Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention

Abstract

The patent foramen ovale (PFO), given its high prevalence in the general population and especially in patients with cryptogenic stroke, has long generated investigation and debate on its propensity for stroke by paradoxical embolism and its management for stroke prevention. The pendulum has swung for percutaneous PFO closure for secondary stroke prevention in cryptogenic stroke. Based on a review of current evidence, the benefit from PFO closure relies on careful patient selection: those under the age of 60 years with few to no vascular risk factors and embolic-appearing stroke deemed cryptogenic after thorough evaluation. As these data look towards influencing guideline statements and device approvals in the future, patient selection remains the crucial ingredient for clinical decision making and future trials.

Atrial septal defect closure in a young patient presenting with recurrent cryptogenic stroke: a case report

“…Cryptogenic stroke is a devastating condition which usually affects younger groups without obvious atherogenic risk factors. It is estimated that 40% of patients with cryptogenic stroke will have some form of inter-atrial shunting and the risk of stroke seems independent of the shunt size [4]. Secondary stroke prevention is the cornerstone of management.…”

Paradoxical embolism through PFO leading to stroke in a gunshot victim with IVC injury

“…IVC injury is a life-threatening situation, especially when coupled with the increased likelihood of multiple concurrent associated injuries and developing other post-operative complications/conditions after repair [ 7 ]. Particularly, patients with known cardiac defects such as a PFO should be regularly monitored due to increased incidence of paradoxical embolism in these patients [ 4 ]. Anticoagulation therapy along with rapid recognition and treatment of stroke in these patients is essential to long-term survival of these patients.…”

“…Complications of IVC injury can be more severe when patients also present with cardiac structural defects, such as a patent foramen ovale (PFO), which can allow for venous system clots to embolize to the arterial circulation. A PFO lends a very high risk to developing cryptogenic stroke, with the defect being the cause in almost a third of strokes [ 4 ]. Numerous cases of bullet embolism in the venous and arterial systems, as well as cryptogenic stroke due to a PFO, have been noted in the literature [ 5 , 6 ].…”

“…Numerous cases of bullet embolism in the venous and arterial systems, as well as cryptogenic stroke due to a PFO, have been noted in the literature [ 5 , 6 ]. However, no cases describing paradoxical embolism through a PFO from an IVC thrombus after trauma with IVC repair have been reported at this time [ 4 – 6 ].…”

Multidisciplinary assessment of patients with ischemic stroke, the structure of a stroke team, and first Egyptian experience in adults undergoing transcatheter PFO closure for PFO-related stroke

“…Cumulative evidence from recent multiple randomized control trials has led to the FDA approval of transcatheter PFO closure in patients less than 60 years for prevention of recurrent stroke after careful patient assessment, and this resulted in increase of the number of the performed procedures worldwide [ 5 ].…”