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Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
Published on: December 23, 2022
Patent Foramen Ovale and Cryptogenic Strokes in the Stroke in Young Fabry Patients Study
Roman Huber1, Ulrike Grittner2, Frank Weidemann2
1From the Department of Neurology, Medical Campus Lake Constance, Klinikum Friedrichshafen, Germany (R.H.); Department of Neurology, University of Ulm, Ulm, Germany (R.H.); Department for Biostatistics and Clinical Epidemiology (U.G.) and Center for Stroke Research (U.G.), Charité-Universitätsmedizin Berlin, Germany; Department of Internal Medicine II, Katharinen Hospital, Unna, Germany (F.W.); Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia (V.T.); Department of Neurology, Justus Liebig University Giessen, Germany (C.T.); Department of Neurology (C.E., F.F.) and Clinical Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology (C.E.), Medical University of Graz, Austria; Department of Neurology, University of Mannheim, Germany (M.W., M.G.H.); Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, incorporating the National Children's Hospital, Dublin, Ireland (D.J.H.M.); Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.); Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., T.T.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Department of Neurology, University Medicine Greifswald, Ernst Moritz Arndt University of Greifswald, Germany (C.K., B.v.S.); Department of Epidemiology and Biometrics, University of Tübingen, Germany (P.M.); Department of Neurology, New York University School of Medicine (E.K.); Department of Clinical Sciences, Section of Neurology, Lund University, Sweden (B.N.); and Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Germany (A.R.). r.huber@klinikum-fn.de.
Background And Purpose:
A patent foramen ovale (PFO) is disproportionately prevalent in patients with cryptogenic stroke. Without alternative explanations, it is frequently considered to be causative. A detailed stratification of these patients may improve the identification of incidental PFO.
Methods:
We investigated the PFO prevalence in 3497 transient ischemic attack and ischemic stroke patients aged 18 to 55 years in the prospective multicenter SIFAP1 study (Stroke in Young Fabry Patients 1) using the ASCO classification. Patients without an obvious cause for transient ischemic attack/stroke (ASCO 0) were divided into subgroups with and without vascular risk factors (ASCO 0+ and 0-). In addition, we looked for PFO-related magnetic resonance imaging lesion patterns.
Results:
PFO was identified in 25% of patients. Twenty percent of patients with a definite or probable cause of transient ischemic attack/stroke (≥1 grade 1 or 2 ASCO criterion; n=1769) had a PFO compared with 29% of cryptogenic stroke patients (ASCO 0 and 3; n=1728; P<0,001); subdivision of cryptogenic strokes revealed a PFO in 24% of 978 ASCO 3 patients (n.s. versus ASCO 1 and 2) and a higher prevalence of 36% in 750 ASCO 0 cases (P<0.001 versus ASCO 3 and versus ASCO 1 and 2). PFO was more commonly observed in ASCO 0- (n=271) than in ASCO 0+ patients (n=479; 48 versus 29%; P<0.001). There was no PFO-associated magnetic resonance imaging lesion pattern.
Conclusions:
Cryptogenic stroke patients demonstrate a heterogeneous PFO prevalence. Even in case of less conclusive diseases like nonstenotic arteriosclerosis, patients should preferentially be considered to have a non-PFO-mediated stroke.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583.
Insights
Patent foramen ovale (PFO) is common in cryptogenic stroke patients, but its prevalence varies. Stratifying these patients helps identify incidental PFOs, suggesting not all PFOs cause stroke.
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Patent foramen ovale (PFO) is frequently implicated in cryptogenic strokes.
- Accurate PFO identification is crucial for stroke management.
- Patient stratification may refine the understanding of PFO's causative role.
Purpose of the Study:
- To investigate PFO prevalence in young patients with transient ischemic attack (TIA) and ischemic stroke.
- To stratify cryptogenic stroke patients using the ASCO classification.
- To explore PFO-related imaging patterns.
Main Methods:
- Prospective, multicenter study (SIFAP1) of 3497 patients (18-55 years).
- ASCO classification used to categorize stroke causes.
- Subgroup analysis of ASCO 0 patients (no obvious cause) into ASCO 0+ (with risk factors) and ASCO 0- (without risk factors).
Main Results:
- Overall PFO prevalence was 25%.
- Cryptogenic stroke patients (ASCO 0 and 3) had higher PFO prevalence (29%) than those with identified causes (20%).
- ASCO 0- patients showed significantly higher PFO prevalence (48%) compared to ASCO 0+ patients (29%). No PFO-specific MRI lesions were found.
Conclusions:
- PFO prevalence is heterogeneous among cryptogenic stroke patients.
- Even with nonstenotic arteriosclerosis, stroke may not be PFO-mediated.
- Detailed patient stratification is key to distinguishing causative PFOs from incidental findings.
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