Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler(TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency(≤ 2 MHz) tr...Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler(TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency(≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called "paradoxical embolism", most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called "microembolic signal grading score". In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage(caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.展开更多
AIM To investigate if patent foramen ovale(PFO) closure device reduces the risk of recurrent stroke in patients with cryptogenic stroke.METHODS We searched five databases-Pub Med,EMBASE,Cochrane,CINAHL and Web-of-Scie...AIM To investigate if patent foramen ovale(PFO) closure device reduces the risk of recurrent stroke in patients with cryptogenic stroke.METHODS We searched five databases-Pub Med,EMBASE,Cochrane,CINAHL and Web-of-Science and clinicaltrials.gov from January 2000 to September 2017 for randomized trials comparing PFO closure to medical therapy in cryptogenic stroke.Heterogeneity was determined using Cochrane's Q statistics.Random effects model was used.RESULTS Five randomized controlled trials with 3440 patients were included in the analysis.Mean follow-up was 50 ± 20 mo.PFO closure was associated with a 41% reduction in incidence of recurrent strokes when compared to medical therapy alone in patients with cryptogenic stroke [risk ratio(RR): 0.59,95%CI: 0.40-0.87,P = 0.008].Atrial fibrillation was higher with device closure when compared to medical therapy alone(RR: 4.97,95%CI: 2.22-11.11,P < 0.001).There was no difference between the two groups with respect to all-cause mortality,major bleeding or adverse events.CONCLUSION PFO device closure in appropriately selected patients with moderate to severe right-to-left shunt and/or atrial septal aneurysm shows benefit with respect to recurrent strokes,particularly in younger patients.Further studies are essential to evaluate the impact of higher incidence of atrial fibrillation seen with the PFO closure device on long-term mortality and stroke rates.展开更多
AIM To test the potential association between atrial septal aneurysm(ASA) and migraine in patent foramen ovale(PFO) closure patients through an observational, singlecenter, case-controlled study.METHODS We studied a t...AIM To test the potential association between atrial septal aneurysm(ASA) and migraine in patent foramen ovale(PFO) closure patients through an observational, singlecenter, case-controlled study.METHODS We studied a total of 450 migraineurs who had rightto-left shunts and underwent PFO closure in a retrospective single-center non-randomized registry from February 2012 to October 2016 on the condition that they were aged 18-45 years old. Migraine was diagnosed according to the International Classification of Headache Disorders, 3^(rd) edition and evaluated using the Headache Impact Test-6(HIT-6). All patients underwent preoperative transesophageal echocardiography, contrast transthoracic echocardiography, and computed tomography or magnetic resonance imaging examinations, with subsequent fluoroscopy-guided PFO closure. Based on whether they have ASA or not, the patients were divided into two groups: A(PFO with ASA, n = 80) and B(PFO without ASA, n = 370). Baseline characteristics and procedural and follow-up data were reviewed. RESULTS Compared to group B, group A had an increased frequency of ischemic lesions(11.3% vs 6.2%, P = 0.038) and migraine with aura(32.5% vs 21.1%, P = 0.040). The PFO size was significantly larger in group A(P = 0.007). There was no significant difference in HIT-6 scores between the two groups before and at the oneyear follow-up after the PFO closure [61(9) vs 63(9), P = 0.227; 36(13) vs 36(10), P = 0.706].CONCLUSION Despite its small sample size, our study suggests that the prevalence of ASA in PFO with migraine patients is associated with ischemic stroke, larger PFO size, and migraine with aura.展开更多
Ectopic pregnancy, in which the fertilized ovum implants on any tissue other than the endometrium, is the most common life-threatening emergency in the first trimester of pregnancy. The incidence of ectopic pregnancy ...Ectopic pregnancy, in which the fertilized ovum implants on any tissue other than the endometrium, is the most common life-threatening emergency in the first trimester of pregnancy. The incidence of ectopic pregnancy is 0.25%-1.0% of all pregnancies, and has increased greatly in the last few decades, from 4.5 per 1000 pregnancies in 1970 to an estimated 19.7 per 1000 pregnancies in 1992.^1展开更多
Background Resection of tumors arising from the tongue base and the parapharyngeal space is difficult for exposure and manipulation because of their obscure location. The aim of this study was to evaluate the surgical...Background Resection of tumors arising from the tongue base and the parapharyngeal space is difficult for exposure and manipulation because of their obscure location. The aim of this study was to evaluate the surgical approach of the pre-mental foramen mandibulotomy for resecting the tumors of tongue base and parapharyngeal space. Methods Fifty-one patients with tumors of tongue base and parapharyngeal space were treated using the mandibulotomy approach on the pre-mental foramen. In the present study, this technique was described in detail. The patients were followed up for three months to six years with a mean of 26 months. Results The tumors of tongue base and parapharyngeal space could be exposed clearly and be resected radically by surgical approach of pre-mental foramen mandibulotomy. The surgical complications were reduced. Conclusions Compared to other surgical approaches, such as lateral mandibulotomy, midline mandibulotomy, the suprahyoid parapharyngeal approach, and paramedian mandibulotomy, we found that the pre-mental foramen mandibulotomy is the ideal choice for resecting the tumors of tongue base and parapharyngeal space.展开更多
