High Frequency of Silent Pulmonary Embolism in Patients With Cryptogenic Stroke and Patent Foramen Ovale

Tanislav, Christian; Puille, M.; Pabst, W.; Reichenberger, Frank; Grebe, Mathias; Nedelmann, Max; Kaps, Manfred; Allendörfer, Jens

doi:10.1161/strokeaha.110.601575

Cited by 32 publications

(36 citation statements)

References 8 publications

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“…Blinded from clinical data all scans were independently evaluated by two experts according to the PIOPED (prospective investigation of pulmonary embolism diagnosis) criteria modified for SPECT images, as described by Reinartz et al [5,9,10]. In scans graded differently a consensus read was undertaken.…”

Section: Methodsmentioning

confidence: 99%

“…As a functional PFO closure was observed after treatment of acute massive pulmonary emboli, a fluctuation in pulmonary atrial pressure might be involved in the mechanism of shunt dynamic across a PFO [2-4]. Considering that silent pulmonary embolism (PE) is a frequent finding in patients with CS and PFO, it raises the question whether an increase in right atrial pressure due to silent pulmonary embolism may have a similar impact on the development of RLS dynamics [5]. We therefore investigated the relevance of silent PE in a cohort of PFO patients with CS with a re-assessment of RLS on follow-up.…”

Section: Introductionmentioning

confidence: 99%

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Factors associated with shunt dynamic in patients with cryptogenic stroke and patent foramen ovale: an observational cohort study

Tanislav

Puille

Grebe

et al. 2011

BMC Cardiovasc Disord

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BackgroundAs previously reported there is evidence for a reduction in right to left shunt (RLS) in stroke patients with patent foramen ovale (PFO). This occurs predominantly in patients with cryptogenic stroke (CS). We therefore analysed factors associated with a shunt reduction on follow-up in stroke patients suffering of CS.MethodsOn index event PFO and RLS were proven by transesophageal echocardiography and contrast-enhanced transcranial Doppler-sonography (ce-TCD). Silent PE was proved by ventilation perfusion scintigraphy (V/Q) within the stroke work-up on index event; all scans were re-evaluated in a blinded manner by two experts. The RLS was re-assessed on follow-up by ce-TCD. A reduction in shunt volume was defined as a difference of ≥20 microembolic signals (MES) or the lack of evidence of RLS on follow-up. For subsequent analyses patients with CS were considered; parameters such as deep vein thrombosis (DVT) and silent pulmonary embolism (PE) were analysed.ResultsIn 39 PFO patients suffering of a CS the RLS was re-assessed on follow-up. In all patients (n = 39) with CS a V/Q was performed; the median age was 40 years, 24 (61.5%) patients were female. In 27 patients a reduction in RLS was evident. Silent PE was evident in 18/39 patients (46.2%). Factors such as atrial septum aneurysm, DVT or even silent PE were not associated with RLS dynamics. A greater time delay from index event to follow-up assessment was associated with a decrease in shunt volume (median 12 vs. 6 months, p = 0.013).ConclusionsIn patients with CS a reduction in RLS is not associated with the presence of a venous embolic event such as DVT or silent PE. A greater time delay between the initial and the follow-up investigation increases the likelihood for the detection of a reduction in RLS.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Factors associated with shunt dynamic in patients with cryptogenic stroke and patent foramen ovale: an observational cohort study

Tanislav

Puille

Grebe

et al. 2011

BMC Cardiovasc Disord

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“…The risk of pulmonary embolism can persist for up to 4 weeks post stroke [67]. A review of a relatively small cohort of cryptogenic stroke patients found a significant incidence of silent pulmonary embolism (37%), but did not comment as to whether or not this led to a resultant hypoxic state [68]. Improvements in mechanical, pharmacological and therapy based regimes are the likely reason pulmonary embolism is now a relative rarity.…”

