Journal of Neurology

, Volume 259, Issue 6, pp 1051–1055

Factors related to recurrence of paradoxical cerebral embolism due to patent foramen ovale

  • Takuya Fukuoka
  • Tomohisa Dembo
  • Harumitu Nagoya
  • Yuji Kato
  • Ohe Yasuko
  • Ichiro Deguchi
  • Hajime Maruyama
  • Yohsuke Horiuchi
  • Hidetaka Takeda
  • Norio Tanahashi
Original Communication

Abstract

Patent foramen ovale (PFO) is an important etiology of ischemic stroke in young adults. We investigated factors contributing to recurrent ischemic stroke in patients with PFO. Subjects comprised 47 patients (mean age, 56.8 ± 14.2 years; range 23–74 years) with ischemic stroke due to PFO who were admitted to our hospital between April 2007 and February 2011. Mean duration of follow-up was 34.5 ± 13 months. Recurrence occurred in 11 cases. Annual recurrence rate was 23.4%. We investigated relationships between recurrence of ischemic stroke and size of PFO (large, >4 mm; medium, 2–3.9 mm; small, <1.9 mm; absent group), maximal number of microbubbles (determined as the number of microembolic signals: small, 0–5; moderate, 6–25; and multiple, ≥26), massive bubble on contrast transesophageal echocardiography or atrial septal aneurysm, D-dimer level and antithrombotic therapy. Univariate analysis showed size of the PFO (P = 0.013), number of microbubbles (P = 0.021), and presence of a massive bubble on echocardiography (P = 0.04) were related to recurrence of ischemic stroke. Logistic analysis identified size of the PFO (P < 0.05) and massive bubble on echocardiography (P < 0.05) as factors related to recurrence of ischemic stroke. In conclusion, size of the PFO and presence of a massive bubble were considered to be factors associated with recurrence of ischemic stroke due to PFO.

Keywords

Paradoxical cerebral embolism Patent foramen ovale (PFO) Size of PFO Massive bubble 

References

  1. 1.
    Schneider B, Zienkiewicz T, Jansen V, Hofmann T, Noltenius H, Meinertz T (1996) Diagnosis of patent foramen ovale by transesophageal echocardiography and correlation with autopsy findings. Am J Cardiol 77(14):1202–1209. pii: S0002-9149(96)00163-4PubMedCrossRefGoogle Scholar
  2. 2.
    Schulman S, Rhedin AS, Lindmarker P, Carlsson A, Larfars G, Nicol P, Loogna E, Svensson E, Ljungberg B, Walter H (1995) A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. Duration of Anticoagulation Trial Study Group. N Engl J Med 332(25):1661–1665. doi:10.1056/NEJM199506223322501 PubMedCrossRefGoogle Scholar
  3. 3.
    Schulman S, Granqvist S, Holmstrom M, Carlsson A, Lindmarker P, Nicol P, Eklund SG, Nordlander S, Larfars G, Leijd B, Linder O, Loogna E (1997) The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med 336(6):393–398. doi:10.1056/NEJM199702063360601 PubMedCrossRefGoogle Scholar
  4. 4.
    Kearon C, Gent M, Hirsh J, Weitz J, Kovacs MJ, Anderson DR, Turpie AG, Green D, Ginsberg JS, Wells P, MacKinnon B, Julian JA (1999) A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 340(12):901–907. doi:10.1056/NEJM199903253401201 PubMedCrossRefGoogle Scholar
  5. 5.
    Agnelli G, Prandoni P, Santamaria MG, Bagatella P, Iorio A, Bazzan M, Moia M, Guazzaloca G, Bertoldi A, Tomasi C, Scannapieco G, Ageno W (2001) Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators. N Engl J Med 345(3):165–169. doi:10.1056/NEJM200107193450302 PubMedCrossRefGoogle Scholar
  6. 6.
    Schneider B, Hofmann T, Justen MH, Meinertz T (1995) Chiari’s network: normal anatomic variant or risk factor for arterial embolic events? J Am Coll Cardiol 26(1):203–210. pii: 073510979500144OPubMedCrossRefGoogle Scholar
  7. 7.
    Steiner MM, Di Tullio MR, Rundek T, Gan R, Chen X, Liguori C, Brainin M, Homma S, Sacco RL (1998) Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke 29(5):944–948PubMedCrossRefGoogle Scholar
  8. 8.
    Schuchlenz HW, Weihs W, Horner S, Quehenberger F (2000) The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events. Am J Med 109(6):456–462PubMedCrossRefGoogle Scholar
  9. 9.
    Mas JL, Zuber M (1995) Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J 130(5):1083–1088PubMedCrossRefGoogle Scholar
  10. 10.
    Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J (2001) Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 345(24):1740–1746. doi:10.1056/NEJMoa011503 PubMedCrossRefGoogle Scholar
  11. 11.
    Nedeltchev K, Arnold M, Wahl A, Sturzenegger M, Vella EE, Windecker S, Meier B, Mattle HP (2002) Outcome of patients with cryptogenic stroke and patent foramen ovale. J Neurol Neurosurg Psychiatry 72(3):347–350PubMedCrossRefGoogle Scholar
  12. 12.
    Kato Y, Dembo T, Takeda H, Fukuoka T, Tanahashi N (2011) Prominent persisting Eustachian valve initiates spontaneous right-to-left shunt and paradoxical embolism in a patient with patent foramen ovale. Neurol Sci. doi:10.1007/s10072-011-0567-7 PubMedGoogle Scholar
  13. 13.
    Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP (2003) Atrial anatomy in non-cardioembolic stroke patients: effect of medical therapy. J Am Coll Cardiol 42(6):1066–1072. pii: S0735109703009070PubMedCrossRefGoogle Scholar
  14. 14.
    Yasaka M, Ikeno K, Otsubo R, Oe H, Nagano K, Minematsu K (2005) Right-to-left shunt evaluated at the aortic arch by contrast-enhanced transesophageal echocardiography. J Ultrasound Med 24(2):155–159. pii: 24/2/155PubMedGoogle Scholar
  15. 15.
    Yasaka M, Otsubo R, Oe H, Minematsu K (2005) Is stroke a paradoxical embolism in patients with patent foramen ovale? Intern Med 44(5):434–438. pii: JST.JSTAGE/internalmedicine/44.434 PubMedCrossRefGoogle Scholar
  16. 16.
    Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP (2002) Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 105(22):2625–2631PubMedCrossRefGoogle Scholar
  17. 17.
    Telman G, Yalonetsky S, Kouperberg E, Sprecher E, Lorber A, Yarnitsky D (2008) Size of PFO and amount of microembolic signals in patients with ischaemic stroke or TIA. Eur J Neurol 15(9):969–972.doi:10.1111/j.1468-1331.2008.02232.x.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Takuya Fukuoka
    • 1
  • Tomohisa Dembo
    • 1
  • Harumitu Nagoya
    • 1
  • Yuji Kato
    • 1
  • Ohe Yasuko
    • 1
  • Ichiro Deguchi
    • 1
  • Hajime Maruyama
    • 1
  • Yohsuke Horiuchi
    • 1
  • Hidetaka Takeda
    • 1
  • Norio Tanahashi
    • 1
  1. 1.Department of Neurology and Cerebrovascular Medicine, Saitama International Medical CenterSaitama Medical UniversityHidakaJapan

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