BACKGROUND A few randomized clinical trials(RCT) and their meta-analyses have found patent foramen ovale closure(PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is exten...BACKGROUND A few randomized clinical trials(RCT) and their meta-analyses have found patent foramen ovale closure(PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.AIM To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.METHODS Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke(IS), transient ischemic attack(TIA), a composite of IS, TIA and systemic embolism(SE), mortality, major bleeding,atrial fibrillation(AF) and procedural complications were the major outcomes.Random-effects model was used to perform analyses.RESULTS Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC,compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95%confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55(0.32-0.93); P = 0.02] and increased the AF risk [4.79(2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86(0.54-1.38); P = 0.54],mortality [0.74(0.28-1.93); P = 0.53] and major bleeding [0.81(0.42-1.56); P = 0.53]between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.CONCLUSION In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.展开更多
Objective:To provide anatomical datum for intrusive operations of lumbar intervertebral foramen,especially that using acupuncture-knife as intrusive tool.Methods:To dissect 10 antisepsis cadavers and observe the expos...Objective:To provide anatomical datum for intrusive operations of lumbar intervertebral foramen,especially that using acupuncture-knife as intrusive tool.Methods:To dissect 10 antisepsis cadavers and observe the exposed blood vessels,ligaments,nerves and their adjacent relations in L1/2~L5/S1intervertebral foramen.Results:Lumbar intervertebral foramen exit zones were almost sealed by nerves and blood vessels.There were two zones with relatively no blood vessel and nerve(triangular working zones)located in the midpoint of the distance between two adjacent roots of transverse processus,and clung to lamina of vertebral arch,and they were also found upon the margo superior of the root of transverse processus,but the ascending lumbar vein or(and)the rami anastomoticus between the remi inferior of intervertebral vein and lumbar veins were observed in 12%triangular working zones upon the margo superior of root of transverse processus.Conclusions:"Triangular working zone"was relatively avascular zone.Pay attention to the possibilty of presence of blood vessels on the entrance passage of intrusive operations on lumbar side rear.The needlepoint should be pierced at the midpoint of the distance between two adjacent roots of transverse processus and cling to the outer edge of lamina of vertebral arch when doing the foraminal lumbar puncture.As lumbar intervertebral foramina exit zone was almost sealed by nerves and blood vessels,blind incising and debonding with acupuncture-knife in this area was relatively much more dangerous.展开更多
Recent trials and metanalysis even not fully conclusive and still debated,at least suggested that mechanical device-based closure of patent foramen ovale(PFO)is more effective than medical therapy in prevent recurrenc...Recent trials and metanalysis even not fully conclusive and still debated,at least suggested that mechanical device-based closure of patent foramen ovale(PFO)is more effective than medical therapy in prevent recurrence of stroke. In a proportion ranging from 20% to nearly 40% of patients in literature,PFO is associated to atrial septal aneurysm(ASA):ASA is a well-known entity often associated with additional fenestration. Additionally small atrial septal defects("Flat ASD") can present with signs of paradoxical embolism and cannot be easily detected by transthoracic echocardiography or even by transesophageal echocardiography and are usually discovered by intracardiac echocardiography at the moment of transcatheter closure. This evidence might change potentially the anatomical diagnosis from PFO to fenestrated ASA or as we called it to "hybrid defect",being a bidirectional flow through a small ASD or/and an additional fenestration,often present. Despite the differences in anatomy,pathophysiology and haemodynamic paradoxical embolism may occur in both entities and also may be the first appearance of fenestrated ASA. Because some overlapping do really exist between PFO and hybrid defects,which are often not clearly differentiable by standard diagnostic tools,it is likely that a proportion of patients evaluated for potential transcatheter closure of PFO had actually a different anatomical substrate. These different anatomical and pathophysiologic entities have not been address in any of the previous trials,potentially having an impact on overall results despite the similar mechanical treatment. Neurologists and general cardiologists in charge of clinical management of PFOrelated cryptogenic stroke should be aware of the role of hybrid defects in the pathophysiology of paradoxical embolism- mediated cerebral ischemic events in order to apply the correct decision- making process and avoid downgrading of patients with paradoxical embolism-related interatrial shunt variants different from PFO.展开更多
