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PubMed1999

Increased prevalence of patent foramen ovale in patients with severe chronic obstructive pulmonary disease.

This study was designed to assess the prevalence of patent foramen ovale (PFO) in patients with severe chronic obstructive pulmonary disease (COPD) and the magnitude of any effects of right-to-left interatrial PFO shunting on systemic arterial oxygen desaturation after the Valsalva maneuver. The prevalence of PFO was compared between a group of 20 patients with severe chronic obstructive pulmonary disease (FEV1% <50%; FEV1/FVC <50%) and 20 control subjects (FEV1% >70%; FEV1/FVC >70%) by contrast transesophageal echocardiography during the Valsalva maneuver with simultaneous measurement of systemic arterial oxygen saturation (SaO2) by pulse oximetry. Patients with severe COPD (FEV1 = 27.2% +/- 8.4%; FEV1 /FVC = 44.3% +/- 11.0%) had a significantly higher pulmonary artery systolic pressure (38.3 +/- 7.3 vs 21.0 +/- 2.4 mm Hg; P <.005), higher prevalence of PFO (14/20 = 70% vs 7/20 = 35%; P <.05), and greater systemic arterial desaturation after Valsalva (Sao2 change: -2.6% +/- 1.4% vs -1.1% +/- 0.9%; P <.005) than control subjects. In the severe COPD group, the degree of systemic arterial desaturation after Valsalva in patients with PFO was significantly greater than in patients without PFO (Sao2 change: -3.1% +/- 1.4% vs -1.5% +/- 0. 5%; P <.05). Significant systemic arterial oxygen desaturation was observed after Valsalva in 45% of patients with interatrial PFO shunting and severe COPD. This significantly correlated with the degree of pulmonary hypertension (r = 0.6; P <.05). We conclude (1) that patients with severe COPD have an increased prevalence of PFO and (2) that approximately one half of subjects with severe COPD and PFO demonstrate statistically significant systemic arterial oxygen desaturation after the Valsalva maneuver.

Aged↗

PubMedDate not supplied

Lung scan in the diagnosis and management of patent foramen ovale pulmonary embolism, paradoxical embolism.

This case illustrates the reopening of foramen ovale in a young patient with chronic pulmonary hypertension caused by bronchiectasis and chronic pulmonary fibrosis, which resulted in a prominent right-to-left shunt and severe hypoxia. Her clinically unsuspected right-to-left shunt was discovered during ventilation-perfusion scan, which was performed for the evaluation of pulmonary embolism. She had common variable immune deficiency, a primary immunodeficiency disease in which B-lymphocytes produce few or no antibodies. Most patients with this syndrome have an intrinsic defect in their B-lymphocytes that results in reduced immunoglobulin production. In these patients, recurrent respiratory tract infections are common and may result in chronic lung disease, fibrosis, particularly bronchiectasis (20-30%) and even cor pulmonale as happened in our patient [J. Clin. Immunol. 9 (1989) 22-33.].

Adult↗

PubMed1997

Intracardiac thrombus trapped in a patent foramen ovale.

We describe a case of impending paradoxical embolism due to a thrombus trapped in a patent foramen ovale in a 22-year-old woman. Transthoracic and transesophageal echocardiography detected the thrombus. She was operated on and discharged asymptomatic.

Adult↗

PubMed2002

Temporary IVC filtration before patent foramen ovale closure in a patient with paradoxic embolism.

Pulmonary embolism (PE) and associated acute peripheral ischemia suggest the diagnosis of paradoxic embolism. The most common intracardiac defect associated with paradoxic emboli is a patent foramen ovale (PFO). Therapeutic options include anticoagulation, thrombolysis, inferior vena cava (IVC) filtration, and closure of the intracardiac defect. The authors discuss the diagnosis and treatment of a young female athlete who presented with massive PE complicated by a paradoxic embolus to the right subclavian artery. Systemic and catheter-directed thrombolysis, IVC filtration, and percutaneous closure of a PFO were performed in an effort to return the patient to the level of competitiveness she desired.

Adolescent↗

PubMed2001

Sensitivity of recordings at sphenoidal electrode site for detecting seizure onset: evidence from scalp, superficial and deep foramen ovale recordings.

