Neues beim Schlaganfall

Zusammenfassung

Diese Übersichtsarbeit fasst neue Erkenntnisse zur Epidemiologie, Diagnostik, Akuttherapie sowie Primär- und Sekundärprävention des Schlaganfalls aus den Jahren 2015 und 2016 zusammen. Große epidemiologische Studien zeigen, dass behandelbare Risikofaktoren wie die arterielle Hypertonie, Diabetes mellitus, Rauchen, Bewegungsmangel und Ernährung bis zu 90 % des Schlaganfallrisikos erklären. Bei asymptomatischen Karotisstenosen haben die Operation und das Stenting vergleichbare Komplikationsraten. Durch randomisierte Studien und große Register hat sich gezeigt, dass sehr viel mehr Patienten als früher für eine systemische Thrombolyse mit rt-PA zugänglich sind. Dies betrifft Patienten im Alter > 80 Jahre, Patienten mit schweren Schlaganfällen und Patienten mit einem systolischen Blutdruck > 160 mmHg. Auch Patienten mit Dissektionen der hirnversorgenden Arterien profitieren von einer Lyse. Die Lyse kann auch bei Einnahme von nicht-Vitamin-K-abhängigen oralen Antikoagulanzien (NOAKs) durchgeführt werden, wenn die letzte Einnahme solange zurückliegt, dass die Gerinnungswerte normal sind. Die wirksamste Therapie distaler Karotisverschlüsse und Verschlüsse der proximalen Arteria cerebri media ist die Lyse gefolgt von der mechanischen Thrombektomie mit einer NNT von 2,6 für einen guten Outcome. Der Thrombozytenfunktionshemmer Ticagrelor war in der frühen Prävention des ischämischen Schlaganfalls oder nach Hochrisiko-TIA nicht wirksamer als Azetylsalizylsäure für den kombinierten vaskulären Endpunkt aus Schlaganfall, Myokardinfarkt und vaskulärem Tod. Diese Substanz verhinderte allerdings signifikant ischämische Insulte. Bei der Therapie zerebraler Blutungen ist bei hohen Blutdruckwerten die Blutdrucksenkung nur marginal wirksam. In der Therapie von durch Vitamin-K-Antagonisten induzierten zerebralen Blutungen ist Prothrombinkomplex (PPSB) besser wirksam als fresh frozen plasma (FFP). Der Verschluss eines offenen Foramen ovale bei Patienten mit kryptogenem Schlaganfall ist nur in Ausnahmefällen gerechtfertigt.

Abstract

This review summarizes new findings on epidemiology, diagnosis, acute therapy, primary and secondary prevention of stroke published in 2015 and 2016. Recent epidemiological studies show that treatable risk factors such as hypertension, diabetes mellitus, smoking, physical inactivity, nutrition and stress can explain 90 % of stroke risk. In patients with asymptomatic high degree carotid stenosis, stenting has a similar complication rate as endarterectomy. New randomised studies and results from large-scale registries indicate that systemic thrombolysis of acute ischemic stroke can be safely performed in more patients than originally labelled for. This applies to patients > 80 years, with severe strokes or with systolic blood pressure values > 160 mmHg. Patients with dissection of brain supplying arteries also benefit from thrombolysis. In patients treated with non-vitamin-K dependent oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF), thrombolysis can be performed if the last intake was ago long enough that coagulation parameters are normal. The most effective treatment of acute occlusions of the distal internal carotid artery and the proximal middle cerebral artery is systemic thrombolysis with rt-PA followed by mechanical thrombectomy with a stent-retriever (number needed to treat = 2.6 for good functional outcome). In patients with mild to moderate ischemic stroke or high-risk TIA, ticagrelor was not superior to aspirin in the prevention recurrent stroke, MI or vascular death. However, ticagrelor was superior to aspirin in preventing recurrent ischemic stroke. In patients with acute cerebral haemorrhage and high blood pressure, lowering of blood pressure has only minor efficacy. In patients with vitamin-K antagonist related intracerebral haemorrhage, Prothrombin complex concentrate (PPSB) is more effective than fresh frozen plasma (FFP). Occlusion of patent foramen ovale in patients with cryptogenic stroke should be restricted to selected cases.

Schlüsselwörter

Schlaganfall - Prävention - Akuttherapie - zerebrale Blutung - offenes Foramen ovale

Keywords

stroke - prevention - acute therapy - cerebral haemorrhage - patent foramen ovale

• Literatur

• 1 Feigin VL, Krishnamurthi RV, Parmar P et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990 – 2013: The GBD 2013 Study. Neuroepidemiology 2015; 45: 161-176
• 2 Feigin VL, Roth GA, Naghavi M et al. Global burden of stroke and risk factors in 188 countries, during 1990 – 2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol 2016; 15: 913-924
• 3 OʼDonnell MJ, Chin SL, Rangarajan S et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016; 388: 761-775
• 4 Moerch-Rasmussen A, Nacu A, Waje-Andreassen U et al. Recurrent ischemic stroke is associated with the burden of risk factors. Acta Neurol Scand 2016; 133: 289-294
• 5 Turakhia MP, Ziegler PD, Schmitt SK et al. Atrial fibrillation burden and short-term risk of stroke: case-crossover analysis of continuously recorded heart rhythm from cardiac electronic implanted devices. Circ Arrhythm Electrophysiol 2015; 8: 1040-1047
• 6 Network NSG, International Stroke Genetics C. Loci associated with ischaemic stroke and its subtypes (SiGN): a genome-wide association study. Lancet Neurol 2015; Dec 18. pii: S1474-4422(15)00338-5 DOI: 10.1016/S1474-4422(15)00338-5. (Epub ahead of print)
• 7 dʼEsterre CD, Boesen ME, Ahn SH et al. Time-dependent computed tomographic perfusion thresholds for patients with acute ischemic stroke. Stroke 2015; 46: 3390-3397
• 8 Herweh C, Ringleb PA, Rauch G et al. Performance of e-ASPECTS software in comparison to that of stroke physicians on assessing CT scans of acute ischemic stroke patients. Int J Stroke 2016; 11: 438-445
• 9 Katsanos AH, Giannopoulos S, Frogoudaki A et al. The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis. Eur J Neurol 2016; 23: 569-579
• 10 Xie X, Atkins E, Jicheng Lv et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet 2016; 387: 435-443
• 11 Group SR, Wright Jr JT, Williamson JD et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373: 2103-2016
• 12 Brott TG, Howard G, Roubin GS et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med 2016; 374: 1021-1031
• 13 Rosenfield K, Matsumura JS, Chaturvedi S et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med 2016; 374: 1011-1020
• 14 Gumbinger C, Reuter B, Hacke W et al. Restriction of therapy mainly explains lower thrombolysis rates in reduced stroke service levels. Neurology 2016; 86: 1975-1983
• 15 Emberson J, Lees KR, Lyden P et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384: 1929-1935
• 16 Fassbender K, Balucani C, Walter S et al. Streamlining of prehospital stroke management: the golden hour. Lancet Neurol 2013; 12: 585-596
• 17 Heuschmann PU, Busse O, Wagner M et al. Schlaganfallhäufigkeit und Versorgung von Schlaganfallpatienten in Deutschland (Frequency and Care of Stroke in Germany). Akt Neurol 2010; 37: 333-340
• 18 Ebinger M, Kunz A, Wendt M et al. Effects of golden hour thrombolysis: a Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) substudy. JAMA Neurol 2015; 72: 25-30
• 19 Kunz A, Ebinger M, Geisler F et al. Functional outcomes of pre-hospital thrombolysis in a mobile stroke treatment unit compared with conventional care: an observational registry study. Lancet Neurol 2016; 15: 1035-1043
• 20 Itrat A, Taqui A, Cerejo R et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol 2016; 73: 162-168
• 21 Warach S. Prehospital thrombolysis for stroke: an idea whose golden hour has arrived. JAMA Neurol 2015; 72: 9-10
• 22 International Stroke Trial-3 collaborative group. Association between brain imaging signs, early and late outcomes, and response to intravenous alteplase after acute ischaemic stroke in the third International Stroke Trial (IST-3): secondary analysis of a randomised controlled trial. Lancet Neurol 2015; 14: 485-496
• 23 Lindley RI, Wardlaw JM, Whiteley WN et al. Alteplase for acute ischemic stroke: outcomes by clinically important subgroups in the Third International Stroke Trial. Stroke 2015; 46: 746-756
• 24 Romano JG, Smith EE, Liang L et al. Outcomes in mild acute ischemic stroke treated with intravenous thrombolysis: a retrospective analysis of the get with the Guidelines-Stroke registry. JAMA Neurol 2015; 72: 423-431
• 25 Weimar C, Kraywinkel K, Hagemeister C et al. Recurrent stroke after cervical artery dissection. J Neurol Neurosurg Psychiatry 2012; 81: 869-873
• 26 Tsivgoulis G, Zand R, Katsanos AH et al. Safety and outcomes of intravenous thrombolysis in dissection-related ischemic stroke: an international multicenter study and comprehensive meta-analysis of reported case series. J Neurol 2015; 262: 2135-2143
• 27 Goyal N, Tsivgoulis G, Zand R et al. Systemic thrombolysis in acute ischemic stroke patients with unruptured intracranial aneurysms. Neurology 2015; 85: 1452-1458
• 28 Neumann-Haefelin T, Hoelig S, Berkefeld J et al. Leukoaraiosis is a risk factor for symptomatic intracerebral hemorrhage after thrombolysis for acute stroke. Stroke 2006; 37: 2463-2466
• 29 Fiehler J, Albers GW, Boulanger JM et al. Bleeding risk analysis in stroke imaging before thromboLysis (BRASIL): pooled analysis of T2*-weighted magnetic resonance imaging data from 570 patients. Stroke 2007; 38: 2738-2744
• 30 Koennecke HC. Cerebral microbleeds on MRI: prevalence, associations, and potential clinical implications. Neurology 2006; 66: 165-171
• 31 Tsivgoulis G, Zand R, Katsanos AH et al. Risk of symptomatic intracerebral hemorrhage after intravenous thrombolysis in patients with acute ischemic stroke and high cerebral microbleed burden: a meta-analysis. JAMA Neurol 2016; 73: 675-683
• 32 Lin Q, Li Z, Wei R et al. Increased risk of post-thrombolysis intracranial hemorrhage in acute ischemic stroke patients with leukoaraiosis: a meta-analysis. PLoS One 2016; 11: e0153486
• 33 Diener HC, Foerch C, Riess H et al. Treatment of acute ischaemic stroke with thrombolysis or thrombectomy in patients receiving anti-thrombotic treatment. Lancet Neurol 2013; 12: 677-688
• 34 Ebner M, Peter A, Spencer C et al. Point-of-care testing of coagulation in patients treated with non-vitamin K antagonist oral anticoagulants. Stroke 2015; 46: 2741-2747
• 35 Berrouschot J, Stoll A, Hogh T et al. Intravenous thrombolysis with recombinant tissue-type plasminogen activator in a stroke patient receiving dabigatran anticoagulant after antagonization with idarucizumab. Stroke 2016; 47: 1936-1938
• 36 Diener HC, Bernstein R, Butcher K et al. Thrombolysis and thrombectomy in patients treated with dabigatran with acute ischemic stroke: Expert opinion. Int J Stroke 2016 Sep 30. pii: 1747493016669849. [Epub ahead of print]
• 37 Diener H, Darius H, Greinacher A et al. Idarucizumab, ein Gegenmittel von Dabigatran. Arzneimitteltherapie 2016 34.
• 38 Rother J, Schellinger PD, Gass A et al. Effect of intravenous thrombolysis on MRI parameters and functional outcome in acute stroke < 6 hours. Stroke 2002; 33: 2438-2445
• 39 Riedel CH, Zimmermann P, Jensen-Kondering U et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 2011; 42: 1775-1777
• 40 Ringleb P, Hamann G, Röther J et al. S2 Leitlinie Akuttherapie des ischämischen Schlaganfalls – Ergänzung 2015 – Rekanalisierende Therapie. 2015
• 41 Badhiwala JH, Nassiri F, Alhazzani W et al. Endovascular thrombectomy for acute ischemic stroke: a meta-analysis. JAMA 2015; 314: 1832-1843
• 42 Goyal M, Menon BK, van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387: 1723-1731
• 43 van den Berg LA, Koelman DL, Berkhemer OA et al. Type of anesthesia and differences in clinical outcome after intra-arterial treatment for ischemic stroke. Stroke 2015; 46: 1257-1262
• 44 Schonenberger S, Mohlenbruch M, Pfaff J et al. Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – a randomized monocentric trial. Int J Stroke 2015; 10: 969-978
• 45 Schonewille WJ, Wijman CA, Michel P et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 2009; 8: 724-730
• 46 Kumar G, Shahripour RB, Alexandrov AV. Recanalization of acute basilar artery occlusion improves outcomes: a meta-analysis. J Neurointerv Surg 2014; 7: 868-874
• 47 Phan K, Phan S, Huo YR et al. Outcomes of endovascular treatment of basilar artery occlusion in the stent retriever era: a systematic review and meta-analysis. J Neurointerv Surg 2016; 8: 1107-1115
