Spontaneous large right-to-left shunt and migraine headache with aura are risk factors for recurrent stroke in patients with a patent foramen ovale (original) (raw)
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Recurrent stroke and patent foramen ovale: a systematic review and meta-analysis
Stroke; a journal of cerebral circulation, 2014
T he frequency of patent foramen ovale (PFO) in the general population has been estimated to be 15% to 35%. 1 In patients with cryptogenic stroke, PFO is more common, but a clear causative relationship is not well established. 2 Recurrent cerebrovascular events are frequent in medically treated patients with a history of paradoxical embolism 3 ; however, in more than one third of these patients concurrent pathogeneses (other than the sole presence of PFO) are identified. 4,5 Thus, it still remains unclear whether PFO is causally related to firstever or recurrent cerebral ischemia or constitutes an incidental finding of diagnostic work-up. 6,7 PFO size and the degree of functional shunting could represent potential risk factors for cerebral ischemia in medically treated patients with PFO. 8 PFOs in patients with cerebral ischemia are thought to be larger 9 and to be more frequently associated with atrial septal aneurysms, compared with the PFOs in asymptomatic patients. 10 Moreover, in transcranial Doppler (TCD) studies, large PFOs were found to be significantly associated with more microembolic signals compared with small PFOs. 11,12 However, data from other studies suggest that the shunt grade assessed with TCD is not associated with the brain infarct volume on computed tomography 13 and that Background and Purpose-Recurrent cerebrovascular events are frequent in medically treated patients with patent foramen ovale (PFO), but it still remains unclear whether PFO is a causal or an incidental finding. Further uncertainty exists on whether the size of functional shunting could represent a potential risk factor. The aim of the present study was to evaluate if the presence of PFO is associated with an increased risk of recurrent stroke or transient ischemic attack and to investigate further if this relationship is related to the shunt size.
Stroke, 2008
on Behalf of the CODICIA (Right-to-Left Shunt in Cryptogenic Stroke) Study; for the Stroke Project of the Cerebrovascular Diseases Study Group, Spanish Society of Neurology Background and Purpose-Few studies have prospectively examined the risk of recurrent stroke associated with patent foramen ovale. We present the results of the Spanish right-to-left shunt (RLSh) multicenter study. Methods-Four hundred eighty-six patients with cryptogenic stoke were included at 17 participating hospitals. Patients were examined by contrast transcranial Doppler methods at baseline. The magnitude of RLSh was quantified during the Valsalva maneuver. Transthoracic and/or transesophageal echocardiography, computed tomography scan, or magnetic resonance imaging was performed. Functional outcome and stroke recurrence were evaluated at 3 months and yearly thereafter. The independent relation between RLSh magnitude and stroke recurrence was analyzed by logistic-regression analysis in the whole group and in the younger subgroup (Ͻ55 years).
Patent Foramen Ovale May Be Causal for the First Stroke but Unrelated to Subsequent Ischemic Events
Stroke, 2011
Background and Purpose-Studies with very long follow-up are scarce in patients with cryptogenic stroke and patent foramen ovale (PFO). Little is known about the etiology of recurrent cerebrovascular events (CVE) in PFO patients. Methods-We collected information on recurrent CVE in 308 patients with cryptogenic stroke and PFO and sought to determine concurrent stroke causes that had emerged or been newly detected since the index event. One hundred fifty-eight patients received aspirin (48%), clopidogrel (2%), or oral anticoagulants (50%; medical group). One hundred fifty patients underwent percutaneous PFO closure (closure group).
Echocardiography-a Journal of Cardiovascular Ultrasound and Allied Techniques, 2015
Background and Purpose: Cardio-embolic phenomenon is believed to underlie a significant proportion of cryptogenic strokes. We recently showed that intrapulmonary shunt (IPS) was associated with cryptogenic stroke and transient ischemic attack (TIA). We hypothesized that patients with prior cryptogenic stroke or TIA that had an IPS were at a higher risk for recurrent ischemic events. Methods: The population included subjects with cryptogenic cerebrovascular accident (CVA) or TIA. Inclusion criteria were age ≥18 years, sinus rhythm, and clinically indicated transesophageal echocardiography (TEE). Exclusion criteria were hemorrhagic CVA, septal defect, and patent foramen. Patients were followed from index TEE. Results: Of 71 patients, 8 were lost to follow-up. A total of 23 patients had and 40 were without IPS. Average follow-up duration was 38.3 AE 19.2 months. Groups were similar at baseline. There was no significant difference in the recurrence of ischemic CVA or TIA in the IPS versus non-IPS groups (0% vs. 7.5%; P = NS). There was no difference between the incidence of hemorrhagic CVA in the IPS and non-IPS groups (4.3% vs. 5.0%; P = NS). The proportion of patients on warfarin in the IPS group was significantly higher compared to the non-IPS group (17.4% vs. 0%; P < 0.05). Conclusions: Patients with IPS and cryptogenic stroke or TIA did not have a higher recurrence of ischemic cerebral events. Warfarin was significantly higher at follow-up in the IPS compared to the non-IPS group, which may explain these findings. A study randomizing patients with IPS and cryptogenic stroke or TIA to warfarin or no warfarin would be of great interest.