OBJECTIVES: Some authors have recently stressed that the position of the tip of sphenoidal electrodes plays a crucial role in their efficacy in detecting ictal onset. An opportunity to test this hypothesis is provided by recordings from the most superficial contacts of foramen ovale (FO) electrode bundles because these contacts are located at the FO, in a position equivalent to that of optimally located sphenoidal electrodes. To simplify wording, recordings obtained by superficial FO electrodes will hereafter be called sphenoidal recordings, although they have not been obtained with standard sphenoidal electrodes. The sensitivities of simultaneous scalp and sphenoidal recordings for detecting ictal onset have been compared with each other, and with a 'gold standard' provided by simultaneous deep intracranial FO recordings from the mesial aspect of the temporal lobe. METHODS: Three hundred and fourteen seizures obtained from 110 patients under telemetric presurgical assessment for temporal lobe epilepsy have been studied. Scalp electrodes included anterior temporal placements. All scalp electrodes were considered when identifying seizure onset but the anterior temporal electrodes were most frequently involved. RESULTS: Ictal onset time at sphenoidal and scalp recordings: initial ictal changes appeared simultaneously in scalp and sphenoidal recordings in 123 seizures (39.2%). Initial changes occurred earlier in sphenoidal recordings in 63 seizures (20.1%), whereas they were seen earlier on the scalp in 76 seizures (24.2%). Artefacts prevented the comparison between sphenoidal and scalp recordings in 16 seizures (5.1%) and no ictal changes were seen on the scalp and/or sphenoidal recordings in 36 seizures (11.5%). In most of the 63 seizures where ictal changes appeared earlier in sphenoidal recordings, a delayed ipsilateral scalp onset was seen as the signal amplitude increased or scalp changes could be identified retrospectively on the scalp with an onset which appeared simultaneous and ipsilateral to the initial sphenoidal changes. Sphenoidal recordings supplied additional information when compared to scalp recordings in only 22 seizures (7%): in 5 seizures with artefacts on the scalp, in 6 seizures with no changes on the scalp and in 11 seizures with discrepant laterality at onset. Congruence in laterality with respect to deep intracraneal FO recordings: of the 61 seizures with unilateral onset on the scalp, onsets at sphenoidal recordings and deep FO electrodes were ipsilateral in most cases. In only 3 of these 61 seizures (4.9%), sphenoidal recordings lateralized ipsilateral to the deep FO electrodes in the presence of a contralateral onset on the scalp. In 14 among the 122 seizures (11.5%) with bilateral asymmetrical onset on the scalp, sphenoidal recordings lateralized seizure onset ipsilateral to the deep FO electrodes in the presence of a contralateral scalp onset. Thus, when compared with scalp EEG, sphenoidal recordings increased laterality congruence with respect to deep FO electrodes in 17 seizures (5.4%). CONCLUSIONS: Extracranial electrodes located next to the FO at the sphenoidal electrode site yield an improvement over suitable surface electrodes in the identification of ictal onset in only 5.4-7% of seizures. Such improvement derives from the fact that the low amplitude signals often seen at seizure onset may show higher amplitude on sphenoidal than on scalp recordings.

Electroencephalography↗

PubMed2001

Using simulated neuronal cell models for detection of epileptic seizures in foramen ovale and scalp EEG.

OBJECTIVE: To demonstrate a novel approach for real-time and automatic detection of epileptic seizures in EEG recorded with foramen ovale (Fov) or scalp electrodes. METHODS: Our seizure detection method is based on simulated leaky integrate and fire units (LIFU), which are classical simple neuronal cell models. The LIFUs are connected to a signal preprocessing stage and increase their spiking rates in response to rhythmic and synchronous EEG signals as typically occur at the onset and during seizures. RESULTS: We analyzed 22 short-term (10+/-3 min) and 4 long-term (18+/-7 h) Fov or scalp EEGs of 10 patients with drug resistant partial epilepsy. Seizures (n=36) were marked by increases of the LIFUs spiking rates above a preset threshold. The durations of increased spiking rates due to seizures were always longer than 10 s (36+/-21 s) and allowed separation from artifacts, which caused only short durations (1.2+/-0.6 s) of high spiking rates. The LIFUs correctly detected all the seizures and produced no false alarms. In the long term Fov EEGs seizure detection occurred before the onset of clinical signs (41+/-22 s). CONCLUSIONS: By using simulated neuronal cell models it is possible to automatically detect epileptic seizures in scalp and Fov EEG with high sensitivity and specificity.

