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Cryptogenic stroke in patients with patent foramen ovale

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Abstract

Paradoxical embolism through a patent foramen ovale (PFO) is a commonly identified potential mechanism of ischemic stroke, especially in young patients. The recurrent stroke rate among young cryptogenic stroke patients with a PFO is modest, but higher than normal for their age. Co-existing atrial septal aneurysm is a substantial, and the only definite, potentiator of stroke risk in patients with PFO, but PFO size, degree of functional shunting, and co-existing hypercoagulable state likely are additional risk factors. Pelvic CT and magnetic resonance venography have improved our ability to detect source venous thromboemboli and underlie new management strategies. Treatment strategies for PFOs in ischemic stroke patients include antiplatelet agents, anticoagulants, surgical closure, or percutaneous closure devices. The completion of ongoing, randomized clinical trials comparing percutaneous closure devices with medical management is likely to be hastened by the recent withdrawal of humanitarian device exemption approvals, and is urgently needed to clarify if the risks of invasive endovascular device placement are outweighed by a long-term reduction in recurrent vascular events.

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References and Recommended Reading

  1. Saver JL: Emerging risk factors for stroke: patent foramen ovale, aortic arch atherosclerosis, antiphospholipid antibodies, and activated protein C resistance. J Stroke Cerebrovasc Dis 1997, 6:167–172.

    Article  Google Scholar 

  2. Hagen PT, Scholz DG, Edwards WD: Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984, 59:17–20.

    PubMed  CAS  Google Scholar 

  3. Nicholls SC, O’Brian JK, Sutton MG: Venous thromboembolism: detection by duplex scanning. J Vasc Surg 1996, 23:511–516.

    Article  PubMed  CAS  Google Scholar 

  4. Meister SG, Grossman W, Dexter L, Dalen JE: Paradoxical embolism. Diagnosis during life. Am J Med 1972, 53:292–298.

    Article  PubMed  CAS  Google Scholar 

  5. Stollberger C, Slany J, Schuster I, et al.: The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism. Ann Intern Med 1993, 119:461–465.

    PubMed  CAS  Google Scholar 

  6. Kim D, Saver JL: Patent foramen ovale and stroke: what we do and don’t know. Rev Neurol Dis 2005, 2:1–7.

    PubMed  Google Scholar 

  7. Cramer SC, Rordorf G, Maki JH, et al.: Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli from Large Veins in Ischemic Stroke (PELVIS) study. Stroke 2004, 35:46–50.

    Article  PubMed  Google Scholar 

  8. Overell JR, Bone I, Lees KR: Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000, 55:1172–1179.

    PubMed  CAS  Google Scholar 

  9. Meissner I, Khandheria BK, Heit JA, et al.: Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study. J Am Coll Cardiol 2006, 47:440–445.

    Article  PubMed  Google Scholar 

  10. Di Tullio MR, Sacco RL, Sciacca RR, et al.: Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol 2007, 49:797–802.

    Article  PubMed  Google Scholar 

  11. Cabanes L, Mas JL, Cohen A, et al.: Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography. Stroke 1993, 24:1865–1873.

    PubMed  CAS  Google Scholar 

  12. De Castro S, Cartoni D, Fiorelli M, et al.: Morphological and functional characteristics of patent foramen ovale and their embolic implications. Stroke 2000, 31:2407–2413.

    PubMed  Google Scholar 

  13. Giardini A, Donti A, Formigari R, et al.: Comparison of results of percutaneous closure of patent foramen ovale for paradoxical embolism in patients with versus without thrombophilia. Am J Cardiol 2004, 94:1012–1016.

    Article  PubMed  Google Scholar 

  14. Karttunen V, Hiltunen L, Rasi V, et al.: Factor V Leiden and prothrombin gene mutation may predispose to paradoxical embolism in subjects with patent foramen ovale. Blood Coagul Fibrinolysis 2003, 14:261–268.

    Article  PubMed  CAS  Google Scholar 

  15. Becker K, Skalabrin E, Hallam D, Gill E: Ischemic stroke during sexual intercourse: a report of 4 cases in persons with patent foramen ovale. Arch Neurol 2004, 61:1114–1116.

    Article  PubMed  Google Scholar 

  16. Wammes-van der Heijden EA, Tijssen CC, Egberts AC: Right-to-left shunt and migraine: the strength of the relationship. Cephalalgia 2006, 26:208–213.