Recurrent Stroke and Massive Right-to-Left Shunt
Stroke, 2008
Background and Purpose— Few studies have prospectively examined the risk of recurrent stroke associated with patent foramen ovale. We present the results of the Spanish right-to-left shunt (RLSh) multicenter study. Methods— Four hundred eighty-six patients with cryptogenic stoke were included at 17 participating hospitals. Patients were examined by contrast transcranial Doppler methods at baseline. The magnitude of RLSh was quantified during the Valsalva maneuver. Transthoracic and/or transesophageal echocardiography, computed tomography scan, or magnetic resonance imaging was performed. Functional outcome and stroke recurrence were evaluated at 3 months and yearly thereafter. The independent relation between RLSh magnitude and stroke recurrence was analyzed by logistic-regression analysis in the whole group and in the younger subgroup (<55 years). Results— Massive RLSh was detected in 200 patients (41.2%). The mean follow-up was 729±411 days. Stroke recurrence was low (5.8%, n=2...
An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke
Neurology, 2013
Objective: We aimed to create an index to stratify cryptogenic stroke (CS) patients with patent foramen ovale (PFO) by their likelihood that the stroke was related to their PFO. Methods: Using data from 12 component studies, we used generalized linear mixed models to predict the presence of PFO among patients with CS, and derive a simple index to stratify patients with CS. We estimated the stratum-specific PFO-attributable fraction and stratum-specific stroke/TIA recurrence rates. Results: Variables associated with a PFO in CS patients included younger age, the presence of a cortical stroke on neuroimaging, and the absence of these factors: diabetes, hypertension, smoking, and prior stroke or TIA. The 10-point Risk of Paradoxical Embolism score is calculated from these variables so that the youngest patients with superficial strokes and without vascular risk factors have the highest score. PFO prevalence increased from 23% (95% confidence interval [CI]: 19%-26%) in those with 0 to 3 points to 73% (95% CI: 66%-79%) in those with 9 or 10 points, corresponding to attributable fraction estimates of approximately 0% to 90%. Kaplan-Meier estimated stroke/TIA 2-year recurrence rates decreased from 20% (95% CI: 12%-28%) in the lowest Risk of Paradoxical Embolism score stratum to 2% (95% CI: 0%-4%) in the highest. Conclusion: Clinical characteristics identify CS patients who vary markedly in PFO prevalence, reflecting clinically important variation in the probability that a discovered PFO is likely to be stroke-related vs incidental. Patients in strata more likely to have stroke-related PFOs have lower recurrence risk. Neurology â 2013;81:619-625 GLOSSARY auROC 5 area under the receiver operating characteristic curve; CS 5 cryptogenic stroke; PFO 5 patent foramen ovale; RoPE 5 Risk of Paradoxical Embolism. Case-control studies suggest that patent foramen ovale (PFO) is a common cause of cryptogenic stroke (CS), likely through a paradoxical (venous-to-arterial) embolism. 1,2 However, CS has many potential causes, and PFO is a common anatomical variant found in approximately 25% of the general population. 3 Thus, a PFO discovered in the setting of a CS may be incidental or stroke-related. Percutaneous mechanical closure of a PFO is frequently considered in patients with CS and PFO. The recently reported CLOSURE trial, however, found no benefit for this approach over medical therapy. 4 Nonetheless, stroke recurrence rates were low overall (limiting statistical power) and most stroke recurrence in both treatment groups was due to stroke of known mechanism, suggesting that many patients with incidental PFOs may have been enrolled. The premise of the Risk of Paradoxical Embolism (RoPE) Study 3 is that only patients with a high attributable recurrence risk have the opportunity to benefit from PFO closure for secondary
Recurrent Stroke/TIA in Cryptogenic Stroke Patients with Patent Foramen Ovale
The Canadian Journal of Neurological Sciences, 2007
Background:Patent foramen ovale (PFO) is present in 40% of patients with cryptogenic stroke and may be associated with paradoxical emboli to the brain. Therapeutic options include antiplatelet agents, anticoagulation, percutaneous device and surgical closure. We assessed the hypothesis that there are differences in rates of recurrent TIA or stroke between patients in the four treatment groups.Methods:Patients presenting from January 1997 with cryptogenic stroke or TIA and PFO were followed prospectively until June 2003. Treatment choice was made on an individual case basis. The primary outcome was recurrent stroke. The secondary outcome was a composite of stroke, TIA, and vascular death.Results:Baseline. Our cohort consisted of 121 patients; 64 (53%) were men. Median age was 43 years. Sixty-nine percent presented with stroke and 31% with TIA. One or more vascular risk factor was present in 40%. Atrial septal aneurysm (ASA) was present in 24%. Treatment consisted of antiplatelet agen...