Mitral Valve Strands and the Risk of Ischemic Stroke in Elderly Patients

Cohen, Ariel; Tzourio, Christophe; Chauvel, Christophe; Bertrand, Bernard; Crassard, Isabelle; Bernard, Yvette; Goullard, L; Falcon, Sylvie; Bousser, Marie‐Germaine; Amarenco, Pierre

doi:10.1161/01.str.28.8.1574

Cited by 51 publications

(23 citation statements)

References 15 publications

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“…In other studies, valvular strands were reported in 6.3 to 22.5% of stroke patients compared with 0.3 to 12% of control subjects. 7,8 A thrombotic or fibrotic origin was suggested by the development of valvular strands during thrombolytic therapy for a mitral valvular thrombus. 9 However, the finding that valvular strands are associated with ischemic stroke does not necessarily mean that they are the active embolic source.…”

Section: Discussionmentioning

confidence: 99%

Focal adherent thrombus in the common carotid artery: clinical, ultrasonographic, and pathogenic aspects in two cases.

Devuyst

Bray

Despland

et al. 2000

Journal of Ultrasound in Medicine

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Thrombi within the carotid artery usually occur in vessels with severe atherosclerotic lesions and may embolize to cause TIAs and ischemic brain infarctions. The risk factors and potential causes for carotid artery thrombus formation in the absence of atherosclerosis are currently only speculative (e.g., embolic occlusion from a cardiac source). 1 Furthermore, a focal adherent thrombus involving the CCA is even more exceptional because of the rarity of severe atherosclerotic disease in this large and nonturbulent vessel. 1,2 A thrombus lodged in the CCA has been reported in only a very few cases in the literature. 2 We present two patients with a focal adherent thrombus in the CCA diagnosed by ultrasonography and confirmed by neuroimaging. The aim of this work is to investigate the ultrasonographic features of this very uncommon finding in young stroke patients. CASE 1A 44 year old woman was admitted to our center in October 1998 for an acute brain infarction in the left MCA territory. The brain MR imaging showed multiple vascular ischemic lesions, these being recent in the left ACA and left MCA territories and old in the right ACA territory. The MR angiography revealed an adherent process (0.5 × 4.2 cm) in the left CCA that was confirmed by CT angiography (Fig. 1). Neither MR angiography nor CT angiography showed any typical signs of a dissection of the left CCA but did show a focal adherent thrombus, resulting in a CCA stenosis of 70 to 80% in lumen diameter reduction. Color duplex flow imaging using a transmission frequency of 4.0 MHz (Acuson 128 XP/10, Mountain View, CA) revealed (1) a slightly decreased flow in the left ICA (PSV = 66 cm/s; EDV = 31 cm/s) as compared with the right ICA (PSV = 76 cm/s; EDV = 37 cm/s) and (2) turbulences manifested by an aliasing phenomenon without significant increase of the blood flow velocities in the left CCA (PSV = 75 cm/s; EDV = 20 cm/s) versus those in the right CCA (PSV = 67 cm/s; EDV = 15 cm/s). Color duplex flow imaging also showed a regular adherent isoechoic lesion on the posterior wall in the left CCA (Fig. 2), with dimensions of 0.4 × 3.8

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Section: Discussionmentioning

confidence: 99%

Focal adherent thrombus in the common carotid artery: clinical, ultrasonographic, and pathogenic aspects in two cases.

Devuyst

Bray

Despland

et al. 2000

Journal of Ultrasound in Medicine

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“…Valvular strand was defined as thin filamentous material Յ1 mm in thickness and extending for Ն2 mm from the edges of mitral or aortic valve, into the left atrium at systole for the mitral valve, and into the left ventricle at diastole for the aortic valve. 4,5 …”

Section: Analysis Of Tapesmentioning

confidence: 99%

“…It suggested that the presence of strands did not increase the chance of adverse events but included only patients aged 60 or older with mitral strands, and medical therapy was not randomized. 5 As such, the adverse event rate in stroke patients that included patients from different age groups or with strands on different valves has never been defined. Most importantly, the efficacy of different medical regimens has never been addressed in a randomized fashion.…”

Section: Homma Et Al Therapy In Patients With Valvular Strandsmentioning

confidence: 99%

“…[1][2][3][4][5] Lee reported that 11 of 50 patients with presumed cerebral embolic event had filamentous strands on the mitral valve. 1 Freedberg found that 10.6% of the patients with embolic events had strands compared with 2.3% in those without such events.…”

mentioning

confidence: 99%

“…The single study addressing this issue was observational without treatment randomization. 5 Accordingly, from the data obtained in the Patent Foramen Ovale in Cryptogenic Stroke Study (PICSS), we sought to define the adverse event rate in stroke patients with valvular strands on mitral and aortic valve, double-blindly randomly assigned to warfarin or aspirin.…”

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confidence: 99%

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Effect of Aspirin and Warfarin Therapy in Stroke Patients With Valvular Strands

Homma

Tullio

Sciacca

et al. 2004

Stroke

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for the PICSS InvestigatorsBackground-Valvular strands are associated with ischemic stroke. The recurrent rate of adverse events in stroke patients with valvular strands has not been defined and, importantly, there are no randomized studies to evaluate efficacy of antithrombotic therapies in these patients. Methods-Patent Foramen Ovale in Cryptogenic Stroke Study (PICSS) enrolled 630 stroke patients, of whom 312 (49.5%) were randomized to warfarin and 318 (50.5%) were randomized to aspirin; 265 patients experienced cryptogenic stroke and 365 experienced stroke with known subtypes. Endpoints were recurrent ischemic stroke or death from any cause. All transesophageal echocardiography studies were blindly, centrally analyzed and all endpoints were blindly adjudicated. Results-Overall, of 619 studies analyzed, valvular strands were present in 39.4% of the patients (244/619), 5.8% (36/619) on the aortic valve and 27.8% (172/619) on the mitral valve, and 5.8% (36/619) on both valves. In an intention-to-treat analysis, there was no significant difference in the time to primary endpoints between patients with and without strands in the overall population (Pϭ0.82; hazard ratio: 1.05; 95% CI: 0.70 to 1.57; 2-year event rates: 16.4% versus 15.5%). Among the patients with strands, there was no significant difference in the time to primary endpoints between those treated with warfarin or aspirin (Pϭ0.21; hazard ratio: 0.67; 95% CI: 0.36 to 1.26; 2-year event rates: 13.5% versus 19.6%). Conclusions-While on medical therapy, valvular strands do not significantly increase recurrent adverse event rates in patients with ischemic stroke. Furthermore, the study does not provide evidence to support an advantage of warfarin or aspirin for this purpose.

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