The left atrial septal pouch (LASP) is formed by incomplete fusion of the septum primum and septum secundum, leaving a cavity open towards the left atrium, but without interatrial shunting. There is no recommendation concerning strategy in the presence of a LASP, especially in the setting of stroke. The aim of this review was to determine whether the LASP could be incriminated as the aetiology of a stroke. We included all pertinent publications on the subject, and calculated hazard ratios for ischaemic stroke and cryptogenic stroke. There were only five case-control studies concerning the LASP, involving 516 stroke patients and 779 controls. Overall LASP prevalence was 21%, with a slightly higher prevalence in the cryptogenic stroke group (26%), but this difference was not statistically significant (P=0.27). In a random-effects meta-analysis, there was no difference between controls and patients with ischaemic stroke (hazard ratio 1.20, 95% confidence interval 0.96-1.53; P=0.14). Cryptogenic stroke appeared more frequently in patients with LASP (hazard ratio 1.53, 95% confidence interval 1.07-2.24; P=0.02), but this was driven by only one severely underpowered study. The published case reports demonstrated that thrombus formation inside the pouch can occur in the presence of major predisposing factors. The LASP can be a site for thrombus formation, leading to embolic events, but its presence does not correlate with an increased incidence of stroke. Associated factors should be taken into consideration in the setting of stroke. Further studies are necessary to validate a possible relationship with cryptogenic stroke.

The apolipoprotein E (APOE) e4 allele is associated with elevated cholesterol and risk of atherosclerosis. However, its role in ischemic stroke (IS) remains controversial. We investigated a possible link between IS or the severity of intracranial atherosclerosis and the APOE promoter polymorphisms À219G/T and þ 113G/C, involved in regulating APOE transcription. We genotyped subjects from a multicentric Belgian case-control study, including 237 middle-aged patients with IS due to small-or large-vessel atherosclerotic stroke and 326 ethnicity-and gender-matched controls and a Finnish autopsy series of 1004 non-stroke cases, who had received a quantitative score of atherosclerosis in the circle of Willis. The APOE e4 þ genotype did not associate with IS, but was related to more severe intracranial atherosclerosis score in men (5.4 vs 4.6, P ¼ 0.044). Within the most common APOE e3/e3 genotype group, the risk of IS associated with the G-allele of the tightly linked À219G/T (OR ¼ 6.2; 95% CI: 1.6 -24.3, P ¼ 0.009) and þ 113G/C (OR ¼ 7.1; 95% CI: 1.7 -29.9, P ¼ 0.007) promoter polymorphisms. There was no difference in the severity of intracranial atherosclerosis between À219G/G genotype carriers and non-carriers. This study suggests a multifaceted role of apoE on the risk of cerebrovascular diseases. The APOE e4 þ genotype did not predict the risk of IS but was associated with severity of subclinical intracranial atherosclerosis in men on the autopsy study. In contrast, the promoter variants were significant predictors of IS, suggesting that quantitative rather than qualitative variation of apoE is related to IS.

A 62-year-old patient presented with persistent cognitive deficits 3 months after a right temporal ischemic stroke due to ipsilateral carotid occlusion. Work-up disclosed hemodynamically significant contralateral carotid artery stenosis and left subclavian steal phenomenon. Brain SPECT imaging revealed bihemispheric chronic brain hypoperfusion that substantially improved on repeat imaging when the subclavian steal was temporarily diminished by inflating a cuff around the left arm. Carotid endarterectomy of the asymptomatic carotid stenosis substantially ameliorated bihemispheric brain perfusion and reversed cognitive impairment. This case highlights that multi-vessel, extracranial atherosclerotic disease may cause chronic diffuse brain hypoperfusion that can be associated with cognitive impairment.

The syndrome of painful arm and moving fingers associates pain in one arm or hand with involuntary movement of one or several fingers. In the four cases described, an association between a central and a peripheral nervous system lesion is demonstrated or suspected. Treatment of the condition is disappointing.