Boston Medical Center, Boston University School of Medicine, Boston, MA USA.
University of Pennsylvania, Philadelphia, USA.
J Stroke Cerebrovasc Dis. 2022 Aug;31(8):106606. doi: 10.1016/j.jstrokecerebrovasdis.2022.106606. Epub 2022 Jun 21.
Embolic stroke of undetermined source (ESUS) accounts for up to 20% of all strokes. Potential contributors to ESUS include patent foramen ovale (PFO) and non-stenotic plaque (<50%, NSP) of the ipsilateral internal carotid artery (ICA). To better differentiate these as unique mechanisms, we explored the prevalence of each in a multicenter observational cohort.
A retrospective multicenter cohort of consecutive patients with ESUS was queried (2015-2021). Patients with unilateral, anterior circulation ESUS who had a computed tomography angiography neck scan and a transthoracic echocardiogram (TTE) and/or transesophageal echocardiogram (TEE) with adequate visualization of a PFO were included. Patients with prior carotid stent, endarterectomy or alternative etiologies were excluded from the study. Descriptive statistics were used to characterize patients with and without PFO, with multivariable logistic regression used to predict the presence of a PFO based on clinicoradiographic factors as well as degree of luminal stenosis and ipsilateral plaque thickness >3mm, based on previously published thresholds of clinical relevance.
Of the 234 included patients with unilateral anterior ESUS and adequate TTE or TEE, 17 (7.3%) had a PFO and 64 (27.4%) had ≥3mm of ipsilateral ICA plaque. Patients with PFO had significantly less NSP and less ipsilateral cervical ICA stenosis (0% [IQR 0-0%] vs. 0% [IQR 0-50%], p=0.03; Table). After adjustment for all predictors of PFO in multivariable regression (p<0.1: Hispanic ethnicity and ipsilateral plaque thickness), ipsilateral NSP was independently associated with a 62% lower odds of harboring a PFO (OR per 1cm of plaque 0.48, 95%CI 0.25-0.94). No patients with a PFO had ≥3mm of ipsilateral ICA plaque.
Ipsilateral NSP is more common in ESUS patients without a PFO. While this study is limited by the small PFO event rate, it supports the notion that NSP and PFO may be independent contributors to ESUS.
不明来源栓塞性卒中（ESUS）占所有卒中的 20%。ESUS 的潜在病因包括卵圆孔未闭（PFO）和同侧颈内动脉（ICA）非狭窄斑块（<50%，NSP）。为了更好地区分这些独特的机制，我们在一个多中心观察队列中探讨了它们的患病率。
回顾性检索了 2015 年至 2021 年间连续发生 ESUS 的多中心队列患者。纳入单侧、前循环 ESUS 患者，且具有 CT 血管造影颈部扫描、经胸超声心动图（TTE）和/或经食管超声心动图（TEE），且 PFO 显示充分。排除既往颈动脉支架、内膜切除术或其他病因的患者。采用描述性统计方法描述有和无 PFO 的患者特征，采用多变量逻辑回归分析根据临床影像学因素以及基于先前发表的临床相关阈值的管腔狭窄程度和同侧斑块厚度>3mm，预测 PFO 的存在。
在 234 例单侧前循环 ESUS 患者中，有 17 例（7.3%）存在 PFO，64 例（27.4%）同侧 ICA 斑块厚度>3mm。有 PFO 的患者 NSP 明显较少，同侧颈内动脉狭窄程度较轻（0%[IQR 0-0%]比 0%[IQR 0-50%]，p=0.03；表）。多变量回归分析中，调整所有 PFO 的预测因素后（p<0.1：西班牙裔和同侧斑块厚度），同侧 NSP 与 PFO 的可能性降低 62%相关（每增加 1cm 斑块 OR 0.48，95%CI 0.25-0.94）。没有 PFO 的患者有同侧 ICA 斑块厚度>3mm。
同侧 NSP 在无 PFO 的 ESUS 患者中更为常见。尽管本研究由于 PFO 发生率较低而受到限制，但它支持 NSP 和 PFO 可能是 ESUS 的独立病因的观点。