• 48 van Houwelingen RC, Luijckx GJ, Mazuri A et al. Safety and outcome of intra-arterial treatment for basilar artery occlusion. JAMA Neurol 2016; 73: 1225-1230
• 49 Rothwell PM, Algra A, Chen Z et al. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet 2016; 388: 135-375
• 50 Kwok CS, Shoamanesh A, Copley HC et al. Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke: pooled analysis of randomized trials. Stroke 2015; 46: 1014-1023
• 51 Palacio S, Hart RG, Pearce LA et al. Effect of addition of clopidogrel to aspirin on stroke incidence: Meta-analysis of randomized trials. Int J Stroke 2015; 10: 686-691
• 52 Bonaca MP, Bhatt DL, Cohen M et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015; 372: 1791-1800
• 53 Johnston SC, Amarenco P, Albers GW et al. Ticagrelor versus aspirin in acute stroke or transient ischemic attack. N Engl J Med 2016; 375: 35-43
• 54 Johnston SC, Easton JD, Farrant M et al. Platelet-oriented inhibition in new TIA and minor ischemic Stroke (POINT) trial: Rationale and design. Int J Stroke 2013; 8: 479-483
• 55 Wang Y, Wang Y, Zhao X et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013; 369: 11-19
• 56 Diener H, Bogousslavsky J, Brass L et al. Acetylsalicylic acid on a background of clopidogrel in high-risk patients randomised after recent ischaemic stroke or transient ischaemic attack: The MATCH trial results. Lancet 2004; 364: 331-334
• 57 Ntaios G, Papavasileiou V, Diener HC et al. Nonvitamin-K-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials. Stroke 2012; 43: 3298-3304
• 58 Giugliano RP, Ruff CT, Braunwald E et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369: 2093-2104
• 59 Arihiro S, Todo K, Koga M et al. Three-month risk-benefit profile of anticoagulation after stroke with atrial fibrillation: The SAMURAI-Nonvalvular Atrial Fibrillation (NVAF) study. Int J Stroke 2016; 11: 565-574
• 60 Chan KE, Edelman ER, Wenger JB et al. Dabigatran and rivaroxaban use in atrial fibrillation patients on hemodialysis. Circulation 2015; 131: 972-979
• 61 Hart RG, Diener HC, Coutts SB et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13: 429-438
• 62 Sanna T, Diener HC, Passman RS et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478-2486
• 63 Diener HC, Easton JD, Granger CB et al. Design of randomized, double-blind, evaluation in secondary stroke prevention comparing the efficacy and safety of the oral thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with embolic stroke of undetermined source (RE-SPECT ESUS). Int J Stroke 2015; 10: 1309-1312
• 64 Brott TG, Howard G, Roubin GS et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med 2016; 374: 1021-1031
• 65 Howard G, Roubin GS, Jansen O et al. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials. Lancet 2016; 387: 1305-1311
• 66 Chimowitz MI, Lynn MJ, Derdeyn CP et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011; 365: 993-1003
• 67 Derdeyn CP, Chimowitz MI, Lynn MJ et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet 2014; 383: 333-341
• 68 Lutsep HL, Barnwell SL, Larsen DT et al. Outcome in patients previously on antithrombotic therapy in the SAMMPRIS trial: subgroup analysis. Stroke 2015; 46: 775-759
• 69 Zaidat OO, Fitzsimmons BF, Woodward BK et al. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA 2015; 313: 1240-1248
• 70 Compter A, van der Worp HB, Schonewille WJ et al. Stenting versus medical treatment in patients with symptomatic vertebral artery stenosis: a randomised open-label phase 2 trial. Lancet Neurol 2015; 14: 606-614
• 71 Mant J, McManus RJ, Roalfe A et al. Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke-Blood Pressure) randomised controlled trial. BMJ 2016; 352: i708
• 72 Wang WT, You LK, Chiang CE et al. Comparative effectiveness of blood pressure-lowering drugs in patients who have already suffered from stroke: traditional and Bayesian network meta-analysis of randomized trials. Medicine (Baltimore) 2016; 95: e3302
• 73 Sillesen H, Amarenco P, Hennerici MG et al. Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Stroke 2008; 39: 3297-3302
