反常性栓塞风险量表在合并卵圆孔未闭的隐源性卒中或短暂性脑缺血发作患者中的应用

摘要/Abstract

摘要：

目的描述卵圆孔未闭（patent foramen ovale，PFO）造成反常性栓塞（paradoxical embolism，PE）的临床表现、影像学特点。验证反常性栓塞风险量表（Risk of Paradoxical Embolism，RoPE）评分。方法本研究为单中心观察性研究，连续性入选2013年1月～2014年6月首都医科大学附属北京天坛医院神经科收治的隐源性卒中或短暂性脑缺血发作（transient ischemic attack，TIA）患者79例，其中经经颅多普勒超声发泡试验（contrast-enhanced transcranial Doppler，cTCD）和经食管超声心动图（transesophageal echocardiography，TEE）确诊合并PFO的患者44例，其中37例为PFO所致PE，7例仅合并 PFO无栓塞症状。由另一名神经科医师盲法评价颅脑磁共振成像，确定其影像学的特点，收集两组患者的人口学信息，临床资料，相关辅助检查（如cTCD、TEE、颈部血管超声及双下肢静脉超声结果），计算并比较两组RoPE评分情况。PFO所致PE患者根据PFO大小分为3组，依据右向左分流量（rightto- left shunt，RLS）大小分为3组。比较不同PFO大小和不同RLS患者之间的临床和影像学特点，并评估不同PFO大小和不同RLS之间的关联性及RoPE评分与PFO的大小和RLS的严重程度之间的关系。结果两组的RoPE评分分别为5（4.5，7.0）和6（4.0，8.0），差异无显著性（P＞0.05）。合并颈内动脉重度狭窄或闭塞，高度提示非PFO相关缺血性卒中（P＜0.01）。小PFO组（＜2 mm）和中/大PFO组（≥2 mm）相比较，两组的RoPE评分分别为（5.5±1.9 vs 6.3±2.0，P＞0.05），后者更容易累及后循环。不同RLS患者之间相比较，3组的RoPE评分分别为（5.4±1.7，6.5±2.7，5.8±2.0，P＞0.05）。PFO 大小和RLS之间无显著性相关（r =0.031，P＞0.05）。结论 PFO和脑梗死的关系可以分为：无相关性（即PFO合并存在）或有相关性（即PE），PE的影像学特点和PFO大小有一定的相关性。RoPE可能有助于进一步区分PFO的大小和RLS的严重程度。

文章导读： 描述卵圆孔未闭所致反常性栓塞的临床和影像学特点，验证反常性栓塞风险量表在合并卵圆孔未
闭的隐源性卒中或短暂性脑缺血发作患者中的应用。

关键词: 卵圆孔未闭; 反常性栓塞; 右向左分流

Abstract:

Objective To describe the clinical and image features of paradoxical embolism due to patent foramen ovale (PFO), and to evaluate the Risk of Paradoxical Embolism (RoPE) score. Methods We retrospectively investigated consecutive patients who were suspected to be paradoxical embolism and having PFO admitted to one stroke center in this observational study. PFO was determined by means of TCD salt injection test (contrast-enhanced transcranial Doppler, cTCD) and transesophageal echocardiography (TEE). Demographic data, clinical features, the results of cTCD, TEE and comprehensive compress ultrasound of deep venous in bilateral lower limbs were retrieved with case report form by a neurologist. The patients were divided into 3 groups according to the size of PFO or to the amount of right-to-left shunt. The MRI was evaluated by another neurologist with blinding to the results of cTCD or TEE. PFO was determined to be related to stroke or just by chance after discussing with consultants. The RoPE score and the imaging features were compared within the groups. The relationship between the size of PFO and the amount of RLS was also examined. Results From Jan. 2013 to Jun. 2014, we recruited 79 adult patients with suspected paradoxical embolism. PFO was positive in 44 patients by both cTCD and TEE. After routine consultation, PFO was determined to be causal in the paradoxical embolism in 37 patients and unrelated to stroke in 7 patients. The RoPE scores were 5 (4.5, 7.0) and 6 (4.0, 8.0) respectively and there was no significant difference. Severe stenosis or occlusion in internal carotid artery was more frequent in the group of ischemic stroke with other reasons. The RoPE scores were (5.5±1.9) for PFO <2 mm and (6.3±2.0) for PFO 2 mm, there was no significant difference between them. The percentage of post-circulation infarction in PFO <2 mm group was less than that in PFO 2 mm (P <0.05) . In the groups by the amount of RLS (1~9 microbubbles, 10~20 microbubbles or >20 microbubbles), the RoPE scores were 5.4±1.7, 6.5±2.7, 5.8±2.0 respectively and were different with no significance. The relationship between the size of PFO and the amount of RLS was tested to be no statistical difference. Conclusion PFO can be causal or unrelated to ischemic stroke. The imaging features might give some clues concerning the size of PFO and the amount of RLS. The RoPE score might provide further information to guide clinical decision.