BACKGROUND Cardiogenic embolism caused by patent foramen ovale(PFO)is a common etiology of cryptogenic stroke(CS),particularly in young and middle-aged patients.Studies about right-to-left shunt(RLS)detection using co...BACKGROUND Cardiogenic embolism caused by patent foramen ovale(PFO)is a common etiology of cryptogenic stroke(CS),particularly in young and middle-aged patients.Studies about right-to-left shunt(RLS)detection using contrast-enhanced transcranial Doppler(c-TCD)are numerous.According to the time phase and number of microbubbles detected on c-TCD,RLS can be classified and graded.We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital.In total,111 PFO-related CS patients were divided according to whether RLS was permanent(microbubbles detected both at resting state and after the Valsalva maneuver)or latent(microbubbles detected only after the Valsalva maneuver)on c-TCD.Each group was subdivided into small,mild and large RLS according to the grade of shunt on c-TCD.A normal control group was composed of 33 patients who suffered from simple dizziness.Intragroup and intergroup differences were analyzed in terms of clinical,laboratory and diffusion-weighted imaging lesion characteristics.The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.RESULTS In 111 patients with PFO-related CS,68 had permanent RLS and 43 had latent RLS.Clinical characteristics and laboratory tests were not significantly different among the permanent RLS,latent RLS and normal control groups.The proportion of patients with multiple territory lesions in the permanent RLS group(50%)was larger than that in the latent RLS group(27.91%;P=0.021).Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group(30.23%vs 8.82%,P=0.004).Permanent-large and latent-展开更多
Transcranial Doppler(TCD) is useful for investigation of intracranial arterial blood flow and can be used to detect a real-time embolic signal. Unfortunately, artefacts can mimic the embolic signal, complicating inter...Transcranial Doppler(TCD) is useful for investigation of intracranial arterial blood flow and can be used to detect a real-time embolic signal. Unfortunately, artefacts can mimic the embolic signal, complicating interpretation and necessitating expert-level opinion to distinguish the two. Resolving this situation is critical to achieve improved accuracy and utility of TCD for patients with disrupted intracranial arterial blood flow, such as stroke victims. A common type of stroke encountered in the clinic is cryptogenic stroke(or stroke with undetermined etiology), and patent foramen ovale(PFO) has been associated with the condition. An early clinical trial of PFO closure effect on secondary stroke prevention failed to demonstrate any benefit for the therapy, and research into the PFO therapy generally diminished. However, the recent publication of large randomized control trials with demonstrated benefit of PFO closure for recurrent stroke prevention has rekindled the interest in PFO in patients with cryptogenic stroke. To confirm that emboli across the PFO can reach the brain, TCD should be applied to detect the air embolic signal after injection of agitated saline bubbles at the antecubital vein. In addition, the automated embolic signal detection method should further facilitate use of TCD for air embolic signal detection after the agitated saline bubbles injection in patients with cryptogenic stroke and PFO.展开更多
Eustachian valve is an embryonic endocardial heart structure;after birth it becomes an embryogenic residue and its persistance in adult life is unusual.</span><span style="font-family:Verdana;">&...Eustachian valve is an embryonic endocardial heart structure;after birth it becomes an embryogenic residue and its persistance in adult life is unusual.</span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">The literature reports some cases of association between Eustachian valve and PFO and is known that the prominent Eustachian valve can represent a way facilitating systemic embolism.</span><span style="font-family:""></span><span style="font-family:Verdana;">Several studies also investigated the role of Eustachian valve in the pathophysiology of both migraine and cerebral embolism.</span><span style="font-family:Verdana;"> </span><span style="font-family:""><span style="font-family:Verdana;">In addiction is known how Eustachian valve may increase the risk of endocarditis, which mostly affects intravenous drug abusers or those with implanted medical devices or central venous catheters. The most commonly identified organism is </span><i><span style="font-family:Verdana;">Staphylococcus aureus</span></i><span style="font-family:Verdana;"> (approximately 53% of cases).</span></span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">We present a case of a 46-year-old woman with known migraine. She was</span><span style="font-family:Verdana;"> hospitalized in Stroke Unit for a cryptogenic stroke with a right-to-left shunt detected with transcranial doppler ultrasound with “bubble test” and a patent foramen ovale with right-to-left shunt with a fenestration of atrial septum and a voluminous Eustachian valve detected with transesophageal echocardiography;she developed fever with a blood cultures positive for methicillin-resis</span><span style="font-family:Verdana;">- </span><span style="font-family:""><span style="font-family:Verdana;">tant </span><i><span style="font-family:Verdana;">Staphylococcus aureus</span></i><span style="font-family:Verdana;"> (MRSA), even if without evidence of endocarditis vegetations.</span></span><span style="font-f展开更多
