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Provoked right-to-left shunt in patent foramen ovale associates with ischemic stroke in posterior circulation.
Stroke. 2014 Dec; 45(12):3707-10.S

Abstract

BACKGROUND AND PURPOSE

Right-to-left shunt (RLS) via the patent foramen ovale is an important cause of cryptogenic stroke. The Valsalva maneuver provokes or enhances RLS, but RLS can also occur during normal respiration. This study examined whether the ischemic lesion pattern differs depending on the character of RLS.

METHODS

All consecutive patients with a patent foramen ovale (diagnosed by transesophageal echocardiography) who had a cryptogenic stroke and underwent transcranial Doppler-patent foramen ovale test (monitoring of microbubbles in the right middle cerebral artery by transcranial Doppler after hand-agitated saline injection) were divided according to whether RLS was constant (microbubbles detected both at baseline and after the Valsalva maneuver) or provoked (microbubbles detected only after the Valsalva maneuver). The groups were compared in terms of clinical and imaging characteristics.

RESULTS

Seventy-six patients met the eligibility criteria: 50 had constant RLS and 26 had provoked RLS. Provoked RLS patients were significantly younger. The ischemic lesions in provoked RLS patients were located predominantly in the vertebro-basilar circulation (73.1% versus 28.0%; P=0.002), whereas constant RLS patients were more likely to have multicirculatory lesions (16.0% versus 0.0%; P=0.045). After adjusting for confounders, provoked RLS associated independently with a vertebro-basilar lesion location (OR=3.306; P=0.03).

CONCLUSIONS

The predominance of posterior-circulatory infarction in provoked RLS patients suggests that the Valsalva maneuver may promote RLS and paradoxical embolization to the posterior circulation.

Authors+Show Affiliations

From the Department of Neurology, Asan Medical Center, Seoul, Korea.From the Department of Neurology, Asan Medical Center, Seoul, Korea.From the Department of Neurology, Asan Medical Center, Seoul, Korea.From the Department of Neurology, Asan Medical Center, Seoul, Korea.From the Department of Neurology, Asan Medical Center, Seoul, Korea. sukwon@amc.seoul.kr.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

25358696

Citation

Kim, Bum Joon, et al. "Provoked Right-to-left Shunt in Patent Foramen Ovale Associates With Ischemic Stroke in Posterior Circulation." Stroke, vol. 45, no. 12, 2014, pp. 3707-10.
Kim BJ, Kim NY, Kang DW, et al. Provoked right-to-left shunt in patent foramen ovale associates with ischemic stroke in posterior circulation. Stroke. 2014;45(12):3707-10.
Kim, B. J., Kim, N. Y., Kang, D. W., Kim, J. S., & Kwon, S. U. (2014). Provoked right-to-left shunt in patent foramen ovale associates with ischemic stroke in posterior circulation. Stroke, 45(12), 3707-10. https://doi.org/10.1161/STROKEAHA.114.007453
Kim BJ, et al. Provoked Right-to-left Shunt in Patent Foramen Ovale Associates With Ischemic Stroke in Posterior Circulation. Stroke. 2014;45(12):3707-10. PubMed PMID: 25358696.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Provoked right-to-left shunt in patent foramen ovale associates with ischemic stroke in posterior circulation. AU - Kim,Bum Joon, AU - Kim,Na-Young, AU - Kang,Dong-Wha, AU - Kim,Jong S, AU - Kwon,Sun U, Y1 - 2014/10/30/ PY - 2014/11/1/entrez PY - 2014/11/2/pubmed PY - 2015/1/22/medline KW - Valsalva maneuver KW - cerebral infarction KW - patent foramen ovale SP - 3707 EP - 10 JF - Stroke JO - Stroke VL - 45 IS - 12 N2 - BACKGROUND AND PURPOSE: Right-to-left shunt (RLS) via the patent foramen ovale is an important cause of cryptogenic stroke. The Valsalva maneuver provokes or enhances RLS, but RLS can also occur during normal respiration. This study examined whether the ischemic lesion pattern differs depending on the character of RLS. METHODS: All consecutive patients with a patent foramen ovale (diagnosed by transesophageal echocardiography) who had a cryptogenic stroke and underwent transcranial Doppler-patent foramen ovale test (monitoring of microbubbles in the right middle cerebral artery by transcranial Doppler after hand-agitated saline injection) were divided according to whether RLS was constant (microbubbles detected both at baseline and after the Valsalva maneuver) or provoked (microbubbles detected only after the Valsalva maneuver). The groups were compared in terms of clinical and imaging characteristics. RESULTS: Seventy-six patients met the eligibility criteria: 50 had constant RLS and 26 had provoked RLS. Provoked RLS patients were significantly younger. The ischemic lesions in provoked RLS patients were located predominantly in the vertebro-basilar circulation (73.1% versus 28.0%; P=0.002), whereas constant RLS patients were more likely to have multicirculatory lesions (16.0% versus 0.0%; P=0.045). After adjusting for confounders, provoked RLS associated independently with a vertebro-basilar lesion location (OR=3.306; P=0.03). CONCLUSIONS: The predominance of posterior-circulatory infarction in provoked RLS patients suggests that the Valsalva maneuver may promote RLS and paradoxical embolization to the posterior circulation. SN - 1524-4628 UR - https://www.unboundmedicine.com/medline/citation/25358696/Provoked_right_to_left_shunt_in_patent_foramen_ovale_associates_with_ischemic_stroke_in_posterior_circulation_ L2 - https://www.ahajournals.org/doi/10.1161/STROKEAHA.114.007453?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -