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Stroke
Published in Henry J. Woodford, Essential Geriatrics, 2022
Trans-oesophageal echocardiography (TOE) has been reported to detect potential sources of embolism in around 40% of people with cryptogenic stroke (i.e. no apparent cause).16 However, the detected abnormality may be patent foramen ovale, which has an unclear role in the pathogenesis of stroke (see page 226), or aortic thrombus (the optimal management of which is unknown). TOE is unlikely to affect the management of many patients. There is a 0.2% risk of serious complications with this procedure (including hypoxia, gastrointestinal bleeding and arrhythmias).17 It is not a routine test but may have a role in a few selected people. Examples would include patients with suspected bacterial endocarditis or atrial myxoma.
The VANISH-2 Study: A Randomized, Blinded, Multicenter Study to Evaluate the Efficacy and Safety of Polidocanol Endovenous Microfoam 0.5% and 1.0% Compared with Placebo for the Treatment of Saphenofemoral Junction Incompetence
Published in Juan Carlos Jimenez, Samuel Eric Wilson, 50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know, 2020
Juan Carlos Jimenez, Samuel Eric Wilson
Study Impact The VANISH-2 trial was a pivotal phase 3 study which helped gain Food and Drug Administration (FDA) approval for Varithena® (Smith and Nephew, Andover, MA, USA). This trial demonstrated an excellent safety profile for this novel, commercially manufactured chemical formulation for polidocanol for treating larger superficial varicose veins. Prior to the availability of Varithena, endovenous liquid sclerosants (i.e., polidocanol, sodium tetradecyl sulfate, etc.) were mixed with room air using the Tessari method.2 This is commonly referred to as “physician compounded foam” (PCF) and served to treat a larger luminal surface area for varicose veins. FDA-approved usage of polidocanol is limited to spider and reticular veins, thus PCF sclerotherapy of larger varicose veins (≥3 mm) is not a formally approved indication. This method results in sclerosant foam with inconsistent bubble size and high nitrogen content. Transient ischemic symptoms and stroke have been reported following administration of physician compounded foam sclerotherapy likely due to patients with patent foramen ovale.3 The incidence of patent foramen ovale in the general population has been reported as high as 26%–59%.4,5 The commercial processing of Varithena results in a 1% polidocanol foam with a 65:35 O2 to CO2 ratio with a nitrogen content less than 0.8%. The more rapidly absorbed bubbles in Varithena result in less risk of clinically significant systemic embolization and this was demonstrated by Regan and Gibson in a recent study.6
Pediatric Imaging in General Radiography
Published in Christopher M. Hayre, William A. S. Cox, General Radiography, 2020
Allen Corrall, Joanna Fairhurst
An atrial septal defect allows oxygenated blood in the left atrium to mix with deoxygenated blood in the right atrium (Tasker, McClure, & Acer, 2013). This is not to be confused with foramen ovale not closing correctly after birth, which is patent foramen ovale (PFO). The defect affects the part of the septum that is involved with the development of the mitral and tricuspid valves allowing oxygenated blood to flow from the left atrium to the right reducing the amount of oxygenated blood to be pumped around the body. This can lead to the heart enlarging as the high blood pressure from the left atrium causes the right side of the heart to dilate to accommodate the blood flowing through the defect. This type of defect is often seen in babies with Down syndrome.
A Case of Transient Visual Field Defect following Administration of Pfizer-BioNTech COVID-19 Vaccine
Published in Ocular Immunology and Inflammation, 2022
Almila Sarıgül Sezenöz, Sirel Gür Güngör, Seda Kibaroğlu
Patent foramen ovale is a remnant of the fetal circulation, which normally closes within the first year of life. However, being the most common congenital heart defect, it persists as a cardiac communication between the left and right atria in 20% to 30% of the general adult population. In most people, it remains asymptomatic and therefore unnoticed for life.17 However, studies have shown that there is a possible connection with PFO and migraine and embolic events.17 In our case, our patient had a small PFO. The imaging studies we ran did not show any evidence of a possible embolus that might have predisposed by the presence of PFO. Therefore, we do not think that the patients’ complaints were directly linked to the PFO. Also, our patient has no personal or family history of migraine or aura before or after, and the one we report is the only episode, which has very close time link to vaccination. Also, the visual complaints of the patient lasted longer than a usual migraine aura. Based on these, we think that aura without migraine type headache or retinal migraine are less likely diagnoses in our case.
Operative treatment for tricuspid valve endocarditis in a premature neonate
Published in Baylor University Medical Center Proceedings, 2021
Gitanjali Indramohan, Sheba John, Christopher E. Greenleaf, Balaguru Duraisamy
A preterm male, at 30 weeks’ gestation and with a birth weight of 1010 g, was transferred from another hospital at 18 days of life (DOL) for management of IE. Initially, he was treated for respiratory distress syndrome related to prematurity. He had an umbilical venous catheter with its tip at the tricuspid valve on DOL 1 to 3. Echocardiogram on DOL 2 showed a patent ductus arteriosus and normal tricuspid valve (Figure 1a). He developed fever and thrombocytopenia on DOL 10. He was started on antibiotic therapy with vancomycin and gentamicin. Echocardiogram revealed a mass on the tricuspid valve measuring 6 mm in diameter, without evidence of stenosis or regurgitation (Figure 1b). There was a small patent foramen ovale with left to right shunt. Blood culture was positive for methicillin-sensitive Staphylococcus aureus. He developed an abscess in the right wrist which was drained on DOL 16. Abdominal ultrasonogram was suspicious for splenic infarct. Eye exam was negative for Roth’s spots. Cerebrospinal fluid culture was negative. Ultrasound of the head was normal on DOL 20.
Neuro-Ophthalmic Literature Review
Published in Neuro-Ophthalmology, 2020
David A. Bellows, John J. Chen, Hui-Chen Cheng, Peter W. MacIntosh, Jenny A. Nij Bijvank, Michael S. Vaphiades, Konrad P. Weber, Sui H. Wong
Using PubMed and published stroke guidelines, the authors performed an evidence-based literature review comparing cryptogenic stroke with the newer concept of embolic stroke of undetermined source (ESUS) which is a subset of cryptogenic stroke that appears embolic/nonlacunar on imaging and for which no source is identified despite an appropriate workup. The authors summarised the most common causes presumed to underlie these strokes, and reviewed the evidence for optimal antithrombotic management. They reviewed the recent clinical trials demonstrating a benefit for percutaneous closure of patent foramen ovale for secondary stroke prevention in select patients. The authors concluded that stroke management is based on evaluation of individual patient-risk factors. Evaluation and treatment is ideally directed by a vascular neurologist to ensure optimal secondary prevention, especially in cases where an underlying aetiology is not identified on initial workup.