In this study, we investigated the changes in the right-to-left shunt (RLS) of the patent foramen ovale (PFO) at different phases of the Valsalva maneuver and analyzed the possible mechanisms. The study population con...In this study, we investigated the changes in the right-to-left shunt (RLS) of the patent foramen ovale (PFO) at different phases of the Valsalva maneuver and analyzed the possible mechanisms. The study population consisted of 57 patients with symptoms highly suggestive of a PFO. These patients had been diagnosed with apsychia, migraine with aura, cerebral infarction, transient ischemic attack (TIA), and cerebral ischemia with unknown cause. Routine echocardiography was performed in all patients to rule out a cardiac malformation. Contrast-transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) were used to visualize and quantify the RLS. The standard apical four chamber view was used to observe the changes of E peak, A peak, and velocity-time integral (VTI) ratio of tricuspid blood flow during the strain phase and release phase of the Valsalva maneuver. Paired t-test was used to compare E peak, A peak, and VTI ratio of tricuspid blood flow during the different phases. The right-to-left shunt across the PFO (PFO-RLS) was graded in the two phases and compared by Kruskal-Wallis test. Compared with the strain phase of the Valsalva maneuver, the parameters of E, A, and VTI in diastolic period in patients with PFO-RLS at the release phase were significantly increased [54.30 ± 13.65 cm/s vs 100.35 ± 21.11 cm/s, 42.21 ± 12.32 cm/s vs 57.30 ± 18.88 cm/s, 10.34 ± 3.27 cm/s vs 19.58 ± 4.56 cm/s, respectively], and the difference was statistically significant. The positive consequence of PFO-RLS, as diagnosed by c-TTE with the Valsalva maneuver at the release phase of the Valsalva maneuver, was significantly higher than that at the strain phase of the Valsalva maneuver. At the beginning of release phase of the Valsalva maneuver, decreased intrathoracic pressure led to increased venous backflow into the right atrium. Thus, high-velocity blood flow rapidly pushed the PFO open, which resulted in a significant increase in the PFO-RLS. Therefore, the increase of the PFO-RLS during the Vals展开更多
Patent foramen ovale （PFO）, a congenital cardiac lesion that persists into adulthood, has become the subject of much clinical interest. PFO has been implicated in several serious clinical syndromes, including parado...Patent foramen ovale （PFO）, a congenital cardiac lesion that persists into adulthood, has become the subject of much clinical interest. PFO has been implicated in several serious clinical syndromes, including paradoxical systemic emboli （which contribute to ischemic stroke）, myocardial infarction, and complications of pulmonary embolism. Currently, two-dimensional transesophageal echocardiography （TEE） is the standard procedure for diagnosing PFO. The diameter and contrast score have been used to size the PFO.~ None of these techniques is optimal as they are all indirect ways of measuring PFOs. Few data exist on the relation between stroke risk, anatomical characteristics, and physiological behavior. The purpose of our study therefore was to explore the clinical feasibility of sizing or displaying the morphology and physiological behavior of PFOs using three-dimensional TEE.展开更多
An elderly gentleman presented to the emergency department with a recent history of dyspnoea, collapse and transient neurological symptoms. He was noted to be hypoxic with a significantly elevated D Dimer. A computer ...An elderly gentleman presented to the emergency department with a recent history of dyspnoea, collapse and transient neurological symptoms. He was noted to be hypoxic with a significantly elevated D Dimer. A computer tomography pulmonary angiogram demonstrated a large embolus with a further filling defects within the left and the right atria, abutting the interatrial septum. Suspicion of a paradoxical pulmonary embolus was raised and the patient subsequently underwent echocardiography which confirmed a patent foramen ovale(PFO). He was commenced on warfarin therapy. In patients with elevated right heart pressure, a PFO can be unmasked and give rise to cerebral emboli. Clinical suspicion should be raised in patients with pulmonary emboli or deep venous thrombosis if there is a concomitant history of focal neurological symptoms.展开更多
BACKGROUND Patent foramen ovale(PFO)-related right-to-left shunts(RLSs)have been impli-cated in cryptogenic stroke and migraine,with larger shunts posing a higher risk.When used individually to detect RLS,contrast tra...BACKGROUND Patent foramen ovale(PFO)-related right-to-left shunts(RLSs)have been impli-cated in cryptogenic stroke and migraine,with larger shunts posing a higher risk.When used individually to detect RLS,contrast transcranial Doppler(cTCD)and contrast transthoracic echocardiography(cTTE)may yield false-negative results.Further,the literature exposes gaps regarding the understanding of the limitations of cTCD and cTTE,presents conflicting recommendations on their exclusive use,and highlights inefficiencies associated with nonsynchronous testing.AIM To investigate the accuracy of multimodal ultrasound to improve diagnostic efficiency in detecting PFO-related RLSs.METHODS We prospectively enrolled four patients with cryptogenic stroke(n=1),migraine(n=2),and unexplained dizziness(n=1)who underwent synchronized cTCD combined with cTTE.The participants were monitored and followed-up for 24 months.RESULTS cTTE identified moderate and large RLSs in patients with recurrent cryptogenic stroke and migraines,whereas cTCD revealed only small RLSs.Moderate and large RLS were confirmed on combined cTTE and cTCD.After excluding other causes,both patients underwent PFO occlusion.At 21-and 24-month follow-up examinations,neither stroke nor migraine had recurred.cTTE revealed a small RLS in a third patient with unexplained dizziness and a fourth patient with migraines;however,simultaneous cTCD detected a large RLS.These patients did not undergo interventional occlusion,and dizziness and headache recurred at the 17-and 24-month follow-up examin-ations.CONCLUSION Using cTTE or cTCD may underestimate RLS,impairing risk assessments.Combining synchronized cTCD with cTTE could enhance testing accuracy and support better diagnostic and therapeutic decisions.展开更多
