Patent foramen ovale and stroke: Difference between revisions
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Factors that might increase the occurrence of recurrent stroke in patients with [[patent foramen ovale]] are atrial [[septal aneurysm]] <ref name="pmid11742048">{{cite journal| author=Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G et al.| title=Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 24 | pages= 1740-6 | pmid=11742048 | doi=10.1056/NEJMoa011503 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742048 }} </ref>, bigger shunts and longer tunnels <ref name="pmid19101242">{{cite journal| author=Goel SS, Tuzcu EM, Shishehbor MH, de Oliveira EI, Borek PP, Krasuski RA et al.| title=Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients. | journal=Am J Cardiol | year= 2009 | volume= 103 | issue= 1 | pages= 124-9 | pmid=19101242 | doi=10.1016/j.amjcard.2008.08.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19101242 }} </ref>. Some systematic reviews done to compare medical versus percutaneous closure, found the rate of recurrent [[strokes]] with medical treatment to be greater than that with percutaneous closure <ref name="pmid14597460">{{cite journal| author=Khairy P, O'Donnell CP, Landzberg MJ| title=Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review. | journal=Ann Intern Med | year= 2003 | volume= 139 | issue= 9 | pages= 753-60 | pmid=14597460 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14597460 }} </ref>. However, the results of these systematic reviews should be carefully interpreted , as the individual studies included in the review were very heterogeneous. | Factors that might increase the occurrence of recurrent stroke in patients with [[patent foramen ovale]] are atrial [[septal aneurysm]] <ref name="pmid11742048">{{cite journal| author=Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G et al.| title=Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 24 | pages= 1740-6 | pmid=11742048 | doi=10.1056/NEJMoa011503 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742048 }} </ref>, bigger shunts and longer tunnels <ref name="pmid19101242">{{cite journal| author=Goel SS, Tuzcu EM, Shishehbor MH, de Oliveira EI, Borek PP, Krasuski RA et al.| title=Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients. | journal=Am J Cardiol | year= 2009 | volume= 103 | issue= 1 | pages= 124-9 | pmid=19101242 | doi=10.1016/j.amjcard.2008.08.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19101242 }} </ref>. Some systematic reviews done to compare medical versus percutaneous closure, found the rate of recurrent [[strokes]] with medical treatment to be greater than that with percutaneous closure <ref name="pmid14597460">{{cite journal| author=Khairy P, O'Donnell CP, Landzberg MJ| title=Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review. | journal=Ann Intern Med | year= 2003 | volume= 139 | issue= 9 | pages= 753-60 | pmid=14597460 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14597460 }} </ref>. However, the results of these systematic reviews should be carefully interpreted , as the individual studies included in the review were very heterogeneous. | ||
==Association of | ==Association of Cryptogenic Stroke/Transient Ischemic Attacks with Patent Foramen Ovale== | ||
*One in every four cases of [[ischemic stroke]] does not have an identifiable cause other than [[Paradoxical embolism|cryptogenic stroke]] which is a diagnosis of exclusion<ref name="pmid2712533">{{cite journal| author=Sacco RL, Ellenberg JH, Mohr JP, Tatemichi TK, Hier DB, Price TR et al.| title=Infarcts of undetermined cause: the NINCDS Stroke Data Bank. | journal=Ann Neurol | year= 1989 | volume= 25 | issue= 4 | pages= 382-90 | pmid=2712533 | doi=10.1002/ana.410250410 | pmc= | url= }} </ref>. | *One in every four cases of [[ischemic stroke]] does not have an identifiable cause other than [[Paradoxical embolism|cryptogenic stroke]] which is a diagnosis of exclusion<ref name="pmid2712533">{{cite journal| author=Sacco RL, Ellenberg JH, Mohr JP, Tatemichi TK, Hier DB, Price TR et al.| title=Infarcts of undetermined cause: the NINCDS Stroke Data Bank. | journal=Ann Neurol | year= 1989 | volume= 25 | issue= 4 | pages= 382-90 | pmid=2712533 | doi=10.1002/ana.410250410 | pmc= | url= }} </ref>. | ||
Revision as of 17:54, 4 January 2013
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]
Overview
There is a lack of consensus about the association of patent foramen ovale and cryptogenic stroke. While some studies have demonstrated an increased incidence of patent foramen ovale (PFO) in younger patients with cryptogenic stroke [1] others failed to show an association [2]. Factors that might increase the occurrence of recurrent stroke in patients with patent foramen ovale are atrial septal aneurysm [3], bigger shunts and longer tunnels [4]. Some systematic reviews done to compare medical versus percutaneous closure, found the rate of recurrent strokes with medical treatment to be greater than that with percutaneous closure [5]. However, the results of these systematic reviews should be carefully interpreted , as the individual studies included in the review were very heterogeneous.
Association of Cryptogenic Stroke/Transient Ischemic Attacks with Patent Foramen Ovale
- One in every four cases of ischemic stroke does not have an identifiable cause other than cryptogenic stroke which is a diagnosis of exclusion[6].
- Cryptogenic stroke occurs more commonly in younger patients.
- The association between the presence of a patent foramen ovale and cryptogenic stroke is controversial and inconsistent. While some studies have demonstrated an increased incidence of patent foramen ovale (PFO) in younger patients with cryptogenic stroke [1] others failed to show an association [2].