Action Potentials↗

PubMed2001

Topography of foramen ovale electrodes by 3D image reconstruction.

To date, the foramen ovale (FO) electrode recording technique has been used in 234 patients at our center to assist in the evaluation of epilepsy surgery. Most of the patients suffered from mesial temporal lobe epilepsy (MTLE) and were candidates for a selective amygdalohippocampectomy. Knowledge of the exact topography of the FO electrodes is mandatory for a more precise anatomo-electro-clinical correlation of seizures and for a better understanding of FO electrode recorded electroencephalogram (EEG) and evoked potentials generated in the hippocampal formation or in nearby thalamic relays or brainstem structures. Here, we describe and illustrate a 3D image reconstruction of FO electrodes in situ as an important step to better define the generators of MTLE seizures as well as of interictal spikes and physiological EEG signals recorded with FO electrodes.

Adult↗

PubMed2003

Prevalence of patent foramen ovale in subjects with obstructive sleep apnea: a transcranial Doppler ultrasound study.

BACKGROUND: Under particular conditions a patent foramen ovale (PFO) can potentially give rise to ischemic stroke by means of paradoxic embolization. In obstructive sleep apnea syndrome (OSAS) right to left shunting (RLSh) can occur through PFO during periods of nocturnal apnea. Our study aimed to evaluate the prevalence of PFO diagnosed by means of transcranial Doppler (TcD) in subjects with OSAS. METHODS: Seventy-eight consecutive subjects with OSAS (mean age 53+/-12 years) and 89 normal controls (mean age 48+/-9 years) underwent TcD with intravenous application of agitated physiological saline solution. The test was performed on patients at rest and during Valsalva maneuver. RESULTS: PFO was present in 21 out of 78 patients with OSA (27%) and in 13 out of 89 control patients (15%). Seventeen out of 21 patients with OSA showed PFO only during Valsalva maneuver (85%) with respect to 12 out of 13 subjects of the control group (92%). Prevalence of PFO in OSAS was statistically different with respect to the control group (P<0.05). However, no statistically significant differences could be found for the prevalence of provocative-only shunting PFO with respect to already at rest shunting PFO in patients with OSAS with respect to the control group. CONCLUSIONS: Prevalence of PFO in subjects with OSA is significantly higher than in normal controls. The shunt is frequently present only during Valsalva maneuver.

Adult↗

PubMed1996

The management of dysphagia in jugular foramen surgery.

From 1985-1994, the Skull Base Unit at St. Vincent's Hospital, Sydney, operated on 61 patients with tumours involving the jugular foramen. Pre-operative assessment by a Speech Pathologist and the institution of swallowing techniques prior to surgery have improved post-operative morbidity. Ancillary procedures at the time of surgery were not required in the majority of cases. An individual assessment of each patient early in the postoperative period was found to be more important with regard to the benefits of supplementary surgery. The majority of patients with dysphagia settled with conservative management and only a few underwent ancillary surgery. It is perceived that the cortical and subcortical control of swallowing is a major factor in the rehabilitation of these patients.

Adolescent↗

PubMed1996

Parapharyngeal vagal neurilemmoma extending to the jugular foramen.

A large vagal neurilemmoma in a 33-year-old man is reported. He complained of slowly progressive palsy of the tongue on the left side. Weakness of soft palate movement was also noted. Magnetic resonance imaging (MRI) revealed a tumour in the left parapharyngeal space with partial extension to the posterior cranial fossa through the jugular foramen. Carotid angiography revealed avascularity of the tumour and anterior shift of the left internal carotid artery. The venous phase showed no blood flow in the internal jugular vein. The tumour was successfully extirpated via a transmandibular transpterygoid approach. Although vagus nerve dysfunction was not observed pre-operatively, the tumour was identified as a neurilemmoma arising from the vagus nerve. The surgical approach should be selected according to the lesion in individual patients. Since neurilemmoma is benign in nature, minimal post-operative sequelae should be expected.

