Patent foramen ovale in a cohort of young patients with cryptogenic ischemic stroke

OBJECTIVE: Although its role is a matter of debate, some studies described a higher prevalence of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) in young stroke patients, with higher risk with PFO / ASA association (OR 4.96). The aim of this study was determine the prevalence of PFO and ASA in a cohort of cryptogenic ischemic stroke (IS) patients younger than 55 years and to follow-up after surgical or percutaneous endovascular closure (PEC). METHOD: In 21 months we identified all patients less than 55 years old with IS who were admitted to our hospital. Cryptogenic IS was considered if there is not an identifiably cause to cerebral ischemia. Transesophageal echocardiography (TEE) was performed in all patients. After interatrial septal abnormalities diagnosis, percutaneous device closure was offered to all. Patients were followed monthly and keeped with oral AAS or Clopidogrel. RESULTS: We identified 189 patients with IS and 32 were less than 55 years old (16.9%). In 29 the IS was cryptogenic. TEE was performed in all patients and some form of interatrial septal abnormality was identified in 12 (12/29 - 41.3%); 5 had a PFO and in 7 there was PFO plus ASA. Ten patients were submitted to PEC and 2 were submitted to surgical closure. In mid-term follow-up (28 months) no ischemic events occurred and 2 patients related disappearance of migraine symptoms. CONCLUSION: Our small series description is in accordance with other studies and suggests a possible relation between interatrial septal abnormalities and IS in a cohort of young patient.

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Surgical Patent Foramen Ovale Closure for Prevention of Paradoxical Embolism–Related Cerebrovascular Ischemic Events

Circulation ◽

10.1161/circ.100.suppl_2.ii-171 ◽

1999 ◽

Vol 100 (suppl_2) ◽

Author(s):

Joseph A. Dearani ◽

Baran S. Ugurlu ◽

Gordon K. Danielson ◽

Richard C. Daly ◽

Christopher G. A. McGregor ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Patent Foramen Ovale ◽

Univariate Analysis ◽

Significant Risk ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Surgical Closure ◽

Ischemic Events ◽

Pfo Closure

Background —The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results —We retrospectively analyzed 91 patients (58 men, 33 women) with ≥1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2±12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n=82) or patch closure (n=9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n=1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with 1 caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5±3.2% at 1 year and 83.4±6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis ( P =0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions —Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.

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Surgical closure of patent foramen ovale is the preferred treatment to prevent recurrent cerebral ischemic events in young patients

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(98)80823-1 ◽

1998 ◽

Vol 31 ◽

pp. 39

Author(s):

B. Cujec ◽

R. Mainra ◽

D.H. Johnson ◽

C. Voll

Keyword(s):

Patent Foramen Ovale ◽

Young Patients ◽

Foramen Ovale ◽

Surgical Closure ◽

Cerebral Ischemic ◽

Ischemic Events

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Safety and efficacy of endovascular patent foramen ovale closure: the first results of a Russian multicenter study

Neurology neuropsychiatry Psychosomatics ◽

10.14412/2074-2711-2020-6-26-32 ◽

2020 ◽

Vol 12 (6) ◽

pp. 26-32

Author(s):

D. V. Ognerubov ◽

A. S. Tereshchenko ◽

A. N. Samko ◽

G. К. Arutyunyan ◽

O. A. Sivakova ◽

...

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Young Patients ◽

Paradoxical Embolism ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

History Of ◽

Pfo Closure

Patent foramen ovale (PFO) is detectable in more than 25% of the adult population and is generally clinically insignificant. However, it can be a cause of paradoxical embolism in some cases. Randomized trials indicate that endovascular PFO closure in patients with a history of cryptogenic stroke is an effective method for the secondary prevention of catastrophic brain damage.Objective: to study the safety and efficiency of endovascular PFO closure in young patients with a history of cryptogenic stroke.Patients and methods. Sixty-two patients, including (22 males and 40 females) women, underwent percutaneous PFO closure in May 2018 to March 2020. The patients' mean age was 37.4±7.6 years. The inclusion criteria were a prior cryptogenic ischemic stroke lasting less than 12 months and PFO with a high risk for paradoxical embolism (PFO concurrent with atrial septal aneurysm or hypermobility; PFO, ≥2 mm size; the presence of the Chiari network and/or the Eustachian valve).Results and discussion. The technical success of the operation was achieved in all cases. In 50 (80.6%) patients, the right chamber of the heart was completely isolated from the left one in the first 3 months. During the first year, the atria were also completely isolated in 10 (16.1%) patients. A left-to-right shunt persisted in 2 (3.2%) patents 12 months later. Two patients were found to have main procedural complications: one had perioperative atrial fibrillation and the other had pseudoaneurysm formation at the puncture site.Conclusion. Endovascular PFO closure is a safe and effective operation for the secondary prevention of recurrent ischemic stroke. In our study, blood shunting through the PFO was stopped in 96.6% of patients at less than 6 months after surgery, which suggests that there is a rapid and effective reduction in the risk of paradoxical embolism.

