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Peral Quirós, F. Acebrón, M.D.C. Blanco Valero, F. Labella Álvarez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Peral Quirós" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Acebrón" ] 2 => array:2 [ "nombre" => "M.D.C." "apellidos" => "Blanco Valero" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Labella Álvarez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173580821000821" "doi" => "10.1016/j.nrleng.2020.08.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580821000821?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485320302796?idApp=UINPBA00004N" "url" => "/02134853/0000003600000007/v1_202108290608/S0213485320302796/v1_202108290608/es/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "COVID-19 related strokes: <span class="elsevierStyleItalic">Pandora's Box may open as the p(c)lot thickens</span>!" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "562" "paginaFinal" => "563" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "R. Magoon" "autores" => array:1 [ 0 => array:3 [ "nombre" => "R." "apellidos" => "Magoon" "email" => array:1 [ 0 => "rohanmagoon21@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi 110001, India" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ictus y COVID-19: una nueva caja de Pandora" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">As I read through the interesting literature focusing on COVID-19 related strokes, featured recently in the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> my inquisitiveness regarding the involved mechanisms of neuro-invasion escalates. Moreover, as the COVID-related ‘clot’ thickens (a result of the pro-inflammatory hypercoagulable mileu), almost in close conjunction does the ‘plot’ thicken interrogating whether the direct consequences of disseminated intravascular coagulation can alone explain the intriguing findings of most COVID-associated strokes being ischemic in nature with many researchers also suggesting these cerebrovascular events to be unrelated to age and associated with few vascular risk factors.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this context, while the thrombo-embolic sequel of COVID-19 is being ardently discussed,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–4</span></a> paradoxical embolization into the cerebral circulation through an undetected probe patent foramen ovale (PPFO) (reported to be as common as 20–25% in the general population), can very well be an important contributing factor.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The premise for the same emanates from the comprehension of the fact that an ongoing inflammatory process leads to pulmonary arterial hypertension (aggravated by hypoxia, positive pressure ventilation and stiff-lung syndrome associated with COVID-19) culminating as accentuated right atrium (RA) pressures augmenting paradoxical embolization from the RA to left atrium (LA) through the PPFO (precluded in healthy subjects owing to the positive physiological LA-RA pressure gradient).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aforementioned constitutes a cardiac anaesthesiologists’ perspective on opening yet another Pandora's Box (referring to a PPFO in this case) concerning the mechanisms leading to stroke in COVID-19 (which in itself has evolved to be nothing less than a natures’ misadventurous stroke) highlighting the significance of a routine echocardiographic surveillance in this predisposed critically ill cohort.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contribution</span><p id="par0020" class="elsevierStylePara elsevierViewall">RM conceptualized and wrote the entire manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">We do not have any conflict of interest, any commercial or financial interest in this material & agree to abide by the rules of your journal regarding publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contribution" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ischaemic stroke and SARS-CoV-2 infection: a causal or incidental association?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Barrios-López" 1 => "I. Rego-García" 2 => "C. Muñoz Martínez" 3 => "J.C. Romero-Fábrega" 4 => "M. Rivero Rodríguez" 5 => "J.A. Ruiz Giménez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neurología (Engl Ed)" "fecha" => "2020" "volumen" => "35" "paginaInicial" => "295" "paginaFinal" => "302" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stroke as a complication and prognostic factor of COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Trejo Gabriel" 1 => "J.M. Galán" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neurología (Engl Ed)" "fecha" => "2020" "volumen" => "35" "paginaInicial" => "318" "paginaFinal" => "322" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COVID-19-related strokes in adults below 55 years of age: a case series" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Ashrafi" 1 => "A. Zali" 2 => "D. Ommi" 3 => "M. Salari" 4 => "A. Fatemi" 5 => "M. Arab-Ahmadi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10072-020-04521-3" "Revista" => array:6 [ "tituloSerie" => "Neurol Sci" "fecha" => "2020" "volumen" => "41" "paginaInicial" => "1985" "paginaFinal" => "1989" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32583169" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurologic features in severe SARS-CoV-2 infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Helms" 1 => "S. Kremer" 2 => "H. Merdji" 3 => "R. Clere-Jehl" 4 => "M. Schenck" 5 => "C. 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