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Updated: Dec 2, 2025
Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
Published on: December 23, 2022
Carotid Atherosclerosis and Patent Foramen Ovale in Embolic Stroke of Undetermined Source
George Ntaios1, Dimitrios Sagris1, Davide Strambo2
1Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
Insights
In embolic stroke of undetermined source (ESUS) patients, a likely pathogenic patent foramen ovale (PFO) was linked to less carotid atherosclerosis. This suggests an inverse relationship between these two stroke sources.
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Embolic stroke of undetermined source (ESUS) presents diagnostic challenges regarding embolic origins.
- Carotid atherosclerosis and patent foramen ovale (PFO) are recognized potential sources of embolism in ESUS patients.
- The interplay between carotid atherosclerosis and PFO in ESUS remains incompletely understood.
Purpose of the Study:
- To investigate the relationship between carotid atherosclerosis and likely pathogenic PFO in ESUS patients.
- To test the hypothesis that ipsilateral carotid atherosclerotic plaques are less common in ESUS patients with likely pathogenic PFO compared to those with incidental PFO or no PFO.
Main Methods:
- Patient cohort comprised 374 ESUS patients.
- Patent foramen ovale (PFO) presence assessed via transthoracic echocardiography with microbubble test and trans-oesophageal echocardiography when needed.
- PFO classified as likely incidental (RoPE score 0-6) or likely pathogenic (RoPE score 7-10).
Main Results:
- Ipsilateral carotid atherosclerosis was present in 165 (44.1%) patients.
- Prevalence of ipsilateral carotid atherosclerosis was significantly lower in patients with likely pathogenic PFO (7.8%) versus likely incidental PFO (46.0%) or no PFO (53.0%) (p<0.001).
- This inverse association persisted after multivariable adjustment (adjusted OR=0.32, 95%CI:0.104-0.994, p=0.049).
Conclusions:
- Carotid atherosclerosis prevalence is inversely associated with the presence of likely pathogenic PFO in ESUS patients.
- Findings suggest distinct embolic mechanisms may dominate in individual ESUS patients.
Background:
Carotid atherosclerosis and likely pathogenic patent foramen ovale (PFO) are two potential embolic sources in patients with embolic stroke of undetermined source (ESUS). The relationship between these two mechanisms among ESUS patients remains unclear.
Aim:
To investigate the relation between carotid atherosclerosis and likely pathogenic PFO in patients with ESUS. We hypothesized that ipsilateral carotid atherosclerotic plaques are less prevalent in ESUS with likely pathogenic PFO compared to patients with likely incidental PFO or without PFO.
Methods:
The presence of PFO was assessed with transthoracic echocardiography with microbubble test and, when deemed necessary, through trans-oesophageal echocardiography. The presence of PFO was considered as likely incidental if the RoPE (Risk of Paradoxical Embolism) score was 0-6 and likely pathogenic if 7-10.
Results:
Among 374 ESUS patients (median age: 61years, 40.4% women), there were 63 (49.6%) with likely incidental PFO, 64 (50.4%) with likely pathogenic PFO and 165 (44.1%) with ipsilateral carotid atherosclerosis. The prevalence of ipsilateral carotid atherosclerosis was lower in patients with likely pathogenic PFO (7.8%) compared to patients with likely incidental PFO (46.0%) or patients without PFO (53.0%) (p<0.001). After adjustment for multiple confounders, the prevalence of ipsilateral carotid atherosclerosis remained lower in patients with likely pathogenic PFO compared to patients with likely incidental PFO or without PFO (adjusted OR=0.32, 95%CI:0.104-0.994, p=0.049).
Conclusions:
The presence of carotid atherosclerosis is inversely related to the presence of likely pathogenic PFO in patients with ESUS.
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