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