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Department of Neurology, University Hospital, Lausanne, Switzerland (Dr. Bogousslavsky) (Dr. Garazi)
Division of Cardiology, University Hospital, Lausanne, Switzerland (Dr. Jeanrenaud) (Dr. Aebischer)
University of Social and Preventive Medicine, Lausanne, Switzerland (Dr. Van Melle)
Address correspondence and reprint requests to Dr. J. Bogousslavsky, Department of Neurology, CHUV, CH-1011 Lausanne, Switzerland.
Patent foramen ovale (PFO) is more common in patients with stroke than in matched controls, but the stroke mechanism and late prognosis are not well known. We studied features, coexisting causes, and recurrences of stroke in 140 consecutive patients (mean age 44 ± 14 years) with stroke and PFO admitted to a population-based primary-care center. We selected the patients from 340 patients (41%) aged 560 years with acute stroke. The initial event was brain infarction in 118 patients (84%) and TIA in 22 (16%). Intracranial embolic occlusions were present on angiography or transcranial Doppler in most patients admitted within 12 hours of onset, whereas a venous source was clinically apparent in only six patients (5.5%). Pulmonary embolism, Valsalva maneuver at onset, and coagulation abnormalities were rare, but one-fourth of the patients had an interatrial septum aneurysm (ISA) that coexisted with PFO. An alternative cause of stroke was present in only 22 patients (16%), usually cardiac (atrial fibrillation, severe mitral valve prolapse, akinetic left ventricular segment). During a mean follow-up of 3 years, the stroke or death rate was 2.4% per year, but only eight patients had a recurrent infarct (1.9% per year). This low rate of recurrence contrasted with the severity of initial stroke, which left disabling sequelae in one-half the patients. Multivariate analysis showed that interatrial communication, a history of recent migraine, posterior cerebral artery territory infarct, and a coexisting cause of stroke were associated with recurrence, whereas ISA and treatment type (coagulant or antiaggregant therapy, surgical closure of PFO) were not. However, given the low number of events, these findings must be taken with caution. In conclusion, our study shows that stroke associated with PFO with or without ISA is not commonly due to a coexisting cause of stroke. It is usually embolic, although a definite source cannot often be demonstrated. The presenting stroke is often severe, but recurrence is uncommon. The demonstration of factors associated with a higher risk of recurrence in subgroups of patients is critical for the long-term management of these patients.
Received August 22, 1995. Accepted in final form October 12, 1995.
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F. Martin, P. L. Sanchez, E. Doherty, P. J. Colon-Hernandez, G. Delgado, I. Inglessis, N. Scott, J. Hung, M. E. E. King, F. Buonanno, et al. Percutaneous Transcatheter Closure of Patent Foramen Ovale in Patients With Paradoxical Embolism Circulation, August 27, 2002; 106(9): 1121 - 1126. [Abstract] [Full Text] [PDF]
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M. U. Braun, D. Fassbender, S. P. Schoen, M. Haass, R. Schraeder, W. Scholtz, and R. H. Strasser Transcatheter closure of patent foramen ovale in patients with cerebral ischemia J. Am. Coll. Cardiol., June 19, 2002; 39(12): 2019 - 2025. [Abstract] [Full Text] [PDF]
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L. Bruch, A. Parsi, M. O. Grad, S. Rux, T. Burmeister, H. Krebs, and F. X. Kleber Transcatheter Closure of Interatrial Communications for Secondary Prevention of Paradoxical Embolism: Single-Center Experience Circulation, June 18, 2002; 105(24): 2845 - 2848. [Abstract] [Full Text] [PDF]
