Recurrent Stroke in a Young Patient with Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Quo Vadis?

So far, there has been no generally accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). As recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation and the concept of ESUS comprises heterogeneous subgroups of patients, including a wide age range, concomitant patent foramen ovale (PFO), variable cardiovascular risk factors as well as a variable probability for atrial fibrillation (AF), an individualized clinical approach is needed. In this context, we here present a case of recurrent stroke in a young patient with ESUS and PFO. During treatment according to our Catch-up-ESUS registry study, prolonged cardiac monitoring diagnosed AF, and PFO closure was omitted.

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Dabigatran or Aspirin After Embolic Stroke of Undetermined Source in Patients With Patent Foramen Ovale

Stroke ◽

10.1161/strokeaha.120.031237 ◽

2021 ◽

Author(s):

Hans-Christoph Diener ◽

Aurauma Chutinet ◽

J. Donald Easton ◽

Christopher B. Granger ◽

Eva Kleine ◽

...

Keyword(s):

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Patent Foramen Ovale ◽

Recurrent Stroke ◽

Meta Analysis ◽

Dabigatran Etexilate ◽

Embolic Stroke ◽

Thrombin Inhibitor ◽

Foramen Ovale ◽

Significant Difference

Background and Purpose: Patent foramen ovale (PFO) may increase the risk of embolic stroke of undetermined source (ESUS). Guidelines suggest anticoagulation may be more effective than antiplatelets in preventing stroke in patients with ESUS and PFO when interventional closure is not performed. Methods: Patients with ESUS randomized to dabigatran (150/110 mg BID) or aspirin (100 mg QD) from the RE-SPECT ESUS study (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) were included. The rate of recurrent stroke (primary end point) and ischemic stroke was reported for patients with and without baseline PFO. A meta-analysis comparing the effects of anticoagulant and antiplatelet therapy on ischemic stroke in patients with PFO was updated to include RE-SPECT ESUS. Results: PFO was present in 680 of 5388 (12.6%) patients with documented PFO status. The risk of recurrent stroke with dabigatran versus aspirin was similar in patients with and without PFO ( P for interaction, 0.8290). In patients with PFO, the meta-analysis found no statistically significant difference between anticoagulant and antiplatelet therapy (odds ratio, 0.70 [95% CI, 0.43–1.14]) for ischemic stroke. Conclusions: There is insufficient evidence to recommend anticoagulation over antiplatelet therapy for patients with ESUS and a PFO. More data are needed to guide antithrombotic therapy in this population. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239120.

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STROKE AND ATRIAL SEPTAL DEFECTS – DECISION MAKING AT THE TURNING OF AGES

Romanian Journal of Neurology ◽

10.37897/rjn.2017.3.4 ◽

2017 ◽

Vol 16 (3) ◽

pp. 101-108

Author(s):

Vlad Eugen Tiu ◽

◽

Athena Ribigan ◽

Raluca Badea ◽

Ovidiu Bajenaru ◽

...

Keyword(s):

Decision Making ◽

Atrial Septal Defect ◽

Young Patient ◽

Patent Foramen Ovale ◽

Septal Defect ◽

Embolic Stroke ◽

Evidence Based ◽

Foramen Ovale ◽

Septal Defects ◽

Evidence Based Decision Making

CLOSE and Gore-REDUCE trials have recently changed the way we approach patients with stroke and patent foramen ovale. We present the case of a young patient with an Embolic Stroke of Undetermined Source (ESUS) and an atrial septal defect causing a large right-to-left shunt, with an ample discussion on evidence-based decision making.

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Successful cerebral protection during removal of large right atrial thrombus with AngioVac in a patient with patent foramen ovale and recent embolic stroke

Journal of Vascular Surgery Cases and Innovative Techniques ◽

10.1016/j.jvscit.2019.03.001 ◽

2019 ◽

Vol 5 (3) ◽

pp. 201-204

Author(s):

Hunter M. Ray ◽

Zain Al Rstum ◽

Naveed U. Saqib

Keyword(s):

Patent Foramen Ovale ◽

Cerebral Protection ◽

Embolic Stroke ◽

Right Atrial ◽

Foramen Ovale ◽

Atrial Thrombus ◽

Right Atrial Thrombus

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Predictors of Development of Atrial Fibrillation in Patients With Embolic Stroke Of Undetermined Source: An Analysis of the RE-SPECT ESUS Trial

Circulation ◽

10.1161/circulationaha.121.055176 ◽

2021 ◽

Author(s):

Maria Cecilia Bahit ◽

Ralph L. Sacco ◽

J. Donald Easton ◽

Juliane Meyerhoff ◽

Lisa Cronin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Body Mass Index ◽