• 74 Scheitz JF, MacIsaac RL, Abdul-Rahim AH et al. Statins and risk of poststroke hemorrhagic complications. Neurology 2016; 86: 1590-1596
• 75 Palmer SC, Mavridis D, Nicolucci A et al. Comparison of clinical outcomes and adverse events associated with glucose-lowering drugs in patients with type 2 diabetes: a meta-analysis. JAMA 2016; 316: 313-324
• 76 Kernan WN, Viscoli CM, Furie KL et al. Pioglitazone after ischemic stroke or transient ischemic attack. N Engl J Med 2016; 374: 1321-1331
• 77 Anderson CS, Heeley E, Huang Y et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368: 2355-2365
• 78 Arima H, Heeley E, Delcourt C et al. Optimal achieved blood pressure in acute intracerebral hemorrhage: INTERACT2. Neurology 2015; 84: 464-471
• 79 Qureshi AI, Palesch YY, Barsan WG et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; 375: 1033-1043
• 80 Ziai WC, Tuhrim S, Lane K et al. A multicenter, randomized, double-blinded, placebo-controlled phase III study of Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III). Int J Stroke 2014; 9: 536-542
• 81 Baharoglu MI, Cordonnier C, Salman RA et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 2016; 387: 2605-2613
• 82 Steiner T, Poli S, Griebe M et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol 2016; 15: 566-573
• 83 Pollack Jr CV, Reilly PA, Eikelboom J et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015; 373: 511-520
• 84 Chao TF, Liu CJ, Liao JN et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation 2016; 133: 1540-1547
• 85 Dubosh NM, Bellolio MF, Rabinstein AA et al. Sensitivity of early brain computed tomography to exclude aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Stroke 2016; 47: 750-755
• 86 Mule S, Soize S, Benaissa A et al. Detection of aneurysmal subarachnoid hemorrhage 3 months after initial bleeding: evaluation of T2* and FLAIR MR sequences at 3 T in comparison with initial non-enhanced CT as a gold standard. J Neurointerv Surg 2016; 8: 813-818
• 87 Molyneux AJ, Birks J, Clarke A et al. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet 2015; 385: 691-697
• 88 Holmes Jr DR, Doshi SK, Kar S et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol 2015; 65: 2614-2623
• 89 Kuramatsu JB, Gerner ST, Schellinger PD et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015; 313: 824-836
• 90 Johnsen S. Left atrial appendage occlusion versus standard medical care in patients with atrial fibrillation and intracerebral hemorrhage: a propensity score matched follow-up study. Barcelona: European Stroke Organisation Conference; 2016 may 11
• 91 Carroll JD, Saver JL, Thaler DE et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368: 1092-1100
• 92 Furlan AJ, Reisman M, Massaro J et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991-999
• 93 Serena J, Marti-Fabregas J, Santamarina E et al. Recurrent stroke and massive right-to-left shunt: results from the prospective Spanish multicenter (CODICIA) study. Stroke 2008; 39: 3131-3136
• 94 Mas JL, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J 1995; 130: 1083-1088
• 95 Meier B, Kalesan B, Mattle HP et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083-1091
• 96 Messe SR, Gronseth G, Kent DM et al. Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter): Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016; 87: 815-821
• 97 Kent DM, Dahabreh IJ, Ruthazer R et al. Device Closure of Patent Foramen Ovale After Stroke: Pooled Analysis of Completed Randomized Trials. J Am Coll Cardiol 2016; 67: 907-917
• 98 Li J, Liu J, Liu M et al. Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack. Cochrane Database Syst Rev 2015 CD009938
• 99 Carroll J. RESPECT: a prospective randomized trial of PFO closure in patients with cryptogenic stroke – long-term results. San Francisco: Transcatheter Cardiovascular Therapeutics; 2015
• 100 Friberg L, Tabrizi F, Englund A. Catheter ablation for atrial fibrillation is associated with lower incidence of stroke and death: data from Swedish health registries. Eur Heart J 2016; 3: 2478-2487
• 101 Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Endorsed by the European Stroke Organisation (ESO). Eur Heart J 2016 Aug 27. pii: ehw210. [Epub ahead of print]