophageal Echocardiographic Correlates of Clinical Risk of Thromboembolism in Nonvalvular Atrial Fibrillation. Journal of the AmericanCollege of Cardiology. 1998; 31(7): 1622-1626.

29.    diesebro J.H., Fuster V. Valvular heart disease and prosthetic heart valves. Thrombosis in cardiovascular disorders. Eds V. Fuster, M. Verstraete.- Philadelphia: W.B.Saunders, 1992; 191-214.

30.    Tunick P.A., Kronzon I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J. 1990; 120: 658-660.

31.    Tunick P.A., Culliford A.T., Lamparello P.J., Kronzon I. Atheromatosis of the aortic arch as an occult source of multiple systemic emboli. Ann Intern Med. 1991; 114: 391392.

32.    Amarenco P., Cohen A., Tzourio C. et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994; 331(22): 1474- 1479.

33.    Bulwa Z., Gupta A. Embolic stroke of undetermined source: The role of the nonstenotic carotid plaque. J Neurol Sci. 2017; 15(382): 49-52.

34.    Viguier A., Pavy le Traon A., Massabuau P. et al. Asymptomatic cerebral embolic signals in patients with acute cerebral ischaemia and severe aortic arch atherosclerosis. Journal of Neurology. 2001; 248: 768-771.

35.    Rundek T., Di Tullio M.R., Sciacca R.R. et al. Association between large aortic arch atheromas and high-intensity transient signals in elderly stroke patients. Stroke. 1999; 33: 2683-2686.

36.    Gupta A., Gialdini G., Lerario M.P.et al. Magnetic resonance angiography detection of abnormal carotid artery plaque in patients with cryptogenic stroke. J Am Heart Assoc. 2015; 4(6): e002012.

37.    Freilinger T.M., Schindler A., Schmidt C.et al. Prevalence of nonstenosing, complicated atherosclerotic plaques in cryptogenic stroke. JACC Cardiovasc Imaging. 2012; 5: 397-405.

38.    Casadei A., Floreani M., Catalini R. et al. Sonographic characteristics of carotid artery plaques: Implications for follow-up planning?J Ultrasound. 2012; 15(3): 151-157.

39.    Rafailidis V., Charitanti A., Tegos T. et al. Contrast-enhanced ultrasound of the carotid system: a review of the current literature. J Ultrasound. 2017; 20(2): 97-109.

40.    Nedeltchev K., der Maur T.A., Georgiadis D. et al. Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry. 2005; 76(2): 191-195.

41.    Caplan L.R. Dissections of brain-supplying arteries. Nat Clin Pract Neurol. 2008; 4(1): 34-42.

42.    Gunther A., Witte O.W., Freesmeyer M. et al. Eur Neurol. 2016; 76(5-6): 284-294.

43.    Clevert D.A., Horng A., Jung E.M. et al. Contrast-enhanced ultrasound versus conventional ultrasound and MS-CT in the diagnosis of abdominal aortic dissection. Clin Hemorheol Microcirc. 2009; 43: 129-139.

44.    Graus F., Rogers L.R., Posner J.B. Cerebrovascular complications in patients with cancer. Medicine. 1985; 64(1): 16-35.

45.    Kurabayashi H., Hishinuma A., Uchida R et al. Delayed manifestation and slow progression of cerebral infarction caused by polycythemia rubra vera. Am J Med Sci. 2007; 333(5): 317-320.

46.    Giray S., Sarica F.B., Arlier Z., Bal N. Recurrent ischemic stroke as an initial manifestation of an concealed pancreatic adenocarcinoma: Trousseau’s syndrome. Chin Med J. 2011; 124(4): 637-640.

Abstract:

We present a case report of successful transcatheter closure of patent foramen ovale (PFO) by transcatheter suturing device «Noblestitch EL».

Materials and methods: cryptogenic stroke may be the consequence of the PFO. Percutaneous PFO closure, being less invasive than surgical closure, is increasingly performed; there are, however, early and long-term risks including: device embolization, fracture, thrombosis, infection, erosions of free atrial wall, arrhythmias. Furthermore, device implantation may complicate future percutaneous access to the left atrium. Partially reabsorbable devices and tissue welding to close PFO have recently been introduced. We present a case report of 33-year-old woman with a history of cryptogenic stroke. Echocardiography imaging with bubble study demonstrated a right-to-left shunt through the PFO at rest. The right femoral vein was cannulated. A «Noblestitch EL» device was advanced across the PFO and thread was passed through the septum primum and secundum. Threads were exteriorized and a knot was advanced to the right atrial septum and cut.

Results: successful closing of PTO was confirmed by transesophageal echocardiogram. Later it was shown complete PFO closing, no right-to-left shunt, even during the Valsalva maneuver, no residual shunt was observed.  

References 

1.    McKenzie J.A., Edwards W., Hagler D.J. Anatomy of the patent foramen ovale for the interventionalist. Catheter Cardiovasc Interv. 2009; 73:821-826.

2.    Messe S.R., Silverman I.E., Kizer J.R. et al. Practice parameter: Recurrent stroke with patent foramen ovale and atrial septal aneurysm: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004; 62:1042-1050.

3.    Del Valle-Fernбndez R., Ruiz C.E. Frontiers of Patent Foramen Ovale Closure and New Design Improvements - A Review of the Literature. Interventional Cardiology Review. 2008; 3(1): 24-27. DOI: 10.15420/icr. 2008.3.1.24

4.    Calvert PA., Rana B.S., Kydd A.C. et al. Patent foramen ovale: anatomy, outcomes and closure. Nat Rev Cardiol. 2011; 8:148-160.

5.    Scacciatella P, Butera G., Meynet I. et al. Percutaneous closure of patent foramen ovale in patients with anatomical and clinical high-risk characteristics: longterm efficacy and safety. J Interv Cardiol. 2011; 24:477-484.

6.    Sievert H., Fischer E., Heinisch C. et al. Transcatheter closure of patent foramen ovale without an implant: Initial clinical experience. Circulation. 2007; 116:1701-1706.

7.    Sigler M., Jux C. Biocompatibility of septal defect closure devices. Heart. 2007; 93:444-449.

8.    Verma S.K., Tobis J.M. Explantation of patent foramen ovale closure devices. A multicenter survey. JACC Cardiovasc Interv. 2011; 4:579-585.

9.    Onorato E., Casilli F., Berti M., Anzola GP Patent foramen ovale closure. Pro and cons. Neurol. Sci. 2008. 29:S28-S32. DOI 10.1007/s10072-008-0881-x

10.  Rana B.S., Thomas M.R., Calvert PA. et al. Echocardiographic evaluation of patent foramen ovale prior to device closure. JACC Cardiovasc Imaging. 2010; 3:749-760.

11.  Slottow T.L., Steinberg D.H., Waksman R. Overview of the 2007 Food and Drug Administration Circulatory System Devices Panel meeting on patent foramen ovale closure devices. Circulation. 2007; 116:677-682.

12.  Onorato E., Casilli F. Influence of PFO Anatomy on Successful Transcatheter Closure. Interv. Cardiol. Clinic. 2013. 2 (1): 51-84. DOI: http://dx.doi.org/10.1016/j.iccl. 2012.09. 009

13.  Ruiz C.E., Kipshidze N., Chiam P, Gogorishvili I. Feasibility of Patent Foramen Ovale Closure With NoDevice Left Behind: First-In-Man Percutaneous Suture Closure. Catheterization and Cardiovascular Interventions. 2008; 71:921-926. DOI 10.1002/ccd.