Body Mass ◽

Recurrent Stroke ◽

Controlled Trial ◽

Clinical Care ◽

Important Variable ◽

Older Age ◽

Embolic Stroke ◽

Cardiac Monitoring

Background: A proportion of patients with embolic stroke of undetermined source (ESUS) have silent atrial fibrillation (AF) or develop AF after the initial evaluation. Better understanding of risk for development of AF is critical to implement optimal monitoring strategies with the goal of preventing recurrent stroke due to underlying AF. The RE-SPECT ESUS trial provides an opportunity to assess predictors for developing AF and associated recurrent stroke. Methods: RE-SPECT ESUS was a randomized, controlled trial (564 sites, 42 countries) assessing dabigatran versus aspirin for the prevention of recurrent stroke in patients with ESUS. Of 5390 patients enrolled and followed for a median of 19 months, 403 (7.5%) were found to develop AF reported as an adverse event or using cardiac monitoring per standard clinical care. Univariable and multivariable regression analyses were performed to define predictors of AF. Results: In the multivariable model, older age (odds ratio [OR] for 10-year increase 1.99 [1.78-2.23]; P<0.001), hypertension (1.36 [1.03-1.79]; P=0.0304), diabetes (OR 0.74 [0.56-0.96]; P=0.022), and body mass index (OR for 5-unit increase 1.29 [1.16-1.43]; P<0.001) were independent predictors of AF during the study. In a sensitivity analysis restricted to 1117 patients with baseline N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurements, only older age and higher NT-proBNP were significant independent predictors of AF. Performances of several published predictive models were assessed, including the HAVOC and CHA2DS2-VASc scores, and higher scores were associated with higher rates of developing AF. Conclusions: Besides age as the most important variable, several other factors, including hypertension, higher body mass index, and lack of diabetes, are independent predictors of AF after ESUS. When baseline NT-proBNP was available, only older age and elevation of this biomarker were predictive of subsequent AF. Understanding who is at higher risk of developing AF will assist in identifying patients who may benefit from more intense, long-term cardiac monitoring.

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Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack

10.1002/14651858.cd009938 ◽

2012 ◽

Author(s):

Jie Li ◽

Ming Liu ◽

Shihong Zhang ◽

Zilong Hao ◽

Canfei Zhang ◽

...

Keyword(s):

Medical Therapy ◽

Transient Ischemic Attack ◽

Patent Foramen Ovale ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

History Of ◽

Ischemic Attack

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Abstract WP264: Frequency of Hypercoagulability in Patients With Embolic Stroke of Undetermined Source and Patent Foramen Ovale

Stroke ◽

10.1161/str.51.suppl_1.wp264 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Michael Liu ◽

Srikant Rangaraju ◽

Alexander Duncan ◽

Samir Belagaje ◽

Trina Belair ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Paradoxical Embolism ◽

Embolic Stroke ◽

Composite Outcome ◽

Foramen Ovale ◽

Primary Mechanism ◽

Detailed Evaluation ◽

D Dimer

Introduction: Patent foramen ovale (PFO) is more commonly found in patients with cryptogenic stroke and paradoxical embolism is commonly assumed to be the primary mechanism. Our objective was to determine the frequency of hypercoagulability in cryptogenic stroke patients and PFO. Methods: Consecutive patients with embolic stroke of undetermined source (ESUS) seen at the Emory Clinic from January 1, 2017 to June 30, 2019 who underwent echocardiogram with bubble study and markers of coagulation and hemostatic activation (MOCHA) testing (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) were included; abnormal MOCHA was defined as ≥ 2 elevated markers. Venous thromboembolism, malignancy, other defined hypercoagulable state, and the composite outcome were assessed at routine follow-up and compared across groups based on PFO status. Results: Of 172 patients (mean age 63 ± 16 years, 60% female), 40 (23%) had a PFO. Compared to the PFO- group, the PFO+ group was younger (p=<0.001), less likely to have hypertension (p<0.001) and diabetes (p=0.011), and had a higher ROPE score (p=0.007) (Table 1). There was no difference in the frequency of abnormal MOCHA between groups and the composite outcome was less frequent in PFO+ versus PFO- patients (p=0.017). In the subgroup of patients <60 years old, there was no difference in the frequency of abnormal MOCHA and the composite outcome. Conclusion: Hypercoagulability as measured by MOCHA was not associated with the presence of PFO in ESUS patients. Based on our results, ESUS patients should undergo a detailed evaluation for alternative causes of stroke other than paradoxical embolism.