Background The incidence of cryptogenic stroke(CS)accounts for about 25%of ischemic stroke.Current studies have shown that cryptogenic stroke is closely related to patent foramen ovale(PFO).Evaluating the correlation ...Background The incidence of cryptogenic stroke(CS)accounts for about 25%of ischemic stroke.Current studies have shown that cryptogenic stroke is closely related to patent foramen ovale(PFO).Evaluating the correlation between PFO and CS needs to be combined with multidisciplinary evaluation.Many clinical studies have shown that drug therapy can reduce the risk of ischemic stroke in elderly PFO patients(>60 years old).However,whether elderly PFO patients(>60 years old)can benefit from PFO closure is still controversial.This article reviewed the research progress of drug therapy and PFO closure therapy for cryptogenic stroke associated with PFO in the elderly.[S Chin J Cardiol 2024;25(1):50-56].展开更多
文摘Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler(TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency(≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called "paradoxical embolism", most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called "microembolic signal grading score". In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage(caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
文摘AIM To investigate if patent foramen ovale(PFO) closure device reduces the risk of recurrent stroke in patients with cryptogenic stroke.METHODS We searched five databases-Pub Med,EMBASE,Cochrane,CINAHL and Web-of-Science and clinicaltrials.gov from January 2000 to September 2017 for randomized trials comparing PFO closure to medical therapy in cryptogenic stroke.Heterogeneity was determined using Cochrane's Q statistics.Random effects model was used.RESULTS Five randomized controlled trials with 3440 patients were included in the analysis.Mean follow-up was 50 ± 20 mo.PFO closure was associated with a 41% reduction in incidence of recurrent strokes when compared to medical therapy alone in patients with cryptogenic stroke [risk ratio(RR): 0.59,95%CI: 0.40-0.87,P = 0.008].Atrial fibrillation was higher with device closure when compared to medical therapy alone(RR: 4.97,95%CI: 2.22-11.11,P < 0.001).There was no difference between the two groups with respect to all-cause mortality,major bleeding or adverse events.CONCLUSION PFO device closure in appropriately selected patients with moderate to severe right-to-left shunt and/or atrial septal aneurysm shows benefit with respect to recurrent strokes,particularly in younger patients.Further studies are essential to evaluate the impact of higher incidence of atrial fibrillation seen with the PFO closure device on long-term mortality and stroke rates.
文摘AIM To test the potential association between atrial septal aneurysm(ASA) and migraine in patent foramen ovale(PFO) closure patients through an observational, singlecenter, case-controlled study.METHODS We studied a total of 450 migraineurs who had rightto-left shunts and underwent PFO closure in a retrospective single-center non-randomized registry from February 2012 to October 2016 on the condition that they were aged 18-45 years old. Migraine was diagnosed according to the International Classification of Headache Disorders, 3^(rd) edition and evaluated using the Headache Impact Test-6(HIT-6). All patients underwent preoperative transesophageal echocardiography, contrast transthoracic echocardiography, and computed tomography or magnetic resonance imaging examinations, with subsequent fluoroscopy-guided PFO closure. Based on whether they have ASA or not, the patients were divided into two groups: A(PFO with ASA, n = 80) and B(PFO without ASA, n = 370). Baseline characteristics and procedural and follow-up data were reviewed. RESULTS Compared to group B, group A had an increased frequency of ischemic lesions(11.3% vs 6.2%, P = 0.038) and migraine with aura(32.5% vs 21.1%, P = 0.040). The PFO size was significantly larger in group A(P = 0.007). There was no significant difference in HIT-6 scores between the two groups before and at the oneyear follow-up after the PFO closure [61(9) vs 63(9), P = 0.227; 36(13) vs 36(10), P = 0.706].CONCLUSION Despite its small sample size, our study suggests that the prevalence of ASA in PFO with migraine patients is associated with ischemic stroke, larger PFO size, and migraine with aura.
文摘Ectopic pregnancy, in which the fertilized ovum implants on any tissue other than the endometrium, is the most common life-threatening emergency in the first trimester of pregnancy. The incidence of ectopic pregnancy is 0.25%-1.0% of all pregnancies, and has increased greatly in the last few decades, from 4.5 per 1000 pregnancies in 1970 to an estimated 19.7 per 1000 pregnancies in 1992.^1
文摘Background Resection of tumors arising from the tongue base and the parapharyngeal space is difficult for exposure and manipulation because of their obscure location. The aim of this study was to evaluate the surgical approach of the pre-mental foramen mandibulotomy for resecting the tumors of tongue base and parapharyngeal space. Methods Fifty-one patients with tumors of tongue base and parapharyngeal space were treated using the mandibulotomy approach on the pre-mental foramen. In the present study, this technique was described in detail. The patients were followed up for three months to six years with a mean of 26 months. Results The tumors of tongue base and parapharyngeal space could be exposed clearly and be resected radically by surgical approach of pre-mental foramen mandibulotomy. The surgical complications were reduced. Conclusions Compared to other surgical approaches, such as lateral mandibulotomy, midline mandibulotomy, the suprahyoid parapharyngeal approach, and paramedian mandibulotomy, we found that the pre-mental foramen mandibulotomy is the ideal choice for resecting the tumors of tongue base and parapharyngeal space.
