| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
From the Department of Neurology (Drs. Messé and Kasner), University of Pennsylvania, Philadelphia; Vascular Neurology (Dr. Silverman), The Stroke Center, Hartford Hospital, Hartford, CT; Division of Cardiology (Dr. Kizer), Department of Medicine and Department of Public Health, Weill Medical College of Cornell University, New York, NY; Division of Cardiology (Dr. Homma), Department of Medicine, Columbia University, New York, NY; Department of Neurology (Dr. Zahn), Toronto Western Hospital, Ontario, Canada; and Department of Neurology (Dr. Gronseth), University of Kansas Medical Center, Kansas City.
Address correspondence and reprint requests to the Quality Standards Subcommittee of the American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116.
Objectives: 1) To evaluate the risk of subsequent stroke or death in patients with a cryptogenic stroke and a patent foramen ovale (PFO), atrial septal aneurysm (ASA), or both. 2) To establish the optimal method of stroke prevention in this population of patients.
Methods: MEDLINE, the Cochrane database of systematic reviews, key meeting abstracts from 1997 to 2002, and relevant reference lists were searched to select studies that prospectively collected outcome data in cryptogenic stroke patients with and without interatrial septal abnormalities. Studies were also selected that prospectively compared at least two treatment options. The quality of each study was graded (class I to IV) using a standard classification-of-evidence scheme for each question. Risk analyses were performed and data were pooled when appropriate.
Results: The literature search generated 129 articles of which only four fulfilled the inclusion and exclusion criteria. Two studies were graded class I, one study was graded class II, and one study was graded class IV for prognosis. Pooled results of the two class I and one class II studies demonstrated no increased risk of subsequent stroke or death in patients with PFO compared to those without (RR = 0.95, 95% CI 0.62 to 1.44). One class I study found increased risk of recurrent stroke in patients with PFO and ASA (annual rate = 3.8% versus 1.05%, RR = 2.98, 95% CI 1.17 to 7.58) but not increased risk of a composite of stroke and death (annual rate = 3.8% versus 1.8%, RR = 2.10, 95% CI 0.86 to 5.06). Regarding therapy, one study was graded class II, one study class III, and two studies class IV. Among patients with cryptogenic stroke and PFO or ASA, there was no significant difference in stroke or death rate in warfarin-treated patients relative to aspirin-treated patients and the confidence intervals were unable to rule out a benefit of one drug over the other (annual rate = 4.7% versus 8.9%, RR = 0.53, 95% CI 0.18 to 1.58). Minor bleeding rates were higher in the cohort of patients who received warfarin (22.9/100 patient-years versus 8.66/100 patient-years, rate ratio = 2.64, p < 0.001). No studies compared medical therapy with surgical or endovascular closure.
Conclusion: PFO is not associated with increased risk of subsequent stroke or death among medically treated patients with cryptogenic stroke. However, both PFO and ASA possibly increase the risk of subsequent stroke (but not death) in medically treated patients younger than 55 years. In patients with a cryptogenic stroke and an atrial septal abnormality the evidence is insufficient to determine if warfarin or aspirin is superior in preventing recurrent stroke or death, but minor bleeding is more frequent with warfarin. There is insufficient evidence to evaluate the efficacy of surgical or endovascular closure.
Received September 3, 2003. Accepted in final form January 13, 2004.
*See Appendix 3 on page 1049 for a listing of QSS members.
Approved by the Quality Standards Subcommittee in July 2003. Approved by the AAN Practice Committee in October 2003. Approved by the AAN Board of Directors in January 2004.
This article has been cited by other articles:
|
|
 |
|
  B. Meier Catheter-Based Closure of the Patent Foramen Ovale Circulation, November 3, 2009; 120(18): 1837 - 1841. [Full Text] [PDF]
|
|
|
|
 |
|
 M. A. Almekhlafi, S. B. Wilton, D. M. Rabi, W. A. Ghali, D. L. Lorenzetti, and M. D. Hill Recurrent cerebral ischemia in medically treated patent foramen ovale: A meta-analysis Neurology, July 14, 2009; 73(2): 89 - 97. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Tamayo and J. U. Harrer Patent foramen ovale and ischemic stroke recurrence: The end of a never-ending story? Neurology, July 14, 2009; 73(2): 84 - 85. [Full Text] [PDF]
|
|
|
|
 |
|
 B. Meier Stroke and migraine: a cardiologist's headache Heart, April 1, 2009; 95(7): 595 - 602. [Full Text] [PDF]
|
|
|
|
 |
|
 J. Serena, J. Marti-Fabregas, E. Santamarina, J. J. Rodriguez, M. J. Perez-Ayuso, J. Masjuan, T. Segura, J. Gallego, A. Davalos, on Behalf of the CODICIA (Right-to-Left Shunt in C, et al. Recurrent Stroke and Massive Right-to-Left Shunt: Results From the Prospective Spanish Multicenter (CODICIA) Study Stroke, December 1, 2008; 39(12): 3131 - 3136. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Windecker and B. Meier Patent Foramen Ovale and Cryptogenic Stroke: To Close or Not to Close? Closure: What Else! Circulation, November 4, 2008; 118(19): 1989 - 1997. [Full Text] [PDF]
