Osgood Marcey, Budman Elizabeth, Carandang Raphael, Goddeau Richard P, Henninger Nils
Department of Neurology, University of Massachusetts Medical School, Worcester, Mass., USA.
Cerebrovasc Dis. 2015;39(3-4):216-23. doi: 10.1159/000376613. Epub 2015 Mar 14.
A substantial proportion of ischemic strokes has no any identified underlying cause. Notably, the prevalence of a patent foramen ovale (PFO) is increased in cryptogenic stroke (CS) populations, which may serve as a conduit for paradoxical emboli originating from deep vein thrombosis (DVT) including the pelvic veins. Yet, there are no published guidelines for the assessment of pelvic veins as part of the stroke workup and few studies have systematically investigated pelvic veins as a potential source for paradoxical emboli in CS patients. Further, there is a relative paucity of data regarding pelvic DVT in CS and results have been conflicting. Hence, we sought to determine the prevalence of pelvic DVT in select CS patients with PFO who underwent magnetic resonance venography (MRV).
We retrospectively identified patients (n = 50) who underwent contrast-enhanced pelvic MRV at the discretion of the treating physician for the evaluation of CS in the presence of a PFO during hospitalization at a single academic stroke center between January 2011 through December 2013. Multivariable logistic regression analyses were used to assess for factors independently associated with the presence of an abnormal MRV pelvis.
Patients (47 ± 13 years of age) had MRV performed 4 ± 3 days after their incident stroke. Nine patients had an abnormal MRV (18%). Of these, four (8%) had pelvic vein thrombosis and 5 (10%) a May-Thurner anatomic variant. All patients with pelvic DVT were subsequently anticoagulated with warfarin (none had abnormal hypercoagulability testing). Clinical clues suggesting paradoxical embolism were present in as many as 40% of patients. On multivariable logistic regression, a history of any risk factors predisposing to DVT (OR 6.7; coefficient 1.9; BCa 95% CI 0.08-20.2; p = 0.014) as well as the number of predisposing risk factors (OR 3.9; coefficient 1.4; BCa 95% CI 0.25-4.2; p = 0.005) predicted the presence of pelvic vein pathology on MRV.
We demonstrate a relatively high prevalence of pelvic DVT among select CS patients emphasizing the importance of considering the pelvic veins as a potential source for emboli particularly in the presence of risk factors known to predispose DVT. Because patients were included at the treating physician's discretion, our results reflect 'real-life' practice. Our results may be of clinical importance as inclusion of pelvic vein imaging in CS patients with PFO had impactful therapeutic and nosologic implications. Further study is needed to define patients most likely to benefit from pelvic vein imaging.
相当一部分缺血性卒中没有明确的潜在病因。值得注意的是，不明原因卒中（CS）人群中卵圆孔未闭（PFO）的患病率增加，这可能是包括盆腔静脉在内的深静脉血栓形成（DVT）导致反常栓塞的通道。然而，目前尚无关于将盆腔静脉评估作为卒中检查一部分的已发表指南，很少有研究系统地调查盆腔静脉作为CS患者反常栓塞的潜在来源。此外，关于CS中盆腔DVT的数据相对较少，结果也存在矛盾。因此，我们试图确定接受磁共振静脉造影（MRV）的特定CS合并PFO患者中盆腔DVT的患病率。
我们回顾性确定了2011年1月至2013年12月期间在单一学术性卒中中心住院期间因治疗医师决定对CS合并PFO进行评估而接受对比增强盆腔MRV的患者（n = 50）。多变量逻辑回归分析用于评估与异常MRV盆腔存在独立相关的因素。
患者（47±13岁）在卒中发作后4±3天进行了MRV检查。9例患者MRV异常（18%）。其中，4例（8%）有盆腔静脉血栓形成，5例（10%）有May-Thurner解剖变异。所有盆腔DVT患者随后均接受华法林抗凝治疗（均无异常高凝试验）。多达40%的患者存在提示反常栓塞的临床线索。在多变量逻辑回归中，任何易患DVT的危险因素病史（OR 6.7；系数1.9；BCa 95% CI 0.08 - 20.2；p = 0.014）以及易患危险因素的数量（OR 3.9；系数1.4；BCa 95% CI 0.25 - 4.2；p = 0.005）可预测MRV上盆腔静脉病变的存在。
我们证明了特定CS患者中盆腔DVT的患病率相对较高，强调了将盆腔静脉视为潜在栓子来源的重要性，特别是在存在已知易患DVT的危险因素时。由于患者是由治疗医师酌情纳入的，我们的结果反映了“现实生活”中的实践。我们的结果可能具有临床重要性，因为在CS合并PFO患者中纳入盆腔静脉成像具有重要的治疗和疾病分类学意义。需要进一步研究以确定最可能从盆腔静脉成像中获益的患者。