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Prevalence of Patent Foramen Ovale in a Cohort of Children With Cryptogenic Ischemic Stroke

Neurology ◽

10.1212/wnl.0000000000012892 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012892

Author(s):

Evelyn K. Shih ◽

Lauren A. Beslow ◽

Shobha S. Natarajan ◽

Christine B. Falkensammer ◽

Steven R. Messe ◽

...

Keyword(s):

Ischemic Stroke ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Recurrence Risk ◽

Atrial Septal Aneurysm ◽

Control Analysis ◽

Healthy Children ◽

Healthy Controls ◽

Foramen Ovale

ObjectiveTo determine the significance of patent foramen ovale (PFO) in childhood stroke, we compared PFO prevalence, PFO features, and stroke recurrence risk in 25 children with cryptogenic arterial ischemic stroke (AIS), 54 children with AIS from a known etiology, and 209 healthy controls.MethodsWe performed a case-control analysis of a 14-year prospectively enrolled single-center cohort of children with AIS who underwent transthoracic echocardiogram (TTE) and compared them to TTEs of otherwise healthy children evaluated for benign cardiac concerns. Stroke patients aged 29 days to 18 years at stroke ictus with confirmed acute AIS on imaging, availability of complete diagnostic studies of stroke risk factors including TTE images available for central review, and at least one follow-up evaluation after index stroke were included.Presence of PFO and high risk PFO features were assessed by 2 independent, blinded reviewers and compared between groups using Fisher’s exact test. Stroke/TIA recurrence risk was determined using Cox proportional hazards models.ResultsOf 154 children with first-ever AIS, 79 were eligible; 25 had cryptogenic AIS and 54 had a known cause. PFO prevalence was higher in the cryptogenic group (7, 28%) compared to both the known stroke etiology group (3, 5.6%, p = 0.009) and non-stroke controls (24, 11.5%, p = 0.03). There were no significant differences in presence of right-to-left shunt and atrial septal aneurysm. Median follow-up time for entire stroke cohort was 20.9 months. Stroke-free recurrence at 2-years did not differ between children with and without PFO (HR 2.0, 95% CI 0.4-9.3, p = 0.39).ConclusionPFO prevalence was higher in children with cryptogenic stroke compared to AIS patients with known etiology and healthy controls. PFO was not associated with increased recurrence risk. Optimal secondary preventative treatment in children with cryptogenic stroke and PFO remains uncertain and requires further study.Classification of Evidence:This study provides Class III evidence that children with cryptogenic ischemic stroke have an increased frequency of PFO compared to children with ischemic stroke of known etiology and healthy controls.

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Surgical Closure of Patent Foramen Ovale is the Preferred Treatment to Prevent Recurrent Cerebral Ischemic Events in Young Patients

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(97)83884-3 ◽

1998 ◽

Vol 31 (2) ◽

pp. 39A

Author(s):

B Cujec

Keyword(s):

Patent Foramen Ovale ◽

Young Patients ◽

Foramen Ovale ◽

Surgical Closure ◽

Cerebral Ischemic ◽

Ischemic Events

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Abstract 2922: Patent Foramen Ovale Is A Cause Of Ischemic Stroke In Patients With Antiphospholipid Syndrome

Stroke ◽

10.1161/str.43.suppl_1.a2922 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Yoshiaki Shimada

Keyword(s):