Adult↗

PubMed1996

Jugular foramen involvement in nasopharyngeal carcinoma.

Nasopharyngeal carcinoma (NPC) may spread posterolaterally with infiltration of the jugular foramen, jugular vein and the cranial nerves IX-XI. Cranial nerve palsies may be evident clinically but the extent of skull base infiltration is best assessed radiologically. Denervation atrophy is well demonstrated by both magnetic resonance imaging (MRI) and computed tomography (CT). Accurate delineation of the lesion is important in prognosis and radiotherapy planning.

Accessory Nerve↗

PubMed2002

Stroke in a scuba diver with patent foramen ovale.

Patent foramen ovale (PFO) is a frequent condition which carries a significant risk for stroke when associated with deep venous thrombosis and primary or secondary coagulation abnormalities. Here, we describe a patient in which scuba diving is thought to be associated with stroke in a subject with an otherwise clinically silent PFO. During a rapid ascent a 43-year-old-scuba diver reported weakness and paresthesias in the right arm which lasted about 10 min. He presented similar symptoms 2 days later 1 h after diving, and a third time on his flight back home. The MRI showed multiple hyperintense areas on T2-weighted images in the white matter. Transoesophageal echocardiography (TEE) showed a PFO, whilst all haematological and haemocoagulation tests were negative. Scuba diving may constitute a patho-physiological condition in the presence of PFO as breath-holding promotes right-to-left shunt and arterialization of venous bubbles.

Adult↗

PubMed2003

Transcranial Doppler and risk of recurrence in patients with stroke and patent foramen ovale.

The importance of patent foramen ovale (PFO) in stroke of unknown cause remains disputed, as PFO may be present in up to 20% of normal people and in a high proportion of patients with non-vascular disorders. Recent evidence suggests that the amount of right-to-left shunt (RLS) may be the crucial factor for stroke occurrence and relapse. The aim of the study was to assess predictors of recurrence in PFO-related stroke patients with particular emphasis on amount of shunting. Patients less than 61 years old who had been admitted for a PFO-related stroke within the previous 5 years, were re-evaluated on a follow-up visit. The clinical syndrome, residual disability, vascular risk factors and number of relapses as the index event were assessed. RLS sizing was semi-quantitatively performed with saline-enhanced transcranial Doppler (TCD), by assuming a cut-off of more or less 10 bubbles recorded in the cerebral vessels as a criterion to discriminate large versus small shunt, respectively. Thereafter patients were prospectively followed-up for a median time of 23 months. Total follow-up was 61 months. Fifty-nine patients (M/F = 23/36, mean age 43 +/- 13) were studied. Overall there were 23 relapses in 13 patients. The amount of shunting was the only significant independent variable associated with relapse: at the end of the follow-up period the recurrence rate was 0.66 and 8.2% per patient per year in patients with small and large shunt, respectively. This difference was statistically significant (chi2 = 10.39, P = 0.0012; OR 17.05, 95% CI 2.10-755.22). In patients with PFO-related stroke, the amount of RLS as assessed with TCD is the only independent predictor of relapse. PFO sizing is mandatory in patients with PFO.

Female↗

PubMed2001

Lateralizing and localizing values of ictal onset recorded on the scalp: evidence from simultaneous recordings with intracranial foramen ovale electrodes.