文摘BACKGROUND A few randomized clinical trials(RCT) and their meta-analyses have found patent foramen ovale closure(PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.AIM To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.METHODS Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke(IS), transient ischemic attack(TIA), a composite of IS, TIA and systemic embolism(SE), mortality, major bleeding,atrial fibrillation(AF) and procedural complications were the major outcomes.Random-effects model was used to perform analyses.RESULTS Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC,compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95%confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55(0.32-0.93); P = 0.02] and increased the AF risk [4.79(2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86(0.54-1.38); P = 0.54],mortality [0.74(0.28-1.93); P = 0.53] and major bleeding [0.81(0.42-1.56); P = 0.53]between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.CONCLUSION In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.
文摘Objective:To provide anatomical datum for intrusive operations of lumbar intervertebral foramen,especially that using acupuncture-knife as intrusive tool.Methods:To dissect 10 antisepsis cadavers and observe the exposed blood vessels,ligaments,nerves and their adjacent relations in L1/2~L5/S1intervertebral foramen.Results:Lumbar intervertebral foramen exit zones were almost sealed by nerves and blood vessels.There were two zones with relatively no blood vessel and nerve(triangular working zones)located in the midpoint of the distance between two adjacent roots of transverse processus,and clung to lamina of vertebral arch,and they were also found upon the margo superior of the root of transverse processus,but the ascending lumbar vein or(and)the rami anastomoticus between the remi inferior of intervertebral vein and lumbar veins were observed in 12%triangular working zones upon the margo superior of root of transverse processus.Conclusions:"Triangular working zone"was relatively avascular zone.Pay attention to the possibilty of presence of blood vessels on the entrance passage of intrusive operations on lumbar side rear.The needlepoint should be pierced at the midpoint of the distance between two adjacent roots of transverse processus and cling to the outer edge of lamina of vertebral arch when doing the foraminal lumbar puncture.As lumbar intervertebral foramina exit zone was almost sealed by nerves and blood vessels,blind incising and debonding with acupuncture-knife in this area was relatively much more dangerous.
文摘Recent trials and metanalysis even not fully conclusive and still debated,at least suggested that mechanical device-based closure of patent foramen ovale(PFO)is more effective than medical therapy in prevent recurrence of stroke. In a proportion ranging from 20% to nearly 40% of patients in literature,PFO is associated to atrial septal aneurysm(ASA):ASA is a well-known entity often associated with additional fenestration. Additionally small atrial septal defects("Flat ASD") can present with signs of paradoxical embolism and cannot be easily detected by transthoracic echocardiography or even by transesophageal echocardiography and are usually discovered by intracardiac echocardiography at the moment of transcatheter closure. This evidence might change potentially the anatomical diagnosis from PFO to fenestrated ASA or as we called it to "hybrid defect",being a bidirectional flow through a small ASD or/and an additional fenestration,often present. Despite the differences in anatomy,pathophysiology and haemodynamic paradoxical embolism may occur in both entities and also may be the first appearance of fenestrated ASA. Because some overlapping do really exist between PFO and hybrid defects,which are often not clearly differentiable by standard diagnostic tools,it is likely that a proportion of patients evaluated for potential transcatheter closure of PFO had actually a different anatomical substrate. These different anatomical and pathophysiologic entities have not been address in any of the previous trials,potentially having an impact on overall results despite the similar mechanical treatment. Neurologists and general cardiologists in charge of clinical management of PFOrelated cryptogenic stroke should be aware of the role of hybrid defects in the pathophysiology of paradoxical embolism- mediated cerebral ischemic events in order to apply the correct decision- making process and avoid downgrading of patients with paradoxical embolism-related interatrial shunt variants different from PFO.
基金People’s Livelihood Science and Technology Project(Research on Application of Key Technologies)of Suzhou(No.SS202061)Technical Cooperation Project of Soochow University(No.H211064).