Ischemic Stroke ◽

Antiphospholipid Syndrome ◽

Patent Foramen Ovale ◽

Multiple Logistic Regression Analysis ◽

Cryptogenic Stroke ◽

Control Group ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

Stroke Patients ◽

Significant Difference

Background: The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, and can be an independent risk factor for a first-ever ischemic stroke especially in young female patients. Patent foramen ovale (PFO) has been established as a cause of cryptogenic stroke. Atrial septal aneurysm (ASA) is associated with PFO. Until recently, the precise pathophysiology of APS as causing ischemic stroke has been essentially unknown. In the present study, we investigated the relationship between APS and potential embolic sources including PFO and ASA using transesophageal echocardiography (TEE). Methods: This study was a retrospective case series design. From July 2006 to June 2008, 120 patients with ischemic stroke who admitted to Juntendo University Hospital underwent TEE. In this study period, consecutive ischemic stoke patients diagnosed as APS based on the modified Sapporo criteria were enrolled and classified into APS group. Controls were selected among age- and gender-matched stroke patients without APS who also underwent TEE. We assessed clinical characteristics and presence of embolic sources including PFO and atrial septal aneurysm (ASA) between APS and Control groups. Results: Nine of ischemic stroke patients with APS and 41 controls were included. Primary APS was present in one patient (11.1%) of the APS group, and APS with SLE were found in eight patients (88.9%). There is no significant difference in age, risk factors for ischemic stroke, and MRI findings between two groups. The prevalence of PFO and ASA were significantly higher in APS group compared to Control group (89% vs 41%, P=0.027; 67% vs 20%, P=0.015, respectively). C reactive protein was relatively higher in APS group. Multiple logistic regression analysis showed that PFO (OR: 13.71; 95% CI: 1.01 to 185.62; P=0.049) and ASA (OR: 8.06; 95% CI: 1.17 to 55.59; P=0.034) were independently associated with the APS group. Conclusion: Atrial septal abnormalities including PFO and ASA are strongly associated with APS group, and could be potential embolic sources in ischemic stroke patients with APS.

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Association between Atrial Septal Aneurysm and Patent Foramen ovale in Young Patients with Recent Stroke and Normal Carotid Arteries

Cerebrovascular Diseases ◽

10.1159/000067114 ◽

2003 ◽

Vol 15 (1-2) ◽

pp. 4-10 ◽

Cited By ~ 26

Author(s):

Anna Vittoria Mattioli ◽

Lorenzo Bonetti ◽

Michele Aquilina ◽

Antonio Oldani ◽

Carlo Longhini ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Carotid Arteries ◽

Young Patients ◽

Atrial Septal Aneurysm ◽

Foramen Ovale

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Atrial septal aneurysms in childhood: prevalence, classification, and concurrent abnormalities

Cardiology in the Young ◽

10.1017/s1047951113000607 ◽

2013 ◽

Vol 24 (3) ◽

pp. 453-458 ◽

Cited By ~ 10

Author(s):

Andreas Giannopoulos ◽

Christoforos Gavras ◽

Stavroula Sarioglou ◽

Fotini Agathagelou ◽

Irene Kassapoglou ◽

...

Keyword(s):

Atrial Septal Defect ◽

Patent Foramen Ovale ◽

Septal Defect ◽

Interatrial Septum ◽

Paediatric Population ◽

Point Of View ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

Increased Risk

AbstractObjectives: This study sought to investigate the prevalence of atrial septal aneurysms in the paediatric population and to define coexisting abnormalities and their incidence. Background: Few papers refer to the prevalence of atrial septal aneurysms in childhood. Methods: We enrolled a total of 4522 children aged more than 12 months who underwent a transthoracic echocardiography. Atrial septal aneurysm was defined as a protrusion of the interatrial septum or part of it >15 mm beyond the plane of the atrial septum or phasic excursion of the interatrial septum during the cardiorespiratory cycle of at least 15 mm in total amplitude and a diameter of the base of the aneurysm of at least 15 mm. Results: Atrial septal aneurysms were found in 47 children (1.04%). They involved almost the entire septum in 14 patients (28.89%) and were limited to the fossa ovalis in 33 (71.11%). An atrial septal aneurysm was an isolated structural defect in 17 (35.56%). In 30 (64.44%) patients, it was associated with interatrial shunting – atrial septal defect and patent foramen ovale. At the echo follow-up after a year, no changes were recorded. Conclusions: Prevalence of atrial septal aneurysms is almost 1%. The most common abnormalities associated are interatrial shunts, that is, a patent foramen ovale and an atrial septal defect. From a medical point of view, it is suggested that no action is to be taken during childhood, as a child with an atrial septal aneurysm is not at increased risk compared with a child without one. Follow-up is scheduled on an individual basis.

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