|
|
|
|
|
|
S. R. Messe and S. E. Kasner Patent Foramen Ovale in Cryptogenic Stroke: Not to Close Circulation, November 4, 2008; 118(19): 1999 - 2004. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Khella and M. B. Bleicher Stroke and Its Prevention in Chronic Kidney Disease Clin. J. Am. Soc. Nephrol., November 1, 2007; 2(6): 1343 - 1351. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. L. P. Slottow, D. H. Steinberg, and R. Waksman Overview of the 2007 Food and Drug Administration Circulatory System Devices Panel Meeting on Patent Foramen Ovale Closure Devices Circulation, August 7, 2007; 116(6): 677 - 682. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. D. Dodd, S. L. Aquino, G. Holmvang, R. C. Cury, U. Hoffmann, T. J. Brady, and S. Abbara Cardiac Septal Aneurysm Mimicking Pseudomass: Appearance on ECG-Gated Cardiac MRI and MDCT Am. J. Roentgenol., June 1, 2007; 188(6): W550 - W553. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Ghosh, A. K. Ghosh, and S. K. Ghosh Patent foramen ovale and atrial septal aneurysm in cryptogenic stroke Postgrad. Med. J., March 1, 2007; 83(977): 173 - 177. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein and P. M. Rothwell Primary Prevention and Health Services Delivery Stroke, February 1, 2007; 38(2): 222 - 224. [Full Text] [PDF]
|
|
|
|
 |
|
 D J H McCabe and R D Rakhit Antithrombotic and interventional treatment options in cardioembolic transient ischaemic attack and ischaemic stroke J. Neurol. Neurosurg. Psychiatry, January 1, 2007; 78(1): 14 - 24. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. K. Malani and H. Ammar Cryptogenic stroke and patent foramen ovale. Ann Intern Med, September 5, 2006; 145(5): 393 - 394. [Full Text] [PDF]
|
|
|
|
|
|
R. G. Holloway Jr. and R. F. Jozefowicz Cryptogenic Stroke and Patent Foramen Ovale Ann Intern Med, September 5, 2006; 145(5): 394 - 394. [Full Text] [PDF]
|
|
|
|
|
|
L. H. Bonati, A. Kessel-Schaefer, A. Z. Linka, P. Buser, S. G. Wetzel, E.-W. Radue, P. A. Lyrer, and S. T. Engelter Diffusion-Weighted Imaging in Stroke Attributable to Patent Foramen Ovale: Significance of Concomitant Atrial Septum Aneurysm Stroke, August 1, 2006; 37(8): 2030 - 2034. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. F. Cianciulli, D. Chejtman, S. B. Lipshitz, M. C. Saccheri, S. L. Dethinne, and H. A. Prezioso Atrial septal aneurysm and spontaneous echo contrast: An association with higher embolic risk? Eur J Echocardiogr, June 1, 2006; 7(3): 243 - 246. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. P. Adams Jr Cardiac Disease and Stroke: Will History Repeat Itself? Mayo Clin. Proc., May 1, 2006; 81(5): 597 - 601. [Full Text] [PDF]
|
|
|
|
|
|
R. L. Sacco, R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, J. Halperin, R. Harbaugh, 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. Circulation, March 14, 2006; 113(10): e409 - e449. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. L. Sacco, R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, J. Halperin, R. Harbaugh, 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, February 1, 2006; 37(2): 577 - 617. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. R. Kizer and R. B. Devereux Clinical practice. Patent foramen ovale in young adults with unexplained stroke. N. Engl. J. Med., December 1, 2005; 353(22): 2361 - 2372. [Full Text] [PDF]
|
|
|
|
|
|
T. Christen, F. Mach, D. Didier, A. Kalangos, V. Verin, and P. T. Trindade Late cardiac tamponade after percutaneous closure of a patent foramen ovale Eur J Echocardiogr, December 1, 2005; 6(6): 465 - 469. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Hara, R. Virmani, E. Ladich, S. Mackey-Bojack, J. Titus, M. Reisman, W. Gray, M. Nakamura, M. Mooney, A. Poulose, et al. Patent Foramen Ovale: Current Pathology, Pathophysiology, and Clinical Status J. Am. Coll. Cardiol., November 1, 2005; 46(9): 1768 - 1776. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J Raaphorst and E J Wouda Thrombus in transit through a patent foramen ovale: paradoxical embolism J. Neurol. Neurosurg. Psychiatry, September 1, 2005; 76(9): 1199 - 1199. [Full Text] [PDF]
|
|
|
|
|
|
S. Homma and R. L. Sacco Patent Foramen Ovale and Stroke Circulation, August 16, 2005; 112(7): 1063 - 1072. [Full Text] [PDF]
|
|
|
|
 |
|
 W. H. Maisel and W. K. Laskey Patent Foramen Ovale Closure Devices: Moving Beyond Equipoise JAMA, July 20, 2005; 294(3): 366 - 369. [Full Text] [PDF]
|
|
|
|
|
|
S. R. Messe, B. Cucchiara, J. Luciano, and S. E. Kasner PFO management: Neurologists vs cardiologists Neurology, July 12, 2005; 65(1): 172 - 173. [Full Text] [PDF]
|
|
|
|
|
|
M. A. Topcuoglu, H. P. Mattle, B. Meier, S. Windecker, for the PC Trial Group, S. R. Messe, S. Homma, and S. E. Kasner 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, December 14, 2004; 63(11): 2198 - 2199. [Full Text] [PDF]
|
|
|
|
|
|
April 27 Highlights and Commentary Neurology, April 27, 2004; 62(8): 1243 - 1243. [Full Text] [PDF]
|
|
Read all Correspondence
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