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Abstract TMP13: Baseline DWMRI Characteristics In Patients With Cryptogenic Stroke And Patent Foramen Ovale: Results From The Closure I Trial

Stroke ◽

10.1161/str.44.suppl_1.atmp13 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Richard Jung ◽

Benny Kim ◽

Joseph Massaro ◽

Anthony J Furlan

Keyword(s):

Patent Foramen Ovale ◽

Cox Regression ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Patient Characteristics ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Anterior Circulation ◽

Significant Difference ◽

Multivariate Proportional Hazard

Background: Cryptogenic stroke may have several etiologies including paradoxical embolism through a patent foramen ovale (PFO). A cardiac source of embolism may be suggested by multiple infarcts, sometimes hemorrhagic, in different vascular distributions or a cortical wedge shaped infarct. We report the baseline diffusion weighted MRI (DWMRI) characteristics in patients with cryptogenic stroke and a patent foramen ovale (PFO) from the CLOSURE I trial. Methods: CLOSURE I compared device closure versus medical therapy for secondary prevention in patients with cryptogenic TIA or stroke and a PFO. Of 909 patients randomized, 562 patients demonstrated acute infarcts on baseline DWMRI and are included in this analysis. Multivariate proportional hazard Cox regression compared imaging subgroups with remaining randomized patients Results: Single infarcts were found in 62% of patients. Of these, 61% were anterior circulation, 30% posterior, and 8.5% were of uncertain territory. Of the anterior circulation infarcts, 40% were cortical, 36% subcortical, and 24% affected both the cortical and subcortical regions. Of the posterior circulation infarcts, 45% were thalamic or cerebellar. Of 562 patients, 18.5% had a single subcortical lesion <1.5cm in diameter and met the radiological definition of an acute lacunar infarct. Multiple infarcts were found in 38%. Infarcts in a single vascular territory were found in 23%, often in the anterior circulation (66%). Infarcts in multiple vascular territories were found in 15%. Hemorrhagic infarction was present in 9%. Adjusting for patient characteristics, no significant difference in 2 year rate of TIA, stroke or death was found compared to remaining randomized patients. Discussion: The specificity of infarct patterns for embolism in patients with cryptogenic stroke and a PFO is uncertain. We found no significant relationship between lacunar or subcortical infarction and the risk of recurrent TIA or stroke. Baseline infarct patterns on DWMRI in patients with cryptogenic stroke and PFO may not be useful in predicting recurrent stroke risk or determining best prevention therapy.

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An unusual combination of patent foramen ovale with pulmonary arteriovenous malformation in a young patient with stroke

Neurology India ◽

10.4103/neuroindia.ni_817_16 ◽

2017 ◽

Vol 65 (4) ◽

pp. 891 ◽

Cited By ~ 3

Author(s):

PushpendraN Renjen ◽

Dinesh Chaudhari ◽

Mahir Meman

Keyword(s):

Arteriovenous Malformation ◽

Young Patient ◽

Patent Foramen Ovale ◽

Pulmonary Arteriovenous Malformation ◽

Foramen Ovale ◽

Unusual Combination

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Efficacy and safety of percutaneous patent foramen ovale closure devices for recurrent stroke: A systemic review and network metaanalysis

Brain Science Advances ◽

10.26599/bsa.2019.9050014 ◽

2019 ◽

Vol 5 (3) ◽

pp. 178-188

Author(s):

Hao Nie ◽

Yang Hu ◽

Zhouping Tang

Keyword(s):

Patent Foramen Ovale ◽

Recurrent Stroke ◽

Meta Analysis ◽

Vascular Complication ◽

Systemic Review ◽

Occurrence Rate ◽

Cochrane Library ◽

Efficacy And Safety ◽

Foramen Ovale ◽

Increased Risk

Background: Randomized controlled trials (RCTs) that directly compare the efficacy and safety of percutaneous patent foramen ovale (PFO) closure devices have not been conducted. Thus, we performed a network meta-analysis to identify the efficacy and safety of occluder devices. Methods: From 1st January, 2000 to 1st May, 2018, we searched Embase, PubMed, and Cochrane Library for RCTs about percutaneous closure devices (such as STARFlex, GORE, and Amplatzer) and medical therapy for cryptogenic cerebral ischemic patients with PFO. The occurrence rate of recurrent stroke, atrial fibrillation (AF), major vascular complication (MVC), headache, transient ischemic attack, and bleeding were compared with the frequentist and Bayesian methods using R statistics. Results: We included 3747 patients from six RCTs. The GORE and Amplatzer occluders were found to be significantly associated with a decreased risk of recurrent stroke [relative risk (RR): 0.37 and 0.49; 95% confidence interval (CI): 0.17–0.81, 0.29–0.83, respectively]. Moreover, STARFlex was correlated to an increased risk of postoperative AF and MVCs (RR: 11.66 and 7.63; 95% CI: 4.87–21.91, 2.34–24.88). Conclusions: Among the three devices, the GORE and Amplatzer occluders are found to be the most effective in preventing secondary stroke in patients with PFO. Meanwhile, STARFlex is the least recommended device because it cannot decrease the risk of recurrent stroke and is the most likely to cause adverse events.

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