J Clin Neurol.  2010 Dec;6(4):212-215. 10.3988/jcn.2010.6.4.212.

Transient Increase in Intrathoracic Pressure as a Contributing Factor to Cardioembolic Stroke

• Seok HY
• Seo WK
• Eun MY
• Kwon DY
• Park MH
• Oh K

• KMID: 1462809
• DOI: http://doi.org/10.3988/jcn.2010.6.4.212

Abstract

BACKGROUND
The hemodynamic effects of increased intrathoracic pressure (ITP) have been the focus of many investigations. However, very little is known about the effects of elevated ITP on the occurrence of stroke.
CASE REPORT
Four young patients with a cardioembolic source of stroke were examined. In all cases the stroke was preceded by an increase in ITP that occurred during coughing, vomiting, or sexual intercourse.
CONCLUSIONS
We suggest that cardioembolic stroke is facilitated by situations in which ITP is elevated.

Keyword

stroke; intrathoracic pressure; embolism

MeSH Terms

Cough
Embolism
Hemodynamics
Humans
Stroke
Vomiting

Figure

• 

  Fig. 1 Diffusion-weighted MRI in four patients. A: Case 1 had infarcts in the distribution of the right middle cerebral artery. B: Case 2 had an infarct in the left insular cortex. C: Case 3 had a left posterior cerebral artery territory infarct with involvement of the occipital lobe. D: Case 4 had infarcts in the distribution of the left middle cerebral artery.

• 

  Fig. 2 Transthoracic echocardiogram in case 2. Apical four-chamber view showing flow acceleration and a left-to-right shunt across the interatrial septum on color Doppler examination (arrow).

• 

  Fig. 3 Transesophageal echocardiogram in case 4. A small movable mass can be seen attached to aortic valve (arrow). The lesion exhibited homogeneous hyperechogenicity. The echographic characteristics are highly suggestive of papillary fibroelastoma.

Reference

1. Sharpey-Schafer EP. Effects of Valsalva's manoeuvre on the normal and failing circulation. Br Med J. 1955. 1:693–695.

2. Uwatoko T, Toyoda K, Fujimoto S, Yasaka M, Ibayashi S, Iida M, et al. [Behavioral situation at onset of paradoxical brain embolism due to patent foramen ovale]. Rinsho Shinkeigaku. 2004. 44:503–507.

3. Evers S, Henningsen H, Ringelstein EB. Transient ischemic attacks caused by trumpet playing. Neurology. 1998. 51:1709–1710.

4. Becker K, Skalabrin E, Hallam D, Gill E. Ischemic stroke during sexual intercourse: a report of 4 cases in persons with patent foramen ovale. Arch Neurol. 2004. 61:1114–1116.

5. Head CE, Thorne SA. Congenital heart disease in pregnancy. Postgrad Med J. 2005. 81:292–298.

6. Okayasu H, Wakayama Y, Takahashi H, Jimi T. [A case of cough hemiplegia]. Rinsho Shinkeigaku. 1993. 33:740–745.

7. Tiecks FP, Lam AM, Matta BF, Strebel S, Douville C, Newell DW. Effects of the valsalva maneuver on cerebral circulation in healthy adults. A transcranial Doppler Study. Stroke. 1995. 26:1386–1392.

8. Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol. 1998. 55:1475–1482.

9. Gray C, Ward JF, Sands JP. Syncope from increased ventricular response in atrial fibrillation during voiding: a new indication for surgical management in benign prostatic hyperplasia. J Urol. 1999. 161:606–607.

10. Nagayoshi H, Janota T, Hnatkova K, Camm AJ, Malik M. Autonomic modulation of ventricular rate in atrial fibrillation. Am J Physiol. 1997. 272:H1643–H1649.