Patent foramen ovale and first stroke
Although, two prospective cohort studies namely, ‘ The Northern Manhattan Study’ (NOMAS) [7] and 'Stroke Prevention: Assessment of Risk in a Community' (SPARC) [8], found an increased incidence of first stroke in patients with patent foramen ovale, both these studies did not reach a statistical significance.
Patent foramen ovale and recurrent stroke
- There exists a discrepancy between influence of patent foramen ovale (PFO) on recurrent stroke (after first episode of cryptogenic stroke).
- Several factors have been found associated with a patent foramen ovale (PFO) that might increase the incidence of recurrent strokes namely, atrial septal aneurysm [3], (ASA) in association with PFO, bigger shunts and longer tunnels [4].
- Nevertheless, some studies have found no association between PFO or abnormal septal morphology with recurrent strokes [9].
- Studies are not able to establish a clear association of patent foramen ovale with recurrent strokes. A possible explanatation for these findings could be-
- The studies didn’t control the nature of treatment after the index episode of stroke i.e. patients with one episode of cryptogenic stroke were given either medical (antiplatelet), percutaneous closure or no treatment depending on physician’s decision. Thus, a possibility could be that medical treatment might be highly effective and obscures the risk of patent foramen ovale[10].
Treatment options in patent foramen ovale with recurrent strokes
- Medical
A metanalysis done by Almekhlafi et al. found that recurrent strokes were about half as likely on warfarin as compared with antiplatelet treatment [10].
- Interventional or Surgical therapy includes:
- Percutaneous device closure (commonest)
- Suture closure
- Radioablative therapy (under-development)
- Open heart Surgery (uncommon)
Surgical closure of patent foramen ovale is uncommon these days especially after development of percutaneous device closure. Some systematic reviews done to compare medical versus percutaneous closure, found that the rate of recurrent strokes with medical treatment (5.2%) is greater than that with percutaneous closure (1.3%) [5], [11],[12] . However, the results of these systematic reviews should be interpreted carefully, because there was lack of uniformity in the selection criteria, duration of follow up and end points in the individual studies that were used for the systematic review.
References
- ↑ 1.0 1.1 Overell JR, Bone I, Lees KR (2000). "Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies". Neurology. 55 (8): 1172–9. PMID 11071496.
- ↑ 2.0 2.1 Poppert H, Morschhaeuser M, Feurer R, Bockelbrink A, Schwarze J, Esposito L; et al. (2008). "Lack of association between right-to-left shunt and cerebral ischemia after adjustment for gender and age". J Negat Results Biomed. 7: 7. doi:10.1186/1477-5751-7-7. PMC 2577085. PMID 18851751.
- ↑ 3.0 3.1 Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G; et al. (2001). "Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both". N Engl J Med. 345 (24): 1740–6. doi:10.1056/NEJMoa011503. PMID 11742048.
- ↑ 4.0 4.1 Goel SS, Tuzcu EM, Shishehbor MH, de Oliveira EI, Borek PP, Krasuski RA; et al. (2009). "Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients". Am J Cardiol. 103 (1): 124–9. doi:10.1016/j.amjcard.2008.08.036. PMID 19101242.
- ↑ 5.0 5.1 Khairy P, O'Donnell CP, Landzberg MJ (2003). "Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review". Ann Intern Med. 139 (9): 753–60. PMID 14597460.
- ↑ Sacco RL, Ellenberg JH, Mohr JP, Tatemichi TK, Hier DB, Price TR; et al. (1989). "Infarcts of undetermined cause: the NINCDS Stroke Data Bank". Ann Neurol. 25 (4): 382–90. doi:10.1002/ana.410250410. PMID 2712533.
- ↑ Di Tullio MR, Sacco RL, Sciacca RR, Jin Z, Homma S (2007). "Patent foramen ovale and the risk of ischemic stroke in a multiethnic population". J Am Coll Cardiol. 49 (7): 797–802. doi:10.1016/j.jacc.2006.08.063. PMID 17306710.
- ↑ Meissner I, Khandheria BK, Heit JA, Petty GW, Sheps SG, Schwartz GL; et al. (2006). "Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study". J Am Coll Cardiol. 47 (2): 440–5. doi:10.1016/j.jacc.2005.10.044. PMID 16412874.
- ↑ Serena J, Marti-Fàbregas J, Santamarina E, Rodríguez JJ, Perez-Ayuso MJ, Masjuan J; et al. (2008). "Recurrent stroke and massive right-to-left shunt: results from the prospective Spanish multicenter (CODICIA) study". Stroke. 39 (12): 3131–6. doi:10.1161/STROKEAHA.108.521427. PMID 18818401.
- ↑ 10.0 10.1 Almekhlafi MA, Wilton SB, Rabi DM, Ghali WA, Lorenzetti DL, Hill MD (2009). "Recurrent cerebral ischemia in medically treated patent foramen ovale: a meta-analysis". Neurology. 73 (2): 89–97. doi:10.1212/WNL.0b013e3181aa2a19. PMID 19439720.
- ↑ Homma S, Sacco RL (2005). "Patent foramen ovale and stroke". Circulation. 112 (7): 1063–72. doi:10.1161/CIRCULATIONAHA.104.524371. PMID 16103257.
- ↑ Wöhrle J (2006). "Closure of patent foramen ovale after cryptogenic stroke". Lancet. 368 (9533): 350–2. doi:10.1016/S0140-6736(06)69087-9. PMID 16876648.