Outcome of patients with cryptogenic stroke and patent foramen ovale

Nedeltchev, Krassen; Arnold, Marcel; Wahl, Andreas; Sturzenegger, Matthias; Vella, E. E.; Windecker, Stephan; Meier, Bernhard; Mattle, Heinrich

doi:10.1136/jnnp.72.3.347

Cited by 79 publications

(53 citation statements)

References 21 publications

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“…Observational studies in this patient population undergoing medical treatment with either antiplatelet therapy or oral anticoagulation reported a risk of recurrent stroke or TIA ranging from 3.4% to 12% during the first year. 12,18,34,[41][42][43][44] Homma and Sacco 38 recently summarized the results of 9 studies of medical treatment in 943 cryptogenic stroke patients and observed an annual risk of recurrent stroke or TIA of 4.2% (95% CI, 3.4% to 5.0%) and of recurrent stroke, TIA, or death of 4.9% (95% CI, 3.8% to 5.9%). Of note, in trials with both antiplatelet therapy and oral anticoagulation, the risk of recurrence appeared lower with the latter.…”

Section: Risk Of Recurrencementioning

confidence: 99%

Patent Foramen Ovale and Cryptogenic Stroke: To Close or Not to Close? Closure: What Else!

Windecker

Meier

2008

Circulation

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A 39-year-old mother of 2 teenage boys complained of severe migraine with aura for Ͼ10 years. Otherwise healthy, she suffered an ischemic stroke that rendered her permanently aphasic. Diagnostic evaluation revealed no evidence of atherosclerosis of the carotid arteries or plaques of the ascending aorta and the aortic arch. The ECG showed normal sinus rhythm, and the patient denied any history of palpitations or arrhythmias. Echocardiography documented normal ventricular function without wall motion abnormalities or evidence of thrombus and normal-appearing valves but a large patent foramen ovale (PFO). The most likely clinical diagnosis is stroke due to paradoxical embolism. The patient's neurologist recommended PFO closure. However, guidelines regarding PFO closure from professional societies remain ambiguous because of insufficient evidence regarding therapeutic measures (Table 1). 1,2 Response by Messé and Kasner p 1998Stroke is the third leading cause of mortality and the most important cause of serious, long-term disability in developed countries. 3 The presented case is testimony to the sad sequelae of stroke that may deprive someone permanently of speech, an emotional and mental tragedy. A classic etiology is not found in up to 40% of ischemic strokes despite an extensive diagnostic evaluation. This is referred to as cryptogenic stroke, a term that strangely ignores the role of the PFO. 4 The foramen ovale is an opening in the atrial septum secundum, with the septum primum functioning as a 1-way valve allowing right-to-left shunt during in utero development. The postnatal decrease in right atrial pressure results first in functional followed by anatomic closure in the ensuing months. Autopsy studies show that fusion of the 2 septae fails to occur in Ϸ1 of 4 people. 5 This is referred to as PFO and represents the most common congenital abnormality. 6 Paradoxical embolism via a PFO has been documented as a stroke mechanism, 7-10 and therapeutic measures aimed at secondary prevention intend to eliminate thrombus formation or its embolization. [11][12][13][14] In the United States, nearly 800 000 strokes occur yearly, of which 10% to 40% are presumed to be cryptogenic (according to the old definition that does not take into account the PFO). Of these, 50% of patients have a PFO. 3 Accordingly, 40 000 to 160 000 of strokes may be attributable to PFO per annum. Association by Chance or Cause-and-Effect RelationshipPart of the controversy surrounding percutaneous PFO closure relates to the fact that paradoxical embolism is rarely a

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Section: Risk Of Recurrencementioning

confidence: 99%

Patent Foramen Ovale and Cryptogenic Stroke: To Close or Not to Close? Closure: What Else!

Windecker

Meier

2008

Circulation

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“…Therapeutic options range from antiplatelet therapy and anticoagulation to surgical or endovascular closure of the atrial shunt and reports have varied considerably (between 0 and 19%) for annual risk of recurrent stroke or TIA. 6,21,[27][28][29][30][31][32] Thus, optimal management of these patients remains a difficult challenge.…”

Section: R E T I R E D R E T I R E Dmentioning

confidence: 99%

Practice Parameter: Recurrent stroke with patent foramen ovale and atrial septal aneurysm: [RETIRED]