Section: Causes Of Hypoxia In Acute Strokementioning

confidence: 99%

Hypoxia after stroke: a review of experimental and clinical evidence

Ferdinand

Roffe

2016

Exp & Trans Stroke Med

104

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BackgroundHypoxia is a common occurrence following stroke and associated with poor clinical and functional outcomes. Normal oxygen physiology is a finely controlled mechanism from the oxygenation of haemoglobin in the pulmonary capillaries to its dissociation and delivery in the tissues. In no organ is this process more important than the brain, which has a number of vascular adaptions to be able to cope with a certain threshold of hypoxia, beyond which further disruption of oxygen delivery potentially leads to devastating consequences. Hypoxia following stroke is common and is often attributed to pneumonia, aspiration and respiratory muscle dysfunction, with sleep apnoea syndromes, pulmonary embolism and cardiac failure being less common but important treatable causes. As well as treating the underlying cause, oxygen therapy is a vital element to correcting hypoxia, but excessive use can itself cause molecular and clinical harm. As cerebral vascular occlusion completely obliterates oxygen delivery to its target tissue, the use of supplemental oxygen, even when not hypoxic, would seem a reasonable solution to try and correct this deficit, but to date randomised clinical trials have not shown benefit.ConclusionWhilst evidence for the use of supplemental oxygen therapy is currently lacking, it is vital to rapidly identify and treat all causes of hypoxia in the acute stroke patient, as a failure to will lead to poorer clinical outcomes. The full results of a large randomised trial looking at the use of supplemental oxygen therapy are currently pending.

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“…In other studies including cryptogenic stroke and patent foramen ovale, PE was found in up 20% to 37% of patients, though the great majority of these cases were asymptomatic and only recognized by dedicated testing required by the research design. 21–22 …”

Section: Discussionmentioning

confidence: 99%

Pulmonary Embolism in Ischemic Stroke: Clinical Presentation, Risk Factors, and Outcome

Pongmoragot

Rabinstein

Nilanont

et al. 2013

JAHA

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BackgroundLimited information is available on the frequency of pulmonary embolism (PE) in patients with an acute ischemic stroke (AIS). We evaluated clinical characteristics, predisposing factors, and outcomes in AIS patients with PE.Methods and ResultsWe included all AIS patients admitted to participating institutions in the Registry of the Canadian Stroke Network. Clinically PE was documented by a physician and confirmed by computed tomography pulmonary angiography within 30 days of the stroke case index. The primary outcome was death or disability at discharge. Secondary outcomes included disposition, length of hospital stay, mortality at 3 months and 1 year. Among 11 287 patients with AIS, PE was found in 89 (0.78%) patients. History of cancer, deep vein thrombosis (DVT)/PE, and DVT during the hospitalization were associated with PE. PE was associated with higher risk of death at 30 days (25.8% versus 13.6%; P<0.001), at 1 year (47.2% versus 24.6%; P<0.001), and disability at discharge (85.4% versus 63.6%; P<0.001). Mean length of stay was longer in stroke patients with PE (36 versus 16 days; P=0.001). After adjusting for age, sex, and stroke severity, PE remained associated with lower survival at 30 days and 1 year, and death or disability at discharge (OR 3.02; 95% CI 1.56 to 5.83).ConclusionsIn this large cohort study, PE occurred in nearly 1% of AIS patients. PE was more common in patients with severe stroke, history of cancer, previous DVT/PE or acute DVT and associated with lower short‐ and long‐term survival, greater disability, and longer length of stay.

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High Frequency of Silent Pulmonary Embolism in Patients With Cryptogenic Stroke and Patent Foramen Ovale

Cited by 32 publications

References 8 publications

Factors associated with shunt dynamic in patients with cryptogenic stroke and patent foramen ovale: an observational cohort study

Factors associated with shunt dynamic in patients with cryptogenic stroke and patent foramen ovale: an observational cohort study

Hypoxia after stroke: a review of experimental and clinical evidence

Pulmonary Embolism in Ischemic Stroke: Clinical Presentation, Risk Factors, and Outcome

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