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S. Homma, R. L. Sacco, M. R. Di Tullio, R. R. Sciacca, J.P. Mohr, and for the PFO in Cryptogenic Stroke Study (PICSS) In Effect of Medical Treatment in Stroke Patients With Patent Foramen Ovale: Patent Foramen Ovale in Cryptogenic Stroke Study Circulation, June 4, 2002; 105(22): 2625 - 2631. [Abstract] [Full Text] [PDF]
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S. De Castro, D. Cartoni, M. Fiorelli, M. Rasura, A. Anzini, E. M. Zanette, M. Beccia, C. Colonnese, F. Fedele, C. Fieschi, et al. Morphological and Functional Characteristics of Patent Foramen Ovale and Their Embolic Implications Stroke, October 1, 2000; 31(10): 2407 - 2413. [Abstract] [Full Text] [PDF]
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J. Hung, M. J. Landzberg, K. J. Jenkins, M. E. E. King, J. E. Lock, I. F. Palacios, and P. Lang Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement J. Am. Coll. Cardiol., April 1, 2000; 35(5): 1311 - 1316. [Abstract] [Full Text] [PDF]
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S. Windecker, A. Wahl, T. Chatterjee, A. Garachemani, F. R. Eberli, C. Seiler, and B. Meier Percutaneous Closure of Patent Foramen Ovale in Patients With Paradoxical Embolism : Long-Term Risk of Recurrent Thromboembolic Events Circulation, February 29, 2000; 101(8): 893 - 898. [Abstract] [Full Text] [PDF]
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H. P. Kuhl, R. Hoffmann, M. W. Merx, A. Franke, C. Klotzsch, W. Lepper, T. Reineke, J. Noth, and P. Hanrath Transthoracic echocardiography using second harmonic imaging: Diagnostic alternative to transesophageal echocardiography for the detection of atrial right to left shunt in patients with cerebral embolic events J. Am. Coll. Cardiol., November 15, 1999; 34(6): 1823 - 1830. [Abstract] [Full Text] [PDF]
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J. A. Dearani, B. S. Ugurlu, G. K. Danielson, R. C. Daly, C. G. A. McGregor, C. J. Mullany, F. J. Puga, T. A. Orszulak, B. J. Anderson, R. D. Brown Jr, et al. Surgical Patent Foramen Ovale Closure for Prevention of Paradoxical Embolism-Related Cerebrovascular Ischemic Events Circulation, November 9, 1999; 100 (2009): II-171 - II-175. [Abstract] [Full Text] [PDF]
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J CHAMBERS Should percutaneous devices be used to close a patent foramen ovale after cerebral infarction or TIA? Heart, November 1, 1999; 82(5): 537 - 538. [Full Text]
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D. W. Droste, M. Reisener, V. Kemeny, R. Dittrich, G. Schulte-Altedorneburg, J. Stypmann, T. Wichter, and E. B. Ringelstein Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts : Reproducibility, Comparison of 2 Agents, and Distribution of Microemboli Stroke, May 1, 1999; 30(5): 1014 - 1018. [Abstract] [Full Text] [PDF]
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H. Ay, F. S. Buonanno, S. A. Abraham, J. P. Kistler, and W. J. Koroshetz An Electrocardiographic Criterion for Diagnosis of Patent Foramen Ovale Associated With Ischemic Stroke Stroke, July 1, 1998; 29(7): 1393 - 1397. [Abstract] [Full Text] [PDF]
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M. M. Steiner, M. R. Di Tullio, T. Rundek, R. Gan, X. Chen, C. Liguori, M. Brainin, S. Homma, and R. L. Sacco Patent Foramen Ovale Size and Embolic Brain Imaging Findings Among Patients With Ischemic Stroke Stroke, May 1, 1998; 29(5): 944 - 948. [Abstract] [Full Text] [PDF]
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B. Kristensen, J. Malm, B. Carlberg, B. Stegmayr, C. Backman, M. Fagerlund, and T. Olsson Epidemiology and Etiology of Ischemic Stroke in Young Adults Aged 18 to 44 Years in Northern Sweden Stroke, September 1, 1997; 28(9): 1702 - 1709. [Abstract] [Full Text]
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