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UBC-Case 1
Samuel Yip PhD, MD, FRCPC
Western Stroke Day 2012
History• 30 year old RH female• Recently from UK• While pushing herself off a table, sudden
onset of left hemiplegia and decrease LOC
• 6 months ago she had1 spell of sudden onset of dizziness
• No neck pain and no neck trauma• No SOB and no leg pain
History
• No other stroke risk factors• Non-smoker• No Family history of stroke
• OCP (12 yrs) for Endometriosis
Examination
• Initial Examination:– AVSS– Mild decrease in left nasolabial fold– Left deltoid weakness of 4+; no drift– NIHSS = 1
Too Good to Treat
Study Year Median NIHSS
N Poor Outcome
Barber et al., 2001 1996-1999 3-mild; 6-RI 98 32.7% (NHD)
Nedeltchev et al., 2007 2000-2006 2 (1 to 14) 162 23.5% (mRS 2 to 5)
Smith et al., 2005 2002 41 32.7% (NHD)
Smith et al., 2011 2003-2009 2 (1 to 5) 29200 28.3% (NHD)
van den Berg et al., 2009 2005 27 11.1% (mRS 2 to 3)
Willey et al, 2011 2004-2008 1(0 to 19) 127 10.2%(NHD)
NHD = No Home Discharge
TREATMENT OPTIONS
• Iv-tPA• Heparin• ASA +/- Plavix• ASA +/- Plavix + Heparin• Enroll into a RCT – TEMPO-1
Fluids, ASA, Heparin sc
BASELINE CTA
24 hr CTA
Case Cont: Investigations
• TTE and TEE showed – Large PFO – Spontaneous Right to Left shunt
• Hypercoagulable workup was negative
• Pelvic and Leg U/S showed no DVTs
Giant Hepatic Hemangiomas
Diagnosis
• ? Paradoxical Embolism– Hepatic Hemangioma – Large venous lakes with potential stasis
• 2 case reports suggesting hemangioma causing pulmonary embolism
– Recent travel– Valsalva maneuver – Large spontaneous right left shunt
Secondary Prevention
• Stop OCP
• ASA 81 mg once a day
• Coumadin
• Coumadin then PFO Closure
PFO and Stroke:
Atrial septum – overlapping of the septum primum and septum secundum.
When the fusion of these 2 structures fails, then a patent foramen is formed.
This act as conduit for R to L shunt in adult life.
PFO and Cryptogenic Stroke• 25% of general population have a PFO• ~ 40% of young cryptogenic stroke
patients have a PFO
Overall et al., 2000
PFO and Stroke:Pathophysiology
• Paradoxical Embolism
Paradoxical Embolism
LA
RAAO
IAS
T
Srivastava etl., NEJM 1997
PFO and Stroke:Pathophysiology
• Paradoxical Embolism
• Atrial Vulnerability – Paroxysmal Atrial Fibrillation
• Endothelial dysfunction
PFO and cryptogenic stroke:Natural History
• Risk of recurrent stroke is low– ~ 0.5 to 1% per year. (From recent cohort
study and placebo randomized control trials ).
PFO in Cryptogenic Stroke Study (PICSS)
• Substudy of WARSS (Multicenter, randomized, DB study, ASA (325 mg) vs Warfarin (mean INR 2.1); n = 2206)– Excluded symptomatic carotid and cardioembolic
stroke
• 630 patients underwent TEE – 42% had a cryptogenic stroke– 39% of the cryptogenic stroke had a PFO
• Primary end point: recurrent ischemic stroke or death in 2 years
Homma et al., Circulation, 2002
PICSS Results
Homma et al., Circulation, 2002
PFO Closure Devices for Cryptogenic Stroke
Study Device Device Medical Risk Ratio (95% CI)
CLOSURE 1 STARFlex Septal Closure System
12/447 13/462 0.90 (0.41,1.98)
RESPECT Amplatzer PFO Occluder
9/499 16/481 0.49 (0.21,1.11)
PC Amplatzer PFO Occluder
1/204 5/210 0.20 (0.02,1.72)
CLOSURE – Fulran et al., NEJM 2012 RESPECT – Carroll et al., TCT 2012PC - Meier, et al., TCT 2012
PFO Closure in Cryptogenic Stroke: Conclusion
There is no evidence for routine PFO closure in patients with cryptogenic stroke.
We should continue to enroll patients in RCT trials to evaluate the effectiveness of endovascular PFO closure as a secondary stroke prevention strategy.
PFO CLOSURE