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Management of right-to-left shunt in cryptogenic cerebrovascular disease: results from the observational Austrian paradoxical cerebral embolism trial (TACET) registry

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Abstract

Paradoxical embolism due to a patent foramen ovale (PFO) is a possible cause of ischemic stroke, particularly in young cryptogenic stroke patients. In most cases, however, it is difficult to establish a firm etiological association and the debate about management is ongoing. The Austrian Paradoxical Cerebral Embolism Trial was designed as a prospective, national, multi-center, non-randomized registry to add further data on this topic before the completion of randomized controlled trials. Over 27 months 188 cryptogenic stroke/TIA patients ≤55 years were entered by 15 Austrian stroke units. Contrast transesophageal echocardiography demonstrated a cardiac right-to-left shunt (RLS) in 176 patients; a pulmonary RLS was assumed in 10, and 2 showed both. Ninety-seven (55 %) patients with cardiac RLS underwent interventional treatment, and this was more likely for patients with stroke as index event, a symptomatic infarction on MRI and a large size of PFO. Over 2 years, recurrences occurred at a rate of approximately 1.3 % for stroke and 4.3 % for TIA, and were especially frequent in patients with pulmonary RLS. When comparing outcomes in patients with cardiac RLS there was a trend for fewer recurrences with interventional management (closure: four TIA in four patients vs. medical: three strokes and seven TIA in nine patients; p = 0.066 for events, p = 0.085 for patients). The complication rate was 13.4, and 5.7 % had residual shunting. The possible causes for paradoxical embolism in young patients with cryptogenic stroke appear more variable than usually considered, and other causes than PFO should not be neglected. Interventional treatment of a cardiac RLS may offer a small benefit, but has to be weighed against possible complications and the problem of establishing causality.

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Acknowledgments

The study was financially supported by the Austrian Society of Stroke Research.

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical standard

This study has been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

Author information

Authors and Affiliations

  1. Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036, Graz, Austria

    Susanna Horner, Kurt Niederkorn, Thomas Gattringer & Franz Fazekas

  2. Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria

    Martin Furtner

  3. Department of Neurology, Academic Teaching Hospital Wagner-Jauregg, Linz, Austria

    Raffi Topakian

  4. Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria

    Wilfried Lang

  5. Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria

    Robert Maier

  6. Division of Paediatric Cardiology, Department of Paediatrics, Medical University of Graz, Graz, Austria

    Andreas Gamillscheg

Authors
  1. Susanna Horner
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  2. Kurt Niederkorn
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  3. Thomas Gattringer
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  4. Martin Furtner
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  5. Raffi Topakian
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  6. Wilfried Lang
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  7. Robert Maier
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  8. Andreas Gamillscheg
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  9. Franz Fazekas
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Corresponding author

Correspondence to Susanna Horner.

Additional information

For the Austrian PFO Study Group and the Austrian Society for Stroke Research.

TACET is a project of the Austrian Society for Stroke Research. http://www.strokecenter.org/trials/clinicalstudies/the-austrian-paradoxical-cerebral-embolism-trial.

Appendix: Investigators and collaborators of the neurological departments/hospitals (The Austrian PFO Study Group)

Appendix: Investigators and collaborators of the neurological departments/hospitals (The Austrian PFO Study Group)

(1) Aichner F, Haring HP, Topakian R, Hinterberger G (Linz), (2) Auff E, Rinner W (Vienna), (3) Berek K, Mayr M (Kufstein), (4) Brainin M, Yilmaz-Kaymaz N (Gugging), (5) Brücke T, Parigger S (Vienna), (6) Deecke L, Lalouschek W (Vienna), (7) Grabmair W, Bocksrucker C (Linz), (8) Offenbacher H, Arlt F (Knittelfeld), (9) Ott E, Horner S, Beitzke M, Pichler G, Krenn U, Weiss S, Legat-Wallner A, Thaler D, Reinbacher E, Pignitter G, Niederkorn K, Fazekas F (Graz), (10) Poewe W, Willeit J, Furtner M, Schmidauer C (Innsbruck), (11) Prainer C (Vienna), (12) Brahmsohler B, Raimann G (Villach), (13) Reisecker F, Söser-Brence I (Graz), (14) Schnaberth G, Schmidbauer M, Zaruba E (Vienna), (15) Wege H, Doppler W, Krenn M, Hoffmann C, Gaulhofer P (Graz).

Cardiological support: Maier R (Department of Internal Medicine, Division of Cardiology, Medical University of Graz), Gamillscheg A (Department of Pediatrics, Division of Cardiology, Medical University of Graz).

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Horner, S., Niederkorn, K., Gattringer, T. et al. Management of right-to-left shunt in cryptogenic cerebrovascular disease: results from the observational Austrian paradoxical cerebral embolism trial (TACET) registry. J Neurol 260, 260–267 (2013). https://doi.org/10.1007/s00415-012-6629-9

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  • DOI: https://doi.org/10.1007/s00415-012-6629-9

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