et al. 2004

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Abstract-Objectives: 1) To evaluate the risk of subsequent stroke or death in patients with a cryptogenic stroke and a patent foramen ovale (PFO), atrial septal aneurysm (ASA), or both. 2) To establish the optimal method of stroke prevention in this population of patients. Methods: MEDLINE, the Cochrane database of systematic reviews, key meeting abstracts from 1997 to 2002, and relevant reference lists were searched to select studies that prospectively collected outcome data in cryptogenic stroke patients with and without interatrial septal abnormalities. Studies were also selected that prospectively compared at least two treatment options. The quality of each study was graded (class I to IV) using a standard classification-of-evidence scheme for each question. Risk analyses were performed and data were pooled when appropriate. Results: The literature search generated 129 articles of which only four fulfilled the inclusion and exclusion criteria. Two studies were graded class I, one study was graded class II, and one study was graded class IV for prognosis. Pooled results of the two class I and one class II studies demonstrated no increased risk of subsequent stroke or death in patients with PFO compared to those without (RR ϭ 0.95, 95% CI 0.62 to 1.44). One class I study found increased risk of recurrent stroke in patients with PFO and ASA (annual rate ϭ 3.8% versus 1.05%, RR ϭ 2.98, 95% CI 1.17 to 7.58) but not increased risk of a composite of stroke and death (annual rate ϭ 3.8% versus 1.8%, RR ϭ 2.10, 95% CI 0.86 to 5.06). Regarding therapy, one study was graded class II, one study class III, and two studies class IV. Among patients with cryptogenic stroke and PFO or ASA, there was no significant difference in stroke or death rate in warfarin-treated patients relative to aspirin-treated patients and the confidence intervals were unable to rule out a benefit of one drug over the other (annual rate ϭ 4.7% versus 8.9%, RR ϭ 0.53, 95% CI 0.18 to 1.58). Minor bleeding rates were higher in the cohort of patients who received warfarin (22.9/100 patient-years versus 8.66/100 patient-years, rate ratio ϭ 2.64, p Ͻ 0.001). No studies compared medical therapy with surgical or endovascular closure. Conclusion: PFO is not associated with increased risk of subsequent stroke or death among medically treated patients with cryptogenic stroke. However, both PFO and ASA possibly increase the risk of subsequent stroke (but not death) in medically treated patients younger than 55 years. In patients with a cryptogenic stroke and an atrial septal abnormality the evidence is insufficient to determine if warfarin or aspirin is superior in preventing recurrent stroke or death, but minor bleeding is more frequent with warfarin. There is insufficient evidence to evaluate the efficacy of surgical or endovascular closure. NEUROLOGY 2004;62:1042-1050 Mission statement. The Quality Standards Subcommittee (QSS) develops evidence based, clinically relevant guidelines to aid in the practice of neurology. This practice parameter assesses the r...

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“…Maybe the surgical or endovascular closure could be the best option in very young patients if we consider the risks of a long life anticoagulation or antiplatelet t h e r a p y. Indeed, the rate of re c u rrent cere b ro v a s c ular events during 2 to 3 years of antithrombotic treatment varies from 3.4% to 9.2%, but if there is ASA in addition to the PFO this risk could incre a s e to 9.0% for stroke and 22% for TIA and/or stroke in 2 years [7][8][9][10] . Recently, some reports have identified additional risk factors that increase the probability of re c u rrence of stroke among PFO patients, like a previous personal history of stroke or TIA, atrial septal hypermotibility, ASA combined with PFO, and the size of PFO7, [11][12][13] .…”

Section: Discussionmentioning

confidence: 99%

“…So, measures to prevent recurrence were of utmost importance. Currently, surgical or percutaneous device closure and medical therapy with long life anticoagulation or antiplatelet agents are the major choices to prevent recurrent strokes or TIA 7 . Maybe the surgical or endovascular closure could be the best option in very young patients if we consider the risks of a long life anticoagulation or antiplatelet t h e r a p y.…”

Section: Discussionmentioning

confidence: 99%

Patent foramen ovale in a cohort of young patients with cryptogenic ischemic stroke

Silva

Rodrigues

Tress³

et al. 2005

Arq. Neuro-Psiquiatr.

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OBJECTIVE: Although its role is a matter of debate, some studies described a higher prevalence of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) in young stroke patients, with higher risk with PFO / ASA association (OR 4.96). The aim of this study was determine the prevalence of PFO and ASA in a cohort of cryptogenic ischemic stroke (IS) patients younger than 55 years and to follow-up after surgical or percutaneous endovascular closure (PEC). METHOD: In 21 months we identified all patients less than 55 years old with IS who were admitted to our hospital. Cryptogenic IS was considered if there is not an identifiably cause to cerebral ischemia. Transesophageal echocardiography (TEE) was performed in all patients. After interatrial septal abnormalities diagnosis, percutaneous device closure was offered to all. Patients were followed monthly and keeped with oral AAS or Clopidogrel. RESULTS: We identified 189 patients with IS and 32 were less than 55 years old (16.9%). In 29 the IS was cryptogenic. TEE was performed in all patients and some form of interatrial septal abnormality was identified in 12 (12/29 - 41.3%); 5 had a PFO and in 7 there was PFO plus ASA. Ten patients were submitted to PEC and 2 were submitted to surgical closure. In mid-term follow-up (28 months) no ischemic events occurred and 2 patients related disappearance of migraine symptoms. CONCLUSION: Our small series description is in accordance with other studies and suggests a possible relation between interatrial septal abnormalities and IS in a cohort of young patient.

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Outcome of patients with cryptogenic stroke and patent foramen ovale

Cited by 79 publications

References 21 publications

Patent Foramen Ovale and Cryptogenic Stroke: To Close or Not to Close? Closure: What Else!

Patent Foramen Ovale and Cryptogenic Stroke: To Close or Not to Close? Closure: What Else!

Practice Parameter: Recurrent stroke with patent foramen ovale and atrial septal aneurysm: [RETIRED]

Patent foramen ovale in a cohort of young patients with cryptogenic ischemic stroke

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