Key words: Patent foramen ovale; Risk of Paradoxical Embolism score; right-to-left shunt

郑华光1，王伊龙1，陈启东1，曲辉1，胡建科1，苑晓春2，陆菁菁1，鞠奕1，宁彬3，何文3，. 反常性栓塞风险量表在合并卵圆孔未闭的隐源性卒中或短暂性脑缺血发作患者中的应用[J]. 中国卒中杂志, 2014, 9(08): 654-662.

ZHENG Hua-Guang*, WANG Yi-Long,Xiao-Chun, LU Jing-Jing, JU Yi, ZHANG Ning,NING Bin, HE Wen, FU Qiang, CHEN Bu-Xing, LIU Li-Ping, YANG Zhong-Hua, WANGChun-Xue, DONG Ke-Hui, ZHAO Xing-Quan, WANG Yong-Ju. Risk of Paradoxical Embolism Score in Cryptogenic Stroke Patients or Tansient
Ischemic Attack with Patent Foramen Ovale[J]. Chinese Journal of Stroke, 2014, 9(08): 654-662.

参考文献

1 Meier B, Frank B, Wahl A, et al. Secondary stroke

prevention:patent foramen ovale, aortic plaque, and

carotid stenosis[J]. Eur Heart J, 2012, 33:705-713.

2 Homma S, Di Tullio MR. Patent foramen ovale and

stroke[J]. J Cardiol, 2010, 56:134-141.

3 Piechowski-Jozwiak B, Bogousslavsky J. Stroke and

patent foramen ovale in young individuals[J]. Eur

Neurol, 2013, 69:108-117.

4 Messé SR, Silverman IE, Kizer JR, et al. Practice

parameter:recurrent stroke with patent foramen ovale

and atrial septal aneurysm:report of the Quality

Standards Subcommittee of the American Academy

of Neurology[J]. Neurology, 2004, 62:1042-1050.

5 Kitsios GD, Lasker A, Singh J, et al. Recurrent stroke

on imaging and presumed paradoxical embolism:a

cross-sectional analysis[J]. Neurology, 2012, 78:993-

997.

6 Yasaka M, Otsubo R, Oe H, et al. Is st roke a

paradoxical embolism in patients with patent foramen

ovale?[J]. Intern Med, 2005, 44:434-438.

7 Alsheikh-Ali AA, Thaler DE, Kent DM. Patent

foramen ovale in cryptogenic stroke:incidental or

pathogenic?[J]. Stroke, 2009, 40:2349-2355.

8 Davis D, Gregson J, Willeit P, et al. Patent foramen

ovale, ischemic stroke and migraine:systematic review

and stratified meta-analysis of association studies[J].

Neuroepidemiology, 2013, 40:56-67.

9 Kent DM, Ruthazer R, Weimar C, et al. An index to

identify stroke-related vs incidental patent foramen

ovale in cryptogenic stroke[J]. Neurology, 2013,

81:619-625.