PURPOSE: The value of scalp recordings to localize and lateralize seizure onset in temporal lobe epilepsy has been assessed by comparing simultaneous scalp and intracranial foramen ovale (FO) recordings during presurgical assessment. The sensitivity of scalp recordings for detecting mesial temporal ictal onset has been compared with a "gold standard" provided by simultaneous deep intracranial FO recordings from the mesial aspect of the temporal lobe. As FO electrodes are introduced via anatomic holes, they provide a unique opportunity to record simultaneously from scalp and mesial temporal structures without disrupting the conducting properties of the brain coverings by burr holes and wounds, which can otherwise make simultaneous scalp and intracranial recordings unrepresentative of the habitual EEG. METHODS: Simultaneous FO and scalp recordings from 314 seizures have been studied in 110 patients under telemetric presurgical assessment for temporal lobe epilepsy. Seizure onset was identified on scalp records while blind to recordings from FO electrodes and vice versa. RESULTS: Bilateral onset (symmetric or asymmetric) was more commonly found in scalp than in FO recordings. The contrary was true for unilateral seizure onset. In seizures with bilateral asymmetric onset on the scalp, the topography of largest-amplitude scalp changes at onset does not have localizing or lateralizing value. However, 75-76% of seizures showing unilateral scalp onset with largest amplitude at T1/T2 or T3/T4 had mesial temporal onset. This proportion dropped to 42% among all seizures with a unilateral scalp onset at other locations. Of those seizures with unilateral onset on the scalp at T1/T2, 65.2% showed an ipsilateral mesial temporal onset, and 10.9% had scalp onset incorrectly lateralized with respect to the mesial temporal onset seen on FO recordings. In seizures with a unilateral onset on the scalp at electrodes other than T1/T2, the proportions of seizures with correctly and incorrectly lateralized mesial temporal onset were 37.5 and 4.2%, respectively. Thus the ratio between incorrectly and correctly lateralized mesial temporal onsets is largely similar for seizures with unilateral scalp onset at T1/T2 (16.7%) and for seizures with unilateral scalp onset at electrodes other than T1/T2 (11.2%). The onset of scalp changes before the onset of clinical manifestations is not associated with a lower proportion of seizures with bilateral onset on the scalp, or with a higher percentage of mesial temporal seizures or of mesial temporal seizures starting ipsilateral to the side of scalp onset. In contrast, the majority (78.4%) of mesial temporal seizures showed clinical manifestations starting after ictal onset on FO recordings. CONCLUSIONS: A bilateral scalp onset (symmetric or asymmetric) is compatible with a mesial temporal onset, and should not deter further surgical assessment. Although a unilateral scalp onset at T1/T2 or T3/T4 is associated with a higher probability of mesial temporal onset, a unilateral onset at other scalp electrodes does not exclude mesial temporal onset. A unilateral scalp onset at electrodes other than T1/T2 is less likely to be associated with mesial temporal onset, but its lateralizing value is similar to that of unilateral scalp onset at T1/T2. The presence of clinical manifestations preceding scalp onset does not reduce the localizing or lateralizing values of scalp recordings.

Adolescent↗

PubMed2003

Indication and techniques of transcatheter closure of patent foramen ovale.

A potential causal relationship of a patent foramen ovale (PFO) and a stroke was first suggested by Cohnheim in 1877.1 Today, this correlation is generally accepted. However, there is still no "gold standard" for the treatment of patients with presumed paradoxical embolism. This article reviews the epidemiology of and the diagnostic methods for PFO, the clinical relationship between PFO and cerebral ischemia, as well as indications and techniques for transcatheter closure of PFO. In the author's opinion, transcatheter PFO closure represents an elegant management for selected patients at risk.

Brain Ischemia↗

PubMed2003

Transcatheter closure of patent foramen ovale: a new migraine treatment?

Transcranial Doppler (TCD) is a very sensitive tool for detecting microembolic signals (MES) in the brain vessels after injection of air-mixed saline in case of right-to-left shunt (RLS). Patent foramen ovale (PFO) can be found in nearly one-half of migraineurs with aura, and, reciprocally, the prevalence of migraine in patients with stroke with PFO is exceedingly high. We aimed to monitor the passage of MES in the brain vessels during transcatheter closure of PFO and to subsequently follow-up patients for both the efficacy of the procedure and the severity of migraine. Seventeen patients suffering from migraine with aura (MA+, n = 8) or without aura (MA-, n = 9) scheduled to undergo transcatheter closure of PFO with Amplatzer PFO occluder devices for paradoxical cerebral embolism were monitored with contrast TCD (DWL, Germany) before, during, and after the procedure to estimate the magnitude of the shunt. Spontaneous embolization to the brain was also recorded. The patients were thereafter followed-up at 1, 3, and 6 months. A composite score of migraine severity, which included frequency, duration, and intensity of the attacks in the previous 3 months (range 0-10), was obtained at the time of the procedure and at the follow-up visits. Complete occlusion of PFO was achieved in all patients after 1 month in most cases. Preoperatively, the migraine score was 6.75 in MA+ and was 6 in MA--patients. After closure, the score dropped to 2.5 in MA+ and to 4.2 in MA--patients at the 6-month follow-up visit, the difference being statistically highly significant in both groups. Overall, 5 of 17 patients no longer complained of migraine, 10 of 17 were substantially improved, and two of 17 were unchanged at 6 months. Migraine aura disappeared in six of eight patients. Closure rate was very satisfactory, from a preoperative average bubble count of 42 to an average of 4 bubbles in the four patients in whom a small residual shunt was still detectable at the 6-month follow-up visit. TCD monitoring provides the most accurate assessment of RLS at the brain level. Closure of PFO with transcatheter devices results in the substantial relief of migraine in patients with stroke with large RLS.