    Article  PubMed  CAS  Google Scholar 

  17. Azarbal B, Tobis J, Suh W, et al.: Association of interatrial shunts and migraine headaches: impact of transcatheter closure. J Am Coll Cardiol 2005, 45:489–492.

    Article  PubMed  Google Scholar 

  18. Mas JL, Arquizan C, Lamy C, et al.: Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001, 345:1740–1746.

    Article  PubMed  CAS  Google Scholar 

  19. Homma S, Sacco RL, Di Tullio MR, et al.: Effect of medical treatment in stroke patients with patent foramen ovale: Patent Foramen Ovale in Cryptogenic Stroke Study. Circulation 2002, 105:2625–2631.

    Article  PubMed  Google Scholar 

  20. Gasiavelis N, Grinnemo KH, Lindblom D, Dellgren G: Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long-term results. Scand Cardiovasc J 2004, 38:375–379.

    Article  PubMed  CAS  Google Scholar 

  21. Klotz S, Tjan TD, Berendes E, et al.: Surgical closure of combined symptomatic patent foramen ovale and atrial septum aneurysm for prevention of recurrent cerebral emboli. J Card Surg 2005, 20:370–374.

    Article  PubMed  Google Scholar 

  22. Schneider B, Bauer R: Is surgical closure of patent foramen ovale the gold standard for treating interatrial shunts? An echocardiographic follow-up study. J Am Soc Echocardiogr 2005, 18:1385–1391.

    Article  PubMed  Google Scholar 

  23. Tsilimingas NB, Reiter B, Kodolitsch YV, et al.: Surgical revision of an uncommonly dislocated self-expanding Amplatzer septal occluder device. Ann Thorac Surg 2004, 78:686–687.

    Article  PubMed  Google Scholar 

  24. Goldstein JA, Beardslee MA, Xu H, et al.: Infective endocarditis resulting from CardioSEAL closure of a patent foramen ovale. Catheter Cardiovasc Interv 2002, 55:217–220, discussion 221.

    Article  PubMed  Google Scholar 

  25. Wertman B, Azarbal B, Riedl M, Tobis J: Adverse events associated with nickel allergy in patients undergoing percutaneous atrial septal defect or patent foramen ovale closure. J Am Coll Cardiol 2006, 47:1226–1227.

    Article  PubMed  Google Scholar 

  26. Anzai H, Child J, Natterson B, et al.: Incidence of thrombus formation on the CardioSEAL and the Amplatzer interatrial closure devices. Am J Cardiol 2004, 93:426–431.

    Article  PubMed  Google Scholar 

  27. Krumsdorf U, Ostermayer S, Billinger K, et al.: Incidence and clinical course of thrombus formation on atrial septal defect and patient foramen ovale closure devices in 1,000 consecutive patients. J Am Coll Cardiol 2004, 43:302–309.

    Article  PubMed  Google Scholar 

  28. Wohrle J: Closure of patent foramen ovale after cryptogenic stroke. Lancet 2006, 368:350–352.

    Article  PubMed  Google Scholar 

  29. Wahl A, Krumsdorf U, Meier B, et al.: Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients. J Am Coll Cardiol 2005, 45:377–380.

    Article  PubMed  Google Scholar 

  30. Windecker S, Wahl A, Nedeltchev K, et al.: Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol 2004, 44:750–758.

    Article  PubMed  Google Scholar 

  31. Off-label practices plague circulatory system device randomized trials. Gray Sheet 2004, 30:18–19.

  32. Messe SR, Silverman IE, Kizer JR, et al.: Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004, 62:1042–1050.

    PubMed  CAS  Google Scholar 

  33. Sacco RL, Adams R, Albers G, et al.: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006, 37:577–617.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. UCLA Stroke Center, 710 Westwood Plaza, Los Angeles, CA, 90095, USA

    Jeffrey L. Saver MD

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  1. Jeffrey L. Saver MD
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Correspondence to Jeffrey L. Saver MD.

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Saver, J.L. Cryptogenic stroke in patients with patent foramen ovale. Curr Atheroscler Rep 9, 319–325 (2007). https://doi.org/10.1007/s11883-007-0039-y

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  • DOI: https://doi.org/10.1007/s11883-007-0039-y

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