is Cryptogenic Stroke and When Do Neurologists Think PFO Closure Is - - PowerPoint PPT Presentation

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is Cryptogenic Stroke and When Do Neurologists Think PFO Closure Is - - PowerPoint PPT Presentation

Jan 02, 2023 38 likes •254 views

The Neurologist as the Gatekeeper of PFO Closure in the US: What is Cryptogenic Stroke and When Do Neurologists Think PFO Closure Is Needed? David E. Thaler, MD, PhD Chairman, Department of Neurology Tufts University School of Medicine

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The Neurologist as the Gatekeeper of PFO Closure in the US: What is Cryptogenic Stroke and When Do Neurologists Think PFO Closure Is Needed?

David E. Thaler, MD, PhD Chairman, Department of Neurology Tufts University School of Medicine Boston, MA

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Disclosure Statement of Financial Interest

  • Grant/Research Support
  • Consulting Fees/Honoraria
  • Major Stock Shareholder/Equity
  • Royalty Income
  • Ownership/Founder
  • Intellectual Property Rights
  • Other
  • Steering Committee,

RESPECT Trial, St Jude Medical

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

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Pt M – 30 y/o F with BRAO 16hrs after airplane flight and PFO

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30 mins s/p apraclonidine drops Final diagnosis: Left ICA dissection and retinal embolism … and incidental PFO

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What is the underlying mechanism?

“Stroke is an

  • bservation not a

diagnosis”

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Common mechanisms of cerebral ischemia

  • “Small vessel disease” - lipohyalinosis
  • Embolism

– Artery-to-artery (carotid, aorta, other) – Cardiac source – Paradoxical

  • Decreased perfusion through a fixed stenosis
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Other causes of cerebral ischemia

  • Vasculitis
  • Collagen vascular diseases: isolated angiitis of the CNS, temporal (giant cell)

arteritis, polyarteritis nodosa, Wegener's granulomatosis, Takayasu's arteritis, syphilis

  • Meningitis: tuberculosis, fungi, syphilis, bacteria, herpes zoster
  • Arterial dissection: carotid, vertebral, basal intracranial arteries
  • Hematologic disorders: polycythemia, thrombocytosis, thrombotic

thrombocytopenic purpura, disseminated intravascular coagulation, dysproteinemias, hemoglobinopathies (sickle cell disease)

  • Miscellaneous: cocaine, amphetamines, moyamoya disease, fibromuscular

dysplasia, CADASIL

  • Hypercoagulable states: secondary to systemic disease, carcinoma

(especially pancreatic), eclampsia, oral contraceptives, lupus, factor C or S deficiency, factor V mutation, etc.

  • Vasospasm: following subarachnoid hemorrhage
  • Reversible cerebral vasoconstriction: idiopathic, eclampsia, trauma
  • Venous: Dehydration, pericranial infection, postpartum and postoperative

states, systemic cancer

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Stroke mimics and chameleons

Lancet Neurol 2011, 10: 550-60

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Stroke mimics

  • Migraine
  • Seizure
  • Subdural hematoma
  • Tumor
  • Syncope
  • Cardiac arrhythmia
  • Panic attack
  • Hypoglycemia
  • Demyelinating

disease

  • Amyloid angiopathy
  • Brain abscess
  • Encephalitis
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Stroke chameleons

Condition Prevalence Altered mental status 31% Syncope 16% Hypertensive emergency 13% Systemic infection 11% Suspected acute coronary syndrome 10% Other (seizure, peripheral vertigo, cord compression, myasthenia gravis, Bell palsy, migraine, hypoglycemia) 20% J Stroke Cerebrovasc Dis 2014 23: 374-378

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Do I know what “neurologists” think?

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Authors by specialty

Neurology Internal Med/Cardiology Other

Ovbiagele Kernan (IM) Heck: Radiology Chimowitz Black (IM) Mitchell: Nursing Fisher Bravata(IM) Richardson: Statistician Furie Ezekowitz (C) Wilson: Neurosurgery Johnston Fang (IM) Hepburn-Smith: Nursing Kasner Rich (C) Mack: Neurosurgery Kittner Panagos: ED Schwamm Gorman Rabinstein

n=10 n=6 n=7

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Classification of Recommendations and Level of Evidence

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2011 2014

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Classification of Recommendations and Level of Evidence 2011 2014

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Recommendation should be changed

  • Class III definition changed
  • Committee erred in interpreting “negative trials”
  • Evidence using the committee’s own words

support at least IIb

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It may never come to this...

CARDIOLOGIST NEUROLOGIST

Slide courtesy of Vincent Thijs, MD

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Suggestions

1.

Neurologists and cardiologists must collaborate

2.

Involve neurologists in the diagnosis of stroke

3.

Exclude other common “cryptogenic” causes: PAF, aortic atheroma, lacunes

4.

Not every dizzy spell is a TIA

5.

Continue aggressive risk factor modification after closure

6.

Continue antithrombotic medication after closure

7.

Involve patients in the decision making

8.

Intersociety position statements