文摘BACKGROUND Cardiogenic embolism caused by patent foramen ovale(PFO)is a common etiology of cryptogenic stroke(CS),particularly in young and middle-aged patients.Studies about right-to-left shunt(RLS)detection using contrast-enhanced transcranial Doppler(c-TCD)are numerous.According to the time phase and number of microbubbles detected on c-TCD,RLS can be classified and graded.We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital.In total,111 PFO-related CS patients were divided according to whether RLS was permanent(microbubbles detected both at resting state and after the Valsalva maneuver)or latent(microbubbles detected only after the Valsalva maneuver)on c-TCD.Each group was subdivided into small,mild and large RLS according to the grade of shunt on c-TCD.A normal control group was composed of 33 patients who suffered from simple dizziness.Intragroup and intergroup differences were analyzed in terms of clinical,laboratory and diffusion-weighted imaging lesion characteristics.The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.RESULTS In 111 patients with PFO-related CS,68 had permanent RLS and 43 had latent RLS.Clinical characteristics and laboratory tests were not significantly different among the permanent RLS,latent RLS and normal control groups.The proportion of patients with multiple territory lesions in the permanent RLS group(50%)was larger than that in the latent RLS group(27.91%;P=0.021).Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group(30.23%vs 8.82%,P=0.004).Permanent-large and latent-
文摘Transcranial Doppler(TCD) is useful for investigation of intracranial arterial blood flow and can be used to detect a real-time embolic signal. Unfortunately, artefacts can mimic the embolic signal, complicating interpretation and necessitating expert-level opinion to distinguish the two. Resolving this situation is critical to achieve improved accuracy and utility of TCD for patients with disrupted intracranial arterial blood flow, such as stroke victims. A common type of stroke encountered in the clinic is cryptogenic stroke(or stroke with undetermined etiology), and patent foramen ovale(PFO) has been associated with the condition. An early clinical trial of PFO closure effect on secondary stroke prevention failed to demonstrate any benefit for the therapy, and research into the PFO therapy generally diminished. However, the recent publication of large randomized control trials with demonstrated benefit of PFO closure for recurrent stroke prevention has rekindled the interest in PFO in patients with cryptogenic stroke. To confirm that emboli across the PFO can reach the brain, TCD should be applied to detect the air embolic signal after injection of agitated saline bubbles at the antecubital vein. In addition, the automated embolic signal detection method should further facilitate use of TCD for air embolic signal detection after the agitated saline bubbles injection in patients with cryptogenic stroke and PFO.
文摘Eustachian valve is an embryonic endocardial heart structure;after birth it becomes an embryogenic residue and its persistance in adult life is unusual.</span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">The literature reports some cases of association between Eustachian valve and PFO and is known that the prominent Eustachian valve can represent a way facilitating systemic embolism.</span><span style="font-family:""></span><span style="font-family:Verdana;">Several studies also investigated the role of Eustachian valve in the pathophysiology of both migraine and cerebral embolism.</span><span style="font-family:Verdana;"> </span><span style="font-family:""><span style="font-family:Verdana;">In addiction is known how Eustachian valve may increase the risk of endocarditis, which mostly affects intravenous drug abusers or those with implanted medical devices or central venous catheters. The most commonly identified organism is </span><i><span style="font-family:Verdana;">Staphylococcus aureus</span></i><span style="font-family:Verdana;"> (approximately 53% of cases).</span></span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">We present a case of a 46-year-old woman with known migraine. She was</span><span style="font-family:Verdana;"> hospitalized in Stroke Unit for a cryptogenic stroke with a right-to-left shunt detected with transcranial doppler ultrasound with “bubble test” and a patent foramen ovale with right-to-left shunt with a fenestration of atrial septum and a voluminous Eustachian valve detected with transesophageal echocardiography;she developed fever with a blood cultures positive for methicillin-resis</span><span style="font-family:Verdana;">- </span><span style="font-family:""><span style="font-family:Verdana;">tant </span><i><span style="font-family:Verdana;">Staphylococcus aureus</span></i><span style="font-family:Verdana;"> (MRSA), even if without evidence of endocarditis vegetations.</span></span><span style="font-f
文摘In this study, we investigated the changes in the right-to-left shunt (RLS) of the patent foramen ovale (PFO) at different phases of the Valsalva maneuver and analyzed the possible mechanisms. The study population consisted of 57 patients with symptoms highly suggestive of a PFO. These patients had been diagnosed with apsychia, migraine with aura, cerebral infarction, transient ischemic attack (TIA), and cerebral ischemia with unknown cause. Routine echocardiography was performed in all patients to rule out a cardiac malformation. Contrast-transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) were used to visualize and quantify the RLS. The standard apical four chamber view was used to observe the changes of E peak, A peak, and velocity-time integral (VTI) ratio of tricuspid blood flow during the strain phase and release phase of the Valsalva maneuver. Paired t-test was used to compare E peak, A peak, and VTI ratio of tricuspid blood flow during the different phases. The right-to-left shunt across the PFO (PFO-RLS) was graded in the two phases and compared by Kruskal-Wallis test. Compared with the strain phase of the Valsalva maneuver, the parameters of E, A, and VTI in diastolic period in patients with PFO-RLS at the release phase were significantly increased [54.30 ± 13.65 cm/s vs 100.35 ± 21.11 cm/s, 42.21 ± 12.32 cm/s vs 57.30 ± 18.88 cm/s, 10.34 ± 3.27 cm/s vs 19.58 ± 4.56 cm/s, respectively], and the difference was statistically significant. The positive consequence of PFO-RLS, as diagnosed by c-TTE with the Valsalva maneuver at the release phase of the Valsalva maneuver, was significantly higher than that at the strain phase of the Valsalva maneuver. At the beginning of release phase of the Valsalva maneuver, decreased intrathoracic pressure led to increased venous backflow into the right atrium. Thus, high-velocity blood flow rapidly pushed the PFO open, which resulted in a significant increase in the PFO-RLS. Therefore, the increase of the PFO-RLS during the Vals
文摘Patent foramen ovale （PFO）, a congenital cardiac lesion that persists into adulthood, has become the subject of much clinical interest. PFO has been implicated in several serious clinical syndromes, including paradoxical systemic emboli （which contribute to ischemic stroke）, myocardial infarction, and complications of pulmonary embolism. Currently, two-dimensional transesophageal echocardiography （TEE） is the standard procedure for diagnosing PFO. The diameter and contrast score have been used to size the PFO.~ None of these techniques is optimal as they are all indirect ways of measuring PFOs. Few data exist on the relation between stroke risk, anatomical characteristics, and physiological behavior. The purpose of our study therefore was to explore the clinical feasibility of sizing or displaying the morphology and physiological behavior of PFOs using three-dimensional TEE.
文摘An elderly gentleman presented to the emergency department with a recent history of dyspnoea, collapse and transient neurological symptoms. He was noted to be hypoxic with a significantly elevated D Dimer. A computer tomography pulmonary angiogram demonstrated a large embolus with a further filling defects within the left and the right atria, abutting the interatrial septum. Suspicion of a paradoxical pulmonary embolus was raised and the patient subsequently underwent echocardiography which confirmed a patent foramen ovale(PFO). He was commenced on warfarin therapy. In patients with elevated right heart pressure, a PFO can be unmasked and give rise to cerebral emboli. Clinical suspicion should be raised in patients with pulmonary emboli or deep venous thrombosis if there is a concomitant history of focal neurological symptoms.
基金Supported by The Shenzhen Second People’s Hospital Clinical Research Fund of the Shenzhen High-level Hospital Construction Project,No.20223357021 and No.20243357001Research Project of Teaching Reform in Shenzhen Second People’s Hospital,No.202209Guangdong Province Basic and Applied Basic Research Fund Project,No.2020B1515120061.
文摘BACKGROUND Patent foramen ovale(PFO)-related right-to-left shunts(RLSs)have been impli-cated in cryptogenic stroke and migraine,with larger shunts posing a higher risk.When used individually to detect RLS,contrast transcranial Doppler(cTCD)and contrast transthoracic echocardiography(cTTE)may yield false-negative results.Further,the literature exposes gaps regarding the understanding of the limitations of cTCD and cTTE,presents conflicting recommendations on their exclusive use,and highlights inefficiencies associated with nonsynchronous testing.AIM To investigate the accuracy of multimodal ultrasound to improve diagnostic efficiency in detecting PFO-related RLSs.METHODS We prospectively enrolled four patients with cryptogenic stroke(n=1),migraine(n=2),and unexplained dizziness(n=1)who underwent synchronized cTCD combined with cTTE.The participants were monitored and followed-up for 24 months.RESULTS cTTE identified moderate and large RLSs in patients with recurrent cryptogenic stroke and migraines,whereas cTCD revealed only small RLSs.Moderate and large RLS were confirmed on combined cTTE and cTCD.After excluding other causes,both patients underwent PFO occlusion.At 21-and 24-month follow-up examinations,neither stroke nor migraine had recurred.cTTE revealed a small RLS in a third patient with unexplained dizziness and a fourth patient with migraines;however,simultaneous cTCD detected a large RLS.These patients did not undergo interventional occlusion,and dizziness and headache recurred at the 17-and 24-month follow-up examin-ations.CONCLUSION Using cTTE or cTCD may underestimate RLS,impairing risk assessments.Combining synchronized cTCD with cTTE could enhance testing accuracy and support better diagnostic and therapeutic decisions.
基金supported by the National Natural Science Foundation of China(No.81370242)the Guangdong Provincial College Students Innovation and Entrepreneurship Training Program in 2023(No.S202310571076)+3 种基金the Zhanjiang Science and Technology Program(No.2022A01166/No.2022A01183)the Non-funded Science and Technology Research Program of Zhanjiang(No.2021B01145)the Guangdong Medical University Youth Scientific Research Training Fund(No.GDMUQ2021011)the Universty-level Innovation and Entrepreneurship Training Program of Guangdong Medical University(No.GDMU2021163/No.GDMU2021207)。
文摘Background The incidence of cryptogenic stroke(CS)accounts for about 25%of ischemic stroke.Current studies have shown that cryptogenic stroke is closely related to patent foramen ovale(PFO).Evaluating the correlation between PFO and CS needs to be combined with multidisciplinary evaluation.Many clinical studies have shown that drug therapy can reduce the risk of ischemic stroke in elderly PFO patients(>60 years old).However,whether elderly PFO patients(>60 years old)can benefit from PFO closure is still controversial.This article reviewed the research progress of drug therapy and PFO closure therapy for cryptogenic stroke associated with PFO in the elderly.[S Chin J Cardiol 2024;25(1):50-56].