Adult↗

PubMed2003

Patent foramen ovale with paradoxical embolism: mid-term results of transcatheter closure in 256 patients.

The purpose of this study was to assess the safety and feasibility of percutaneous interventional closure of patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) in symptomatic patients. Between June 1999 and June 2002, we performed transcatheter closure of PFO in 256 consecutive symptomatic patients (female/male = 1.45; mean age 48 +/- 16 years; range 14-75): ischemic stroke (n = 101), transient ischemic attack (n = 144), peripheral and coronary arterial embolism (n = 17); multiple events (n = 23); platypnea-orthodeoxia syndrome (n = 2); refractory hypoxemia (n = 1); and migraine aura (n = 27). The implanted devices were an Amplatzer PFO Occluder (n = 248), a Gore-HELEX Septal Occluder (n = 4), and PFO STAR (n = 4). Most procedures (n = 176.69%) were done under two-dimensional intracardiac echocardiography (ICE) guidance alone; in the last 30 patients, 3D/4D ICE reconstruction (TomTec Imaging Systems) 6mbH was obtained. In 30 cases, ICE and contrast enhanced-TCD have been used simultaneously in the catheterization laboratory. The devices were placed correctly in all patients. Mean fluoroscopy time was 9.45 +/- 5 minutes (range = 2.5-35 minutes); mean procedural time was 57 +/- 21 minutes (range = 15-135 minutes). Total occlusion rate at follow-up (mean 19 months, range 1-33) was 98.1%. No significant recurrent neurological events were observed. Transcatheter closure of PFO with or without ASA is a safe and effective, minimally invasive procedure that ensures high closure rate and avoids life-long anticoagulation. Mid-term follow-up results appear favorable with respect to recurrent thromboembolic events.

Adolescent↗

PubMed2003

Role of intracardiac echocardiographic guidance in transcatheter closure of atrial septal defects and patent foramen ovale using the Amplatzer device.

Transesophageal echocardiography (TEE) has been successfully used for guiding transcatheter device closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO). However, the use of TEE for device closure requires general anesthesia. Experience with intracardiac echocardiographic (ICE) guidance to close ASD and PFO is limited. One hundred eleven patients (76 female/35 male) with secundum ASD (82 patients) and PFO (29 patients) associated with a stroke underwent an attempt of transcatheter closure of their defects under ICE guidance using the new AcuNav catheter. The median age of patients was 40 years (range 2.5-80.7) and the median weight was 66 kg (range 12.7-128 kg). The median two-dimensional size of secundum defects as measured by ICE was 17 mm (range 3-32 mm). The median balloon stretched diameter of the ASDs was 22 mm (range 4-36 mm). Five patients had more than one defect that required placement of two devices to close the defects. The median Qp/QS ratio for patients with secundum ASD was 2.1 (range 1-18). ICE provided adequate views of the defects and surrounding structures and the various stages of device deployment. All patients had successful device placement, including the patients who received simultaneous two devices with immediate complete closure of the defects in 100 patients, whereas four and seven patients had trivial and small residual shunt, respectively. The median fluoroscopy time was 10.2 minutes (range 3.7-38.4 minutes) and the median total procedure time was 60 minutes (range 28-180 minutes). There were no complications related to the use of the AcuNav catheter. We conclude that ICE provided unique images of the atrial communications and facilitated device closure of secundum ASD and PFO in children and adults. We believe ICE should replace TEE as a guiding imaging tool for ASD and PFO device closure, thus eliminating the need for general anesthesia.

Adolescent↗