10 Meier B, Kalesan B, Mattle HP, et al. Percutaneous

closure of patent foramen ovale in cryptogenic

embolism[J]. N Engl J Med, 2013, 368:1083-1091.

11 Steiner MM, Di Tullio MR, Rundek T, et al. Patent

foramen ovale size and embolic brain imaging

findings among patients with ischemic stroke[J].

Stroke, 1998, 29:944-948.

12 Lamy C, Giannesini C, Zuber M, et al. Clinical and

imaging findings in cryptogenic stroke patients with

and without patent foramen ovale:the PFO-ASA Study.

Atrial Septal Aneurysm[J]. Stroke, 2002, 33:706-711.

13 Furlan AJ, Reisman M, Massaro J, et al. Closure or

medical therapy for cryptogenic stroke with patent

foramen ovale[J]. N Engl J Med, 2012, 366:991-999.

14 Carroll JD, Saver JL, Thaler DE, et al. Closure of

patent foramen ovale versus medical therapy after

cryptogenic stroke[J]. N Engl J Med, 2013, 368:1092-

1100.

15 Agarwal S, Bajaj NS, Kumbhani DJ, et al. Metaanalysis

of transcatheter closure versus medical

therapy for patent foramen ovale in prevention

of recurrent neurological events after presumed

paradoxical embolism[J]. JACC Cardiovasc Interv,

2012, 5:777-789.

16 Rengifo-Moreno P, Palacios IF, Junpaparp P, et al.Patent foramen ovale transcatheter closure vs. medical

therapy on recurrent vascular events:a systematic

review and meta-analysis of randomized controlled

trials[J]. Eur Heart J, 2013, 34:3342-3352.

17 Wahl A, Jüni P, Mono ML, et al. Long-term propensity

score-matched comparison of percutaneous closure

of patent foramen ovale with medical treatment after

paradoxical embolism[J]. Circulation, 2012, 125:803-

812.

18 Capodanno D, Milazzo G, Vitale L, et al. Updating

the evidence on patent foramen ovale closure versus

medical therapy in patients with cryptogenic stroke:a

systematic review and comprehensive meta-analysis

of 2,303 patients from three randomised trials and

2,231 patients from 11 observational studies[J].

EuroIntervention, 2014, 9:1342-1349.

19 Homma S, Sacco RL, Di Tullio MR, et al. Effect

of medical treatment in stroke patients with patent

foramen ovale:patent foramen ovale in Cryptogenic

Stroke Study[J]. Circulation, 2002, 105:2625-2631.

20 Thaler DE, Ruthazer R, Weimar C, et al. Recurrent

stroke predictors differ in medically treated patients

with pathogenic vs other PFOs[J]. Neurology, 2014,

83:221-226.

21 Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and

thrombolytic therapy for valvular disease:Antithrombotic

Therapyand Prevention of Thrombosis, 9th ed: American

College of Chest Physicians Evidence-Based Clinical

Practice Guidelines[J]. Chest, 2012, 141:e576S-e600S.

22 Kernan WN, Ovbiagele B, Black HR, et al. on behalf

of the American Heart Association Stroke Council,

Council on Cardiovascular and Stroke Nursing,

Council on Clinical Cardiology, and Council on

Peripheral Vascular Disease. Guidelines for the

Prevention of Stroke in Patients With Stroke and

Transient Ischemic Attack:A Guideline for Healthcare

Professionals From the American Heart Association/

Amer ican St roke Association[J]. St roke, 2014,

45:2160-2236.

23 Pr i s t ipi no C, An zol a GP, Ba l le r i n i L, e t a l .

Management of patients with patent foramen ovale and

cryptogenic stroke:a collaborative, multidisciplinary,

position paper:executive summary[J]. Catheter

Cardiovasc Interv, 2013, 82:122-129.

24 Telman G, Yalonetsky S, Kouperberg E, et al. Size of

PFO and amount of microembolic signals in patients

with ischaemic stroke or TIA[J]. Eur J Neurol, 2008